Antidepressant Medications

selective serotonin reuptake inhibitors (SSRIs)

• blocks neuronal reuptake of serotonin increasing availability of serotonin

• ex: fluoxetine, sertraline

• side effects: sexual dysfunction, agitation, anxiety, sleep disturbance, GI upset, sweating, and headache

  • hyponatremia in the elderly

  • can increase bleeding risk

• helpful in treating anxiety

• 2-4 weeks to see improvement

  • full effects take longer

  • dose increases are often needed

• tapered discontinuation of the drug is recommended

  • client may experience rebound anxiety, insomnia, and restlessness

• washout period

  • when an SSRI is withdrawn and another is introduced

• zoloft best choice for pregnancy and breast feeding

serotonin and norepinephrine reuptake inhibitors (SNRIs)

• blocks the reuptake of serotonin and norepinephrine

• ex: duloxetine, venlafaxine

• venlafaxine

  • can elevate BP

  • significant discontinuation syndrome

• duloxetine (cymbalta)

  • FDA approved for fibromyalgia/chronic musculoskeletal pain

norepinephrine dopamine reuptake inhibitors (NDRIs)

• bupropion

• contraindications

  • eating disorder

  • seizure disorder

• can elevate blood pressure

• decreased sexual side effects

• not as likely to induce mania

• may be combined with SSRIs

• zyban

  • often used for smoking cessation

serotonin antagonist and reuptake inhibitors (SARIs)

• nefazodone

• trazadone

  • helpful for insomnia

  • priapism

• vortiozetine (trintellix)

  • costly

• SPARI - serotonin partial antagonist and reuptake inhibitor

  • vilazodone (vibryd)

  • costly

serotonin syndrome = emergency!

• in combination with other serotonergic drug

  • can occur:

    • with another antidepressant

    • or OTC cold medications

• symptoms are similar to NMS

  • difference

    • causitive drug

    • degree of muscle rigidity

• treatment

  • stop med

  • cyproheptadine

    • serotonin receptor blockade

  • dantrolene or diazepam

    • for muscle rigidity

  • symptomatic treatment

• S/S include:

  • diarrhea, fever, diaphoresis, tachycardia, hypertension, delirium, hyperactivity or restlessness

• black box warning

  • young people under the age of 25 for increased risk of suicidality with antidepressants

  • morphed into a general warning for all age groups

tricyclic antidepressants (TCAs)

• inhibits reuptake of norepinephrine and serotonin

  • making them more available to postsynaptic sites

• not first line drugs

  • potentially lethal cardiotoxicity (dysrhythmias, MI, and heart block)

• contraindications

  • history of angle closure glaucoma

  • seizure history

• used with caution for pregnant women

• side effects

  • sedation, weight gain, postural hypotension

• has anticholinergic effects

• given 7-10 days at a time

  • overdose risk

• adverse reactions

  • with MAOs phenothiazines, antabuse (disulfram) oral contraceptives, alcohol, and some anti-hypertensives

monoamine oxidase inhibitors (MAOIs)

• not first drug of choice

• breaking down monoamine oxidase allows for increase in specific neurotransmitters (serotonin, norepinephrine, and dopamine)

• side effects:

  • orthostatic hypotension, weight gain, tachycardia, sexual dysfunction, vertigo, weakness, fatigue, insomnia, hypomanic/manic behaviors

• food restrictions - tyramine

  • avocados, smoked salmon, fermented foods, beer, soy sauce, aged cheese, etc

• hypertensive crisis - can result from having tyramine

  • severe headache, stiff/sore neck, hyperpyrexia, hemorrhage, seizures, coma, death

• multiple drug interactions

other options

• aripiprazole (abilify) along with an SSRI

• cariprazine (vraylar) used with bipolar depression

• lithium along with an SSRI

• mirtazapine-alpha 2 antagonist, works on serotonin and histamine receptors

• helpful for individuals with depression that have trouble sleeping but weight gain can be a problem

• herbal supplements - st.john’s wort - should not take with an antidepressant

• TMS

• light box

• ECT

• psychotherapy

ketamine (aka special K or K)

• blocks glutamate from binding to the NMDA receptors

• nasal spray, derivative of PCP

• used as anesthetic agent in veterinary medicine; used as date-rape drug

• dispensing is limited and is a DEA schedule 3 medication

• monitor for dissociation (disconnected from thoughts and surroundings)

• significant monitoring for 2 hours post inhalation; twice weekly for 4 weeks, then 1x weekly, then taper depending on symptoms

• addition to antidepressants for those with treatment-resistant depression

brexanolone (zulresso)

• first and only FDA-approved medication specifically for postpartum depression

• neuroactive steroid that is thought to produce its effects by influencing GABA-A receptors

• scheduled 4 drug with some abuse potential

• restricted program distribution

• 1x IV infusion over 2.5 days

• monitor continuous pulse ox for hypoxia

• monitor when with children