SSRIs

S/NRIs

Tricyclics

MAOIs

Atypical

SSRIs

S/NRIs

Tricyclics

MAOIs

Atypical

Depressed Mood

Loss of pleasure or interest

Insomnia

Anorexia

Mental slowing and loss of concentration

Feelings of guilt, worthlessness, helplessness

Thoughts of death and suicid

Sx must be present most of the day, nearly every day for at least 2 weeks

Seen early in treatment (first 6-8 weeks)

Rx should be written for the smallest number of doses consistent with good ptnt management.

Tricyclic Antidepressants

MOA:

Adverse Effects:

Most dangerous adverse effects:

MOA: Block neuronal reuptake of NE and Serotonin

AE: Sedation, orthostatic hypotension, anticholinergic effects, diaphoresis, seizures, hypomania, yawngasm

Most dangerous: cardiac toxicity (exacerbates arrhythmias, risk of MI)

May increase risk of suicide in early tx

Depression

Bipolar

Other: Neuropathic pain, chronic insomnia, ADHD, Panic disorder, OCD

MAOI

Direct-acting sympathomimetic

Indirect-acting sympathomimetic

Anticholinergic agents

CNS depressants

Gastric lavage

Ingestion of activated charcoal

Physostigmine

Propranolol, lidocaine, phenytoin

No hypotension, sedation or anticholinergic effects at normal dosing

OD doesn't cause cardiac toxicity so safer for patients with heart problems.

Death by OD is extremely rare. 

Fluoxetine

MOA:

Use:

Side Effects:

Drug Interactions:

MOA: Selective inhibition of Serotonin reuptake   --> CNS excitation

Use: OCD, Bulimia, Premenstrual dysphoric disorder

SE: Serotonin syndrome (2-72 hours after tx), withdrawal syndrome (agitation, changes in appetite and bp. If you taper dose down you won't get this), Neonatal effects, Teratogenesis (avoid in late stage pregnancy b/c can lead to serotonin syndrome in baby, NT defects seen in animals but not humans), extrapyramidal, bruxism, bleeding, sexual dysfunction, weight gain. 

Drug interactions: Warfarin, MAOIs, Tricyclic antidepressants and lithium

Sertraline

MOA: 

Uses:

Side effects:

Interactions:

MOA: blocks uptake of serotonin and dopamine

Uses: major depression, panic disorder, OCD, PTSD, premenstrual dysphoric disorder, social anxiety disorder. Minimal effects on seizure threshold.

SE: HA, N, D, Tremor, Insomnia, Weight gain, Agitation, sexual dysfunction, Neonatal abstinence syndrome, premature pulmonary HTN, nervousness.

Interactions: MAOIs, Pimozide

Fluvoxamine

MOA:

Use:

Side Effects:

MOA: SSRI

Use: OCD not depression

SE: N,V, constipation, weight gain, dry mouth, HA, sexual dysfunction, abnormal liver function, sedative

Paroxetine

MOA

Indications

SE

MOA: SSRI, shows benefits within a week or 2

Use: major depression, OCD, social phobia, panic, generalized anxiety, PTSD, premenstrual dysphoric disorder.

Citalopram:

MOA:

Use:

Half life:

Side effects:

MOA: unknown. Doesn't block receptors for serotonin, ach, NE or histamine

Use: Major depression

Half life: 35 hours

SE: Nausea, somnolence, dry mouth, sexual dysfunction, neonatal abstinence syndrome

Escitalopram

MOA:

Side effects:

MOA: unknown. S-isomer of citalopram but better tolerated

Sede effects: Temporary: nausea, insomnia, somnolence, sweating, fatigue

Venlafaxine

MOA:

Use:

Side effects:

MOA: SNRI

Use: depression, generalized anxiety, social anxiety disorder

SE: Nausea, HA, anorexia, nervousness, sweating, somnolence, insomnia, diastolic HTN, sexual dysfunction, hyponatremia (CV problems, arrhythmia, mm pain), neonatal withdrawal syndrome

Duloxetine

MOA:

Use:

PK:

SE:

Drug interactions:

MOA: SNRI, weakly inhibits dopamine

Use: DIABETIC PERIPHERAL NEUROPATHY, depression

PK: Food reduces rate of absorption, highly bound to albumin, half life 12 hours

SE: Nausea, somnolence, dry mouth, sweating, insomnia Blurred vision,  cross breast milk. 

Drug interactions: R'OH, MAOI, Drugs that inhibit CYP1A2 and CYP2D6

MAOI

MOA:

Use: 

SE:

Interactions:

MOA: Irreversible inhibition of MAO's. No breakdown of NE, DA, Serotonin. Lasts 2 weeks.

Use: Bulimia, OCD, Panic attacks

SE: CNS stimulation, orthostatic hypotension, HTN crisis with tyramine (cheese)

Interactions: Indirect-acting sympathomimetic agents, Antidepressants, antihypertensive drugs, meperidine (decreases binding of MAOs)

Takes weeks to months to show benefit

Transdermal MAOI

much lower risk of hypertensive crisis 

Bupropion

MOA:

Use:

Benefits:

SE:

MOA: stimulant an suppress appetite. Does not affect serotonergic, cholinergic or histaminergic transmission

Use: depression

Benefits: no weight gain, increases sexual desire and pleasure, smoking cessation, quick acting (1-3 weeks)

SE: Seizures, Agitation, Tremor, Tachycardia, Blurred vision, dizziness, HA, insomnia, dry mouth, GI upset, constipation, weight loss

Atypical antidepressant

Causes sedation

Tx Depression due to effectiveness, rapid onset

Given to ptnts who have failed to respond to drugs or are severely depressed, suicidal.

Adverse effect: loss of memory for events immediately surrounding treatment.

LT therapy of tx resistant depression when at least 4 antidepressant drugs have failed

MOA: Stimulates cholinergic release

Side effects: hoarseness, voice alteration, cough, dyspnea