Anti depressants

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Broad Over-view of classification of anti-depressants, indications & side-effects.

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Anti depressants

  1. 1. Anti-Depressants Dr.Harim Mohsin
  2. 2. First things first  Depression is a medical condition & not any fault of the individual concerned.  Assessment & evaluation is mandatory-Severity, etiology & risk-factors.  Treatment plan comprises of medication, psychological & social support.
  3. 3. Indications  Depression Moderate-Severe, Atypical, SAD, Depressive episode of Bipolar disorder.  Anxiety disorders GAD, Panic Disorder, Social Anxiety, Adjustment disorders, Agoraphobia, OCD, PTSD.
  4. 4. Mode of Action
  5. 5. Mode of action All antidepressants function by increasing availability of monoamines (5-HT, NA or DA) by one of the following methods:  Presynaptic inhibition of reuptake of 5-HT, NA or DA.  Antagonist activity at presynaptic inhibitory 5HT or NA receptors which enhances neurotransmitter release.  Inhibition of Monoaminase oxidase, reducing NT breakdown.  Increasing availability of NT precursors. Initial resolution of depressive symptoms takes minimum of 2-4 weeks.
  6. 6. Classification Broadly into 2 Types:  Re-uptake Inhibitors  Enzyme Inhibitors
  7. 7. Classification  Selective serotonin reuptake inhibitors (SSRIs) Monoamine oxidase inhibitors (MAOIs) – –  Serotonin-norepinephrine reuptake inhibitors (SNRIs) Irreversible Reversible   Norepinephrine reuptake inhibitors (NRIs)  Tricyclic antidepressants (TCAs)  Norepinephrine-dopamine reuptake inhibitors (NDRIs)  Serotonin antagonist and reuptake inhibitors (SARIs) Noradrenergic and specific serotonergic antidepressant (NaSSA)  Tetracyclic antidepressants (TeCAs)
  8. 8. SSRIs (Selective serotonin reuptake inhibitors) Mechanism: Increases 5HT in synaptic cleft.  Citalopram (Cipram)  Escitalopram (Cipralex, Citanew, Neolexa)  Paroxetine (Paroxin, Seroxat)  Fluoxetine (Prozac, Depex)  Fluvoxamine (Faverin)  Sertraline (Zoloft, Sert):
  9. 9. Indications  Depression  Panic Disorder with agoraphobia  Social Anxiety/ GAD/ OCD  Bulimia  PTSD
  10. 10. Side-effects         GI discomfort/ nausea Sexual dysfunction Sleep disturbance Dry mouth Tremor Headache Anxiety/ restlessness. Fatigue Caution:  Be aware of interactions-inhibitory effects on P450 & changes with alcohol, anticoagulants, MAOIs, TCA, smoking etc.
  11. 11. TCA Mechanism Mechanism:  Reuptake inhibition NA, 5HT & DA.
  12. 12. TCAs (Tricyclic antidepressants )  Amitriptyline (Tryptanol)  Clomipramine (Clomfranil)  Desipramine (Norpramin,Pertofrane)  Dosulepin (Prothiaden)  Doxepin (Doxin)  Imipramine (Tofranil, Imidol)  Nortriptyline (Sensival)
  13. 13. Indications  Depression  Nocturnal Enuresis (Amitriptyline/ Imipramine)  Phobic/Obsessional  Cataplexy States with narcolepsy
  14. 14. Side-effects        Dry mouth, Caution: Blurred vision,  Arrhythmias & ECG Sedation, changes. Monitor Orthostatic hypotension, Cardiac function, LFTs, Constipation, UCEs. urinary incontinence. Disorientation or  Should be used confusion cautiously in elderly.
  15. 15. SNRIs (Serotonin-norepinephrine reuptake inhibitors ) Mechanism: Similar to SSRI, Inhibit 5HT & NA (high doses DA) Indications: GAD, Depression.  Venlafaxine (Efexor)  Duloxetine (Oxcym DR, Hapibar, Lyta)  Levomilnacipran (Fetzima)  Tramadol (Tramal, Ultram)  Sibutramine (Meridia, Reductil) Side-effects: Similar to SSRIs & may cause HTN.
  16. 16. MAOIs (Monoamine oxidase inhibitors)   Irreversible inhibition of MAO-A (acts on NA, DA, 5HT & Tyramine) & MAO-B (acts on DA, Tyramine, Phenylethylamine, benzylamine) leading to accumulation of monoamines in Synaptic Cleft.  RIMAs: Reversible inhibition of MAO-A.
  17. 17. Indications  Depression (atypical)  Parkinson's Disease,  Migraine prophylaxis  Other disorders: panic disorder with agoraphobia, social phobia, bulimia, PTSD, borderline personality disorder, and bipolar depression.
  18. 18. MAOIs (Monoamine oxidase inhibitors) Irreversible  Isocarboxazid (Marplan)  Phenelzine (Nardil)  Selegiline (Selgin, Eklin) Reversible  Moclobemide (Aurorix, Manerix)  Pirlindole (Pirazidol)
  19. 19. MOA Inhibitors- Say No.
  20. 20. Side-Effects  Hypertensive crisis  Dizziness/ Headaches  Hepatotoxicity  Sleep disturbance  Weight gain  Sexual dysfunction  Drug Interactions Caution:  Dietary restriction (Tyramine) e.g: cheese, chocolate, wine, beans & soy products.  Serotonin Syndrome: Lifethreatening condition with somatic, autonomic & cognitive effectsTachycardia, myoclonus, tremors, altered Mental status, hyperthermia, DIC, metabolic disturbances.
  21. 21. Tetracyclic antidepressants (TeCAs) Mode: Similar to TCA without anticholinergic SE Indications: TCA with sedation. S/E- Cardiotoxicity     Mirtazapine (Remeron) Mianserin (Bolvidon, Norval, Tolvon) Amoxapine (Asendin) Maprotiline (Ludiomil) Noradrenergic and specific serotonergic antidepressant (NaSSA) Mode: α2 inhibitor (^NA/5HT), 5HT1, 5HT2 antagonist. Indications: Depression (+anxiety,wt loss) adjunct SSRI/venlafaxine to improve SxD, GI discomfort. Advantages: Low Toxicity, less sexual dysfunction & GI upset.
  22. 22. (SARIs) Serotonin antagonist and reuptake inhibitors Mode: 5HT reuptake inhibitor & antagonist. (sedation/ antihistamine) Indication: Depression (+insomnia) / Anxiety Advantage: Less antimuscranic/ cardiotoxic than TCA.  Trazodone (Deprel)  Etoperidone (Axiomin, Etonin)  Nefazodone (Serzone, Nefadar)
  23. 23. Other anti-depressants  Norepinephrine-dopamine reuptake inhibitors (NDRIs) Mode: NA/DA reuptake inhibition Indications: Depression (with marked psychomotor retardation or hypersomnia), Nicotine/stimulants dependence, ADHD. Advantage: Unusual mode of action-alerting effects, controls impulse disorders & secondary benefits as AD. S/E: Seizures & hypersensitivity.  Bupropion (Wellbutrin, Zyban)
  24. 24. Other anti-depressants  Norepinephrine reuptake inhibitors (NRIs)- Indication: Atypical Depression Reboxetine (Edronax)
  25. 25. Adjunctive treatments Itself doesn’t possess antidepressant quality but works in combination. Atypical antipsychotics  Aripiprazole (Aripip)  Olanzapine (Olanzia,Amprexa)  Quetiapine (Qusel)  Risperidone (Risperdal,Persch, Neoris)      Others Carbamazepine Lamotrigine (Lamictal) Lithium salts Triiodothyronine (T3; a thyroid hormone)
  26. 26. Alternate treatments Psychotherapy / counseling  Phytotherapy: St-John’s Wort  Exercise  Nutritional Supplements- Vitamins, minerals, O3-FA.  Adequate sleep.  Avoid Alcohol & other recreational drugs  Meditation, Acupuncture, chiropractice & yoga. 
  27. 27. Think Positive! Thank You

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