Antidepressant Medication
Tricyclic or Typical Antidepressants - Effects norepinephrine, serotonin, and
acetylcholine
A. These are the “old” antidepressants. Their side effect profiles were difficult.
B. The most dangerous aspect of these drugs are their cardiotoxicity, making
them very dangerous in overdose situations.
C. Here is a list of these drugs:
TRADE NAME
Elavil®
Sinequan®, Adapin®
Pamelor®, Aventyl®
-Tricyclics Tofranil®
Norpramin®
Vivactyl®
Ludiomil®
Asendin®
GENERIC NAME
amitriptyline
doxepin
nortriptyline
imipramine
desipramine
protriptyline
maprotiline
amoxapine
Side effects of antidepressant medications-TricyclicsA. Drowsiness: may be a beneficial effect in patients with insomnia
B. Anticholinergic side effects:
- increase in heart rate
- dry mouth
- blurred vision
- constipation
- urinary retention
- nasal congestion
C. Cardiovascular side effects:
- postural hypotension
- arrhythmias
D. Miscellaneous side effects:
- agranulocytosis
- menstrual irregularities
- weight gain
- precipitation of mania in manic-depressive patients
- decrease seizure threshold - ie. increased seizure activity
- stomach upset
- sexual dysfunction
SSRI Antidepressants or Serotonin Specific Re-uptake Inhibitors
A.
B.
C.
D.
These medications effect serotonin only.
Better side effect profile
Low overdose lethality
These drugs are:
1. Prozac/Fluoxetine - 20 mg
2. Luvox/Fluvoxamine - 50-100 mg
3. Paxil/Paroxetine 20 mg
4. Zoloft/Sertraline 50-100 mg
5. Celexa - 20-60 mg
E. Individual side effect profiles exist, but some are typical for all
F. These are: GI upset, sexual dysfunction, dry mouth
G. Individual profiles are:
1. Prozac-Very energizing, decreases appetite, can cause anxiety,
insomnia
2. Zoloft-Fewest side effects, Headaches are common problem and always
take with food for the best response
3. Paxil-most calming, used for patients with high anxiety, has more
anticholinergic effects, especially dry mouth and constipation
4. Celexa-Cheaper, less interactions with other medications, safer for
elderly
Serotonin and Norepiniphrine Reuptake Inhibhitors (SNRIs)
A. Venlafaxine- effexor- low doses prevent re-uptake of serotonin at higher doses
also prevents re-uptake of norepinephrine. At the highest dose prevents reuptake of dopamine
- Pros: minimal drug interaction risk, effective with geriatric pts., low
sexual side effects; Energizing
B. Duloxetine (cymbalta) - low doses prevent re-uptake of serotonin at higher
doses also prevents re-uptake of norepinephrine. At the highest dose
prevents re-uptake of dopamine
- Pros: minimal drug interaction risk, effective with geriatric pts., low
sexual side effects
Novel Antidepressants
A. Buproprion - wellbutrin - is unique in that it there is dopamine uptake
inhibition; it does not effect serotonin. Effective as an addition to SSRIs to
diminish sexual dysfunction.
- Pros: Lowest side effects, unique mechanism; works in depressions
where no other drug work. Low mania induction, low sexual side
effects
- Cons: SEIZURES, especially in high-risk individuals (bulimics, head
injury, multiproblem pts.) Divide doses to decrease risk. Also, seizure
release has great decrease in seizures.
- Dosing: Bupropion SR Begin at 100 Mg BID, then 150 BID
B. Trazodone- Desyrel: very weak NE and 5ht
- Pros: Great for sleep induction. Nonaddicting
- Cons: Can cause anticholenergic side effects, can cause priapism
(continues erection) rare side effect, but very painful
- Dosing: Range is from 25 to 150 mg. Usually dosed HS
E. Mirtazapine - Remoran: Decrease re-uptake of serotonin and to a lesser
extent, Norepinephrine
- Pros: Great for sleep induction and increases appetite. Also, has a low
interaction profile with other medications. Once daily dosing at night.
Low sexual side effects
- Cons: Can cause platelets to decrease in a few cases. Increase in wt.
and sedation
- Dosing: range is from 15 Mg to 45 Mg at HS
Monamine Oxidase Inhibitors (MAOIs)
A. Isocarbaxil (Marplan)
B. Phenelzine (Nardil)
C. Tranylcypromine (Parnate)
MAO inhibitors interact with other medications including prescription over-thecounter and herbal preparations
Requires a tyramine-free diet
Hypertensive crisis
Over-the-Counter Supplements
1. Herbal antidepressant
A. St. John’s Wort
B. Used in Germany more than Prozac
C. Be aware that different products can vary
D. Mode of action is similar to SSRI in that they promote serotonin in the
synapse
H. Takes at least 3 weeks to feel positive effects
2. Nutraceutical - A natural product that promotes good health
A. SAM-e - S-adenosylmethionine - is found in all living cells and is formed
from the sulfur containing amino acid metionine and the molecule
adenosine-triphosphate
B. Mode of action - enhances brain dopamine and serotonin metabolism and
receptor function.
C. SAM-e outsells Prozac in Italy
D. This product for mild to moderate depression
E. Expensive - Available in 100 and 200 mgs, usual dose is 400 mg