Antidepressants Antidepressants can take between 10-20 days to begin making an effect.

After symptoms have improved they should be continued for at least 6 months at the same dose. 1. 2. 3. 4. Serotonin-selective reuptake inhibitors (SSRIs) Tricyclics (TCAs) Monoamine oxidase inhibitors (MAOIs) Other

SSRIs E.g. Fluoxetine, paroxetine & sertraline 1st line Treatment Safer in overdose than other antidepressants Mechanism: Block serotonin (5-HT) reuptake at pre-synaptic membranes Resulting in increased synaptic 5-HT

Pharmokinetics: Well absorbed orally life varies between 15-24 hrs Fluoxetine life 24-96 hrs Paroxetine & Fluoxetine increase TCA toxicity dont use in combination

Side Effects: Dry mouth Nausea Vomiting & diarrhoea Dizziness Sedation Sexual dysfunction Agitation Akathisia Parkinsonism & convulsions (both rare)

SSRI Discontinuation Syndrome Occurs most frequently if paroxetine is suddenly stopped. Symptoms include:
Headache Dizziness Shock-like sensations Paraesthesia GI symptoms Lethargy Insomnia Changes in mood

Serotonin Syndrome Rare Potentially fatal Due to increased 5-HT activity

Symptoms:
Psychological agitation, confusion Neuro nystagmus, myoclonus, tremor, seizures Other hyperpyrexia, autonomic instability

TCAs E.g. Imipramine, clomipramine & amitriptyline Possibly better than SSRIs in severe depression, however are much more toxic in overdose! Mechanism They block the reuptake of 2 things: 1. 5-HT (clomipramine more 5-HT selective) 2. Noradrenaline (lofepramine more selective) Pharmokinetics Rapidly absorbed orally 90% bound to albumin Metabolized in the Liver

Side Effects Anticholinergic dry mouth, blurred vision, constipation & urinary retention (strong with amitriptyline) Postural hypotension & sedation due to being an adrenergic receptor antagonist Weight & sexual dysfunction 5HT blockade Day time drowsiness & difficulty concentrating

Caution in patients with: Close angle glaucoma Prostatism Epilepsy Hepatic Impairment Cardiac disease

MAOIs E.g. Phenelzine & isocarboxacid Not widely used only in resistant depression or atypical depression Tyramine Reaction Causes: Foods containing tyramine e.g. cheese, game, yeast & some alcoholic drinks Sympathomimetic drugs e.g. non-prescription cold remedies

Results in a severe hypertensive reaction which can cause a subarachnoid bleed.

Mechanism Increase 5HT & Noradrenaline due to blocking there metabolism.

Side Effects Anticholinergic (see above) Weight-gain Insomnia Postural hypotension Tremor Limb parasthesia Peripheral oedema

Useful things to remember: 1. In pregnancy fluoxetine or the TCAs, nortriptyline, amitriptyline & imipramine 2. If breast-feeding SSRIs either paroxetine or sertraline 3. If a chronic health problem is present citalopram or sertraline as they cause fewer interactions 4. In children fluoxetine (after psychological input e.g. CBT)