ANTIDEPRESSANTS

Prof dr. Sujith J Chandy

Group Director, CPMM
Siloam Hospitals

Classification of Major Affective

Disorders
Major Affective
Disorders

Episodal
Depression

Seasonal
Affective
Disorder
Atypical
Depression

Major/
Endogenous
Depression

Mania

Bipolar
depression

Episodal (reactive) Depression

Adverse life events
Physical illness
Hormonal steroids
Drugs
Other psychiatric disorders

Reactive (episodal) Depression

More than 60% of all depressions
Core depressive syndrome: feelings of
misery, apathy, inadequacy, pessimism,
anxiety, tension, guilt
Bodily complaints
May improve spontaneously or through
counselling and sometimes drugs help

Major Endogenous Depression

Recurrent, Cyclic, Seasonal
Precipitating event not associated with
degree of depression
Automaton (unresponsive)

Major Endogenous Depression

Core Symptoms:
Symptoms:
Feeling of misery, apathy and pessimism
Withdrawn
Low self esteem, feelings of guilt, inadequacy and ugliness
Loss of interest in pleasurable activities
Indecisiveness, loss of motivation
Retardation of thought & action.
Sleep disturbance & weight change
Psychomotor agitation or retardation
In severe cases,accompanied by hallucinations and delusions
Recurrent suicidal ideation, a suicide attempt or specific suicide plan.
plan.

Mania
Mania alone is rare (10%) and frequently cycles with Major/endogenous
depression
Manic--Depressive Psychosis, Bipolar Disorder
Manic

Core Symptoms:
Elevated high mood.
Talkative, go onon-and
and--on about the things they will do.
Increased selfself-esteem
Auditory hallucinations
Decreased need to sleep
Lack of judgment, indiscrete
Super ME

Biological Basis for Depression

1. Has a genetic component

2. Depression can be drug

drug--induced eg reserpine
3. Depression can be drugdrug-repressed eg.
Stopping CNS stimulants
Depression can be treated with drugs.
Severe Depression can be treated with
Electroconvulsive Therapy (ECT).

Biogenic Theory of Depression

The precise cause of affective disorders
remains elusive
Evidence implicates alterations in the firing
patterns of a subset of biogenic amines in
the CNS:
- Norepinephrine (NE) and Serotonin
(5HT)
Activity of NE and 5 -HT systems?

NE System
Almost all NE pathways in brain originate from cell bodies
of neuronal cells in locus coereleus in the midbrain
They send their axons diffusely to the cortex, cerebellum
and limbic areas (hippocampus, amygdala, hypothalamus,
thalamus)..
thalamus)
Mood: higher functions performed by the cortex
Cognitive function: function of cortex
Drive and motivation:
motivation: function of brainstem
Memory and emotion:
emotion: function of the
hippocampus and amygdala
Endocrine response:
response: function of hypothalamus

Serotonin System
As with NE system, serotonin neurons located in pons
and midbrain (raphe nuclei) send their projections diffusely
to the cortex, hippocampus, amygdala, hypothalamus,
thalamus
Same areas implicated in depression
This system is also involved in:
in:
Anxiety
Sleep
Sexual behavior
Rhythms (Suprachiasmatic nucleus)
Temperature regulation
CSF production

Antidepressants
1. Tricyclic antianti-depressants (TCAs)
Imipramine, desipramine, nortriptyline,
nortriptyline,
protryptyline,, amytriptiline, doxepin
protryptyline
2. Monoamine oxidase inhibitors (MAOIs)
isocarboxacid, phenelzine, tranylcypromine
3. Selective serotonin reuptake inhibitors (SSRIs)
fluoxetine, sertraline, paroxetine
4. Atypical antianti-depressants (Others)
amoxapine, bupropion, maprotiline,
nomifensine, mianserin, venlafaxine, trazadone

Tricyclic Antidepressants (TCAs)

amytriptiline
imipramine
desipramine
nortriptyline
protryptyline
doxepin

Tricyclic Antidepressants (TCAs)

Characteristic three ring nucleus
High protein binding, high lipid solubility

3Amines
Amines::
2Amines:
Selectivity

Imipramine, Amitriptyline

Desipramine, Nortriptyline
2o Amines -- NE > 5-HT
3o Amines
Amines--- 5-HT > NE

TCA Mechanism of Action

Inhibition of Neurotransmitter reuptake

Immediate action - NE and 55-HT in synapse
After chronic treatment (2 - 4 weeks)
- Adaptive Responses eg. Sensitization of 55-HT receptors
Takes up to 4 weeks for all TCA antidepressants to have an
optimal effect

TCA - ADR
Dry mouth, constipation, blurred vision, urinary retention muscarinic blockade
Orthostatic hypotension - 1 blockade
Drowsiness, sedation and weight gain - Histamine
Histamine-Receptor blockade
Palpitations, dizziness - NE in Heart
Sexual dysfunction & loss of libido

TCA Other Effects

Metabolism of TCA affected by: Smoking, Barbiturates,
estrogens, neuroleptics and anticonvulsants
Can lower seizure threshold
All potentiate CNS depressants (BZDs, Barbiturates,
alcohol) - coma and death
TCA administration in bipolar disorder may precipitate
acute mania or rapid cycling
Fatal in overdose (a 2 wk supply can kill anyone)

MAO INHIBITORS
Developed for the treatment of tuberculosis (iproniazid
derivatives) 1951
Not widely used today - small number of patients appear
to do better in MAOIs than TCAs or newer drugs
Are readily absorbed from GI tract and widely distributed
throughout the body
May have active metabolites, inactivated by acetylation
Effects persist even after these drugs are no longer
detectable in plasma (1(1-3 weeks)

MAO INHIBITORS - Mechanism

Inhibit MAO enzymes (non
(non--selective):
1) Irreversible MAO inhibitors
Phenelzine and isocarboxazid
2) Reversible MAO Inhibitors
Tranylcypromine
prolonged blockade, but reversible within 4hr.
Decreases metabolism of most biogenic amines (NE, 5HT,
DA, tyramine)

MAO INHIBITORS - selectivity

MAO-A
NE, 5MAO5-HT, Tyramine
MAO--B
DA
MAO

Selective MAOIs:
MAOIs:
Inhibitors of MAOMAO-A
Moclobemide, Clorgyline
Inhibitors of MAOMAO-B
 Deprenyl, Selegiline

MAO INHIBITORS Adverse Effects

Side effects:
Hypertensive crisis
Postural Hypotension
Hepatotoxicity
Sedation
Drug Interactions:
Wine and Cheese Reaction
Hyperexcitement Syndrome

MAO INHIBITORS - Interactions

Wine--andWine
and-Cheese Reaction
Interaction with tyraminetyramine-containing foods (fermented
foods in particular, such as wine and cheese).
MAO
MAO--A => Tyramine in the body =>
=>NE in
circulation => induces hypertensive crisis => can lead
to intracranial bleeding and other organ damage

Hyperexcitation Syndrome
Interaction with drugs metabolized by MAOs (e.g.
Meperidine, SSRIs, TCAs, alcohol, CNS depressants )
- high fever, delirium and hypertension

SSRIs
Selective Serotonin Reuptake Inhibitors
Fluoxetine
Sertraline
Paroxetine
Citalopram
Fluvoxamine
(Labeled for obsessiveobsessive-compulsive disorder)

SSRIs
Most widely prescribed drugs for depression
They have few side effects and seem to be rather safe
More rational prescribing and better patient compliance
Adverse effects include: nausea, decreased libido,
decrease sexual function
Low threat for overdose

SSRIs
Mechanism - Specific serotonin uptake inhibitors
increase 55-HT by inhibiting reuptake
Fluoxetine is the prototype
Approximately 70% of depressed patients will respond to
an SSRI therapy at the end of 6 weeks
T1/2 of 16 24 hrs. except for fluoxetines metabolite
norfluoxetine (T1/2 = 8 days)
Fluoxetine and paroxetine inhibit liver enzymes,
particularly CYP450CYP450-2D6 DI with others eg. metoprolol

SSRIs Adverse Effects

Adverse Effects

Insomnia,, anxiety, restlessness, trembling, weakness

Insomnia

Drug-drug interactions
Drugdangerous with other antidepressants, MAOIs in particular
Serotonin Syndrome:
Syndrome:
hyperthermia, muscle rigidity, myoclonus, rapid changes in mental
status and vital signs.
- important to wait up to 6 weeks after medication is stopped, before
starting with another antidepressant

Heterocyclics
Second Generation heterocyclics
Amoxapine
Maprotiline
Trazodone
Bupropion

Third Generation heterocyclics

Mirtazapine
Venlafaxine
Nefazodone

Heterocyclics
The second and third generation antidepressants are by
no means a homogeneous group they are sometimes
called ATYPICAL ANTIDEPRESSANTS
As with the TCA's , they all have variable bioavailability
High protein binding
Some have active metabolites
Trazodone and Venlafaxine have the shortest plasma halfhalflives, which mandates divided doses during the day

Heterocyclics
Amoxapine
NE reuptake inhibitor
DA receptor antagonism => parkinson's-like symptoms
Metabolite of Loxapine (an anti-psychotic) - retains some
antipsychotic activity
Useful if psychosis is present

Maprotiline
Blocks NE reuptake
Resembles desipramine with less sedative and
antimuscarinic side effects
Evokes seizures at high doses

Heterocyclics
Bupropion
Resembles amphetamine
Blocks DA / NE reuptake (NDRI) - minimal on 5HT
CNS stimulation
Inhibits appetite
Aggravates psychosis

Venlafaxine
Inhibit reuptake of 5HT , NE (SNRI)
No anticholinergic effects
Drowsiness, weakness
Short plasma half life

Heterocyclics
Trazodone
Blocks reuptake of serotonin
Highly sedative (hypnotic)
minimal antimuscarinic action
Nefazodone - less sedating
Mirtazapine
Derivative of Mianserin
Antagonizes 2-adrenergic receptors, thus increasing NE
and 55-HT release.
Very sedating
Weight gain and appetite stimulation

Uses of antidepressants
Depression:

psychomotor agitation Amitriptyline, doxepin, trazodone

psychomotor retardation bupropion
Psychoses Amoxapine
No anti cholinergic SSRI

Phobia and Panic disorders SSRI

Obsessive compulsive disorders SSRI
Non--psychiatric uses:
Non

Enuresis
Chronic pain
pain


neuropathic low dose TCA
nicotine dependence - Bupropion
ethanol withdrawal symptoms - Citalopram

Anti--Manic Drugs
Anti
Lithium (Li+) remains the drug of choice for the
treatment and prophylaxis of mania
Useful in refractory depression when added to
SSRIs or TCAs, but not a good antidepressant
alone..
alone
Acute manic episodes are managed with lithium
salts (carbonate or citrate) alone, or in
combination with:
1) carbamazepine
2) Valproic acid

Lithium
Li

Small monovalent cation - atomic number 3

Available as oral tablets
The mechanism of antimanic and antidepressant action in
the CNS is not known
Evidence suggests that it interferes with synthesis,
storage, release, and reuptake of monoamine
neurotransmitters.
Onset of acute antimanic effect is seen in 5 to 7 days
Full therapeutic effect is established in 10 to 21 days

Lithium - ADR
Has narrow therapeutic index needs periodic plasma
level monitoring 0.6 to 1.5 mEq/L
ADR:
GI upset
May decrease thyroid function
May induce ECG changes T wave inversion
Neuroleptics may produce more severe
extrapyramidal syndromes when combined with lithium
Not to be taken with thiazide diuretics - Lithium
clearance is reduced by 25%.