Anti-Depressants

Dr.Harim Mohsin

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.

Indications

Depression
Moderate-Severe, Atypical, SAD, Depressive episode of Bipolar disorder.

Anxiety disorders
GAD, Panic Disorder, Social Anxiety, Adjustment disorders, Agoraphobia, OCD, PTSD.

Others :
Enuresis (bedwetting), neuropathic pain, Eating disorders (Bulimia), chronic pain etc.

Mode of Action

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.

Classification
Broadly into 2 Types:
Re-uptake

Inhibitors
Enzyme Inhibitors

Classification

Selective serotonin reuptake inhibitors

(SSRIs)

Monoamine oxidase inhibitors (MAOIs)

Serotonin-norepinephrine reuptake
inhibitors (SNRIs)

Norepinephrine reuptake inhibitors

(NRIs)

Tricyclic antidepressants (TCAs)

Norepinephrine-dopamine reuptake
inhibitors (NDRIs)

Serotonin antagonist and reuptake

inhibitors (SARIs)

Irreversible
Reversible

Noradrenergic and specific serotonergic

antidepressant (NaSSA)

Tetracyclic antidepressants (TeCAs)

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):

Indications
Depression
Panic

Disorder with agoraphobia

Social Anxiety/ GAD/ OCD
Bulimia
PTSD

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.

TCA Mechanism
Mechanism:
Reuptake inhibition
NA, 5HT & DA.

TCAs (Tricyclic antidepressants )

Amitriptyline

(Tryptanol)
Clomipramine (Clomfranil)
Desipramine (Norpramin,Pertofrane)
Dosulepin (Prothiaden)
Doxepin (Doxin)
Imipramine (Tofranil, Imidol)
Nortriptyline (Sensival)

Indications
Depression
Nocturnal

Enuresis (Amitriptyline/
Imipramine)

Phobic/Obsessional
Cataplexy

States

with narcolepsy

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.

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.

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.

Indications
Depression

(atypical)

Parkinson's Disease,

Migraine prophylaxis

Other disorders: panic disorder with agoraphobia,

social phobia, bulimia, PTSD, borderline personality
disorder, and bipolar depression.

MAOIs (Monoamine oxidase inhibitors)

Irreversible
Isocarboxazid (Marplan)
Phenelzine (Nardil)
Selegiline (Selgin, Eklin)
Reversible
Moclobemide (Aurorix,
Manerix)
Pirlindole (Pirazidol)

MOA Inhibitors- Say No.

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.

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: 2 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.

(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)

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)

Other anti-depressants

Norepinephrine reuptake inhibitors (NRIs)-

Indication: Atypical Depression

Reboxetine (Edronax)

Adjunctive treatments

Itself doesnt 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)

Alternate treatments
Psychotherapy / counseling
Phytotherapy: St-Johns Wort
Exercise
Nutritional Supplements- Vitamins, minerals, O3-FA.
Adequate sleep.
Avoid Alcohol & other recreational drugs
Meditation, Acupuncture, chiropractice & yoga.

Think Positive!

Thank You