ANTI-DEPRESSANTS

SOUMYA MARY
1ST YEAR MSc (N)
 DEPRESSION
Depression is a common psychiatric disorder but the
cause for it is not clear.
Depression could be reactive or endogenous.

Reactive depression is due to stressful and distressing

circumstances in life.
Endogenous depression is major depression and results
from a biochemical abnormality in the brain. Deficiency
of monoamine (noradrenaline, 5 hydroxytryptamine)
activity in the CNS is thought to be endogenous
depression.
 ANTI-DEPRESSANTS
CLASSIFICATION

Tricyclic antidepressants (TCA) Imipramine,

desipramine, clomipramine, amitriptyline,
notriptyline, doxepin.

Selective serotonin reuptake inhibitors (SSRI)

Fluoxetine, fluoxamine, paroxetine, citalopram,
sertraline
 Monoamine oxidase (MAO) inhibitors
Phenelzine, tranylcypromine, isocarboxazid,
moclobemide.

Atypical antidepressants Trazodone, nefazodone,

venlafaxine bupropion, mianserine, mirtazapine,
reboxetine
TRICYCLIC ANTIDEPRESSANTS (TCA)

MECHANISM OF ACTION

TCAs block the reuptake of neurotransmitters

(noradrenaline or 5-HT) into the nerve-endings
and thereby prolong their action on the
receptors. Thus they potentiate amine
neurotransmission in the CNS.
 CNS In normal subjects, TCA cause dizziness,
drowsiness, confusion and difficulty in thinking.
In depressed patients, after 2-3 weeks of treatment,
elevation of mood occurs; the patients show more
interest in the surroundings and the sleep pattern
becomes normal.

CVS Postural hypotension and tachycardia (due to

blockade of 1 adrenergic and muscarinic receptors.

ANS TCAs have anticholinergic properties and cause

dry mouth, blurred vision, constipation and urinary
retention
 PHARMACOKINETICS

TCAsare rapidly absorbed, extensively protein

bound and metabolised in the liver.

They have a long t1/2 and can be given once

daily.

Onlong term administration, accumulation

can occur resulting in cumulative toxicity.
 ADVERSE EFFECTS

Sedation

Postural hypotension
Tachycardia

Sweating

Anticholinergic side effects

Weight gain due to increased appetite

Precipitate convulsions in epileptics

Hallucinations and mania in some patients

 Acute toxicity symptoms
(mimic symptoms of atropine poisoning)

Delirium

Excitement

Hypotension

Convulsions

Fever

Arrhythmias

Respiratory depression
 TREATMENT OF SIDE EFFECTS
Physostigmine for atropinelike effects

Sodium bicarbonate for acidosis

Phenytoin for seizures and arrhythmias.

Maintenance of BP, respiration, fluid and electrolyte

balance
TOLERANCE AND DEPENDENCE

Gradual tolerance to the sedative and

anticholinergic effects over 2-3 weeks.

Starting with a low dose and gradually increasing

the dose minimises the side effects.

Following longterm treatment, TCAs should be

gradually withdrawn, as withdrawal symptoms
like headache, anxiety and chills can occur due to
physical dependence
SELECTIVE SEROTONIN REUPTAKE
INHIBITORS (SSRI)

Antidepressant actions and efficacy of SSRIs are

similar to TCAs.

Include fluoxetine, fluvoxamine, paroxetine,

citalopram, sertraline and venlafaxine.
 MECHANISM OF ACTION

Block the reuptake of serotonin (5

hydroxytryptomine) into the nerve-endings of the
brain.

Increase serotonin levels in the synapses.

Thus correct the monoamine deficiency in these

neurons.
 ADVANTAGES OVER TCAS

Low cardiovascular side effects

Negligible anticholinergic side effects

Less sedation

Preferred in elderly

Safer in overdose

SSRIs are generally well accepted by

patients because of fewer side effects
ADVERSE EFFECTS

Nausea

Vomiting

Insomnia

Anxiety

Sexual dysfunction.
MAO INHIBITORS
MAO is an enzyme which metabolises noradrenaline,
serotonine and dopamine.

Drugs which inhibit this enzyme enhance the

neuronal levels of noradrenaline, dopamine and 5-HT
in the neurons.

Antidepressant actions develop slowly over weeks of

treatment.
 SIDE EFFECTS

Hypotension

Weight gain
Restlessness

Insomnia (due to CNS stimulation)

Anticholinergic effects

Liver dysfunction (rarely)

ATYPICAL ANTIDEPRESSANTS

Trazodone

Bupropion

Mianserin

Nefasodone

Mirtazapine
 ADVANTAGES

Fewer side effects particularly sedation

and anticholinergic effects.
Safer in over dose.

Effective in patients not responding to

TCA.
Bupropion is useful in depression with
anxiety. It is also useful to stop the
cigarette smoking habit along with
nicotine patch.
USES OF ANTIDEPRESSANTS

Endogenous depression
Panic attacks

Obsessive compulsive

Nocturnal eneuresis (Bed wetting)

Psychosomatic disorders

Other indications
NURSING IMPLICATIONS

Many patients in depression have suicidal

tendencies. They need to be carefully monitored.
Most antidepressants take 2-3 weeks for
therapeutic benefit. Patients attendants should
be informed of this.
Most antidepressants cause anticholinergic side
effects these should watched for and
appropriately dealt with
Managing anticholinergic side effects

Strict vitals monitoring especially BP

NURSING IMPLICATIONS

Caution about orthostatic hypotension

Avoid
taking tyramine rich food while on
MAOIs to prevent hypertensive crisis.