PSYCHIATRY: DEPRESSION Tx| S.M.

CHOK (Manchester Medical School)

ANTIDEPRESSANTS
SSRIs

SNRIs

TCAs

MAOIs

Mechanism of
Action

block the reuptake of serotonin in the

brain

block the reuptake of noradrenaline &

serotonin by the presynaptic nerves

inhibition of noradrenaline and

serotonin reuptake

inhibit monoamine oxidase, causing

accumulation of amine
neurotransmitters

Examples

duloxetine
venlafaxine
desvenlafaxine

amitriptyline
clomipramine
imipramine
lofepramine
nortriptyline

Recommendation

1st line Tx for depression

better tolerated, safer in overdose

patients with severe depression may

older type of antidepressant
respond better to an SNRI
SE and toxicity in overdosage are
lower risk of drug-to-drug interactions
problems

older type of antidepressant

dangerous interactions with some
foods and drugs

Contraindication

cautions: patients with epilepsy,

cardiac disease, DM, angle-closeure
glaucoma, Hx of mania or bleeding
disorder
should not be used if patient enters a
manic phase

cautions: cardiac disease (HPTN and

arrhythmias), DM, Hx of epilepsy or
mania, angle-closure glaucoma,
bleeding disorders or concomitant
use of drugs that risk of bleeding

MI, arrhythmias
manic phase of bipolar
acute porphyria
should not be started until 2/52 after
stopping MAOIs

should not be started until 2/52 after

a TCAs/a previous MAOIs has been
stopped
other antidepressants should not be
started for 2/52 after MAOIs has
been stopped
pressor effects of tyramine (in some
foods) may cause a dangerous BP

Withdrawal
Symptoms

dizziness
flu-like symptomes
anxiety
urinary urgency
diarrhoea

influenza-like symptoms
insomnia
vivid dreams
movement disorders
mania

Citalopram
Escitalopram
Fluoxetine
Paroxetine
Sertraline

GI disturbances
headache
anxiety
dizziness
paraesthesia
electric shock sensation in the head,
neck and spine
tinnitus
sleep disturbances
fatigue
influenza-like symptoms

Overdosage
cardiovascular and
epileptogenic effects

phenelzine
tranylcypromine
isocarboxazid
moclobemide

agitation
irritability
ataxia
movement disorders
insomnia
drowsiness
vivid dreams
cognitive impairment
slowed speech
hallucination
paranoid delusions

PSYCHIATRY: DEPRESSION Tx| S.M.CHOK (Manchester Medical School)

SSRIs
Side Effects

SNRIs

less sedative, fewer cardiotoxic and

antimuscarinic SE than TCAs

Venlafaxine/Desvenlafaxine BP
Duloxetine may worsen liver problem

GI SE
nausea, vomiting, abdo pain,
dyspepsia, weight loss (anorexia) or
weight gain (appetite),
constipation, diarrhoea

Serotonin Syndrome
(if used with other antidepressants,
certain pain or headache meds, and
herbal supplement St.John's wort)
anxiety
agitation
sweating
confusion
tremors
restlessness
lack of coordination
tachycardia

Hypersensitivity Reaction
rash, urticaria, angioedema,
anaphylaxis, arthralgia, myalgia,
photosensitivity
CNS SE
headache, insomnia, tremor,
dizziness, hallucination, mania or
hypomania, drowsiness, anxiety,
convulsions, suicidal behaviour
Other SE
dry mouth
movement disorders
visual disturbances
bleeding disorders
hyponatraemia

GI SE
risk of GI bleeding
nausea
changes in appetite
constipation
dry mouth
Other SE
arrhythmias
insomnia
dizziness
fluid retention
difficulty with micturition
urinary incontinence
sensory disturbances
sexual dysfunction
tinnitus
alopecia
rash, photosensitivity

TCAs
Cardiovascular SE
arrhythmias and heart block
postural HPTN
tachycardia
ECG changes
CNS SE
anxiety, confusion, sleep
disturbances, dizziness, agitation,
irritability
Antimuscarinic SE
dry mouth, blurred vision,
constipation, urinary retention
Endocrine SE
breast enlargement
gynaecomastia
galactorrhoea
weight gain (appetite)
hyponatraemia (elderly)
Other SE
nausea, vomiting
taste disturbances
tinnitus
rash, urticaria, pruritis
photosensitivity
alopecia
sweating

MAOIs

hepatic impairment
risk of neonatal malformation
hypotension
insomnia
weight gain
nausea
agitation