Broad Over-view of classification of anti-depressants, indications & side-effects.

1. Anti-Depressants
Dr.Harim Mohsin

2. 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.

3. Indications

Depression
Moderate-Severe, Atypical, SAD, Depressive episode of
Bipolar disorder.

Anxiety disorders
GAD, Panic Disorder, Social Anxiety, Adjustment disorders,
Agoraphobia, OCD, PTSD.

4. Mode of Action

5. 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.

6. Classification
Broadly into 2 Types:
 Re-uptake
Inhibitors
 Enzyme Inhibitors

7. Classification

Selective serotonin reuptake inhibitors
(SSRIs)
Monoamine oxidase inhibitors (MAOIs)
–
–

Serotonin-norepinephrine reuptake
inhibitors (SNRIs)
Irreversible
Reversible


Norepinephrine reuptake inhibitors
(NRIs)

Tricyclic antidepressants (TCAs)

Norepinephrine-dopamine reuptake
inhibitors (NDRIs)

Serotonin antagonist and reuptake
inhibitors (SARIs)
Noradrenergic and specific serotonergic
antidepressant (NaSSA)

Tetracyclic antidepressants (TeCAs)

8. 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):

9. Indications
 Depression
 Panic
Disorder with agoraphobia
 Social Anxiety/ GAD/ OCD
 Bulimia
 PTSD

10. 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.

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

12. TCAs (Tricyclic antidepressants )
 Amitriptyline
(Tryptanol)
 Clomipramine (Clomfranil)
 Desipramine (Norpramin,Pertofrane)
 Dosulepin (Prothiaden)
 Doxepin (Doxin)
 Imipramine (Tofranil, Imidol)
 Nortriptyline (Sensival)

13. Indications
 Depression
 Nocturnal
Enuresis (Amitriptyline/
Imipramine)
 Phobic/Obsessional
 Cataplexy
States
with narcolepsy

14. 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.

15. 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.

16. 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.

17. Indications
 Depression
(atypical)

Parkinson's Disease,

Migraine prophylaxis

Other disorders: panic disorder with agoraphobia,
social phobia, bulimia, PTSD, borderline personality
disorder, and bipolar depression.

18. MAOIs (Monoamine oxidase inhibitors)
Irreversible
 Isocarboxazid (Marplan)
 Phenelzine (Nardil)
 Selegiline (Selgin, Eklin)
Reversible
 Moclobemide (Aurorix,
Manerix)
 Pirlindole (Pirazidol)

19. MOA Inhibitors- Say No.

20. 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.

21. 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: α2 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.

22. (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)

23. 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)

24. Other anti-depressants

Norepinephrine reuptake inhibitors (NRIs)-
Indication: Atypical Depression
Reboxetine (Edronax)

25. Adjunctive treatments
Itself doesn’t 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)

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

27. Think Positive!
Thank You