Antidepressants and Mood Stabilizers April 7, 2010 1.

Discuss antidepressants (5) and mood stabilizers (2) with a patient, explaining the benefits, side effects, onset of effect, and expected duration of therapy Antidepressant
TCA (e.g. amitriptyline/Elavil)

Benefits
Effective and inexpensive

Adverse Effects
sedation (blocks histamine) hypotension (blocks -1) dry mouth, constipation (cholinergic blockade) weight gain (blocks histamine) *cardiotoxicity nausea, diarrhea (serotonin 2 stimulation) restlessness, insomnia (NT reuptake inhibition) 30-50% sexual side effects (serotonin 2 receptor stimulation) dizziness, postural hypotension (alpha-1 blockade) insomnia (NT reuptake block) **drug and dietary interactions (found in aged cheese, red wine) can cause hypertensive state significant sedation and weight gain (histamine inhibition) insomnia (due to lack of serotonergic effect), upset stomach seizure risk (not good for epileptics!)

SSRI (e.g. fluoxetine/Prozac)

Relative safety in overdose

MAO Inhibitors (e.g. phenelzine/Nardil)

Effective and inexpensive

Mirtazapine (Remeron)

Bupropion (Wellbutrin)

Low to no sexual dysfunction, low to no nausea or headache Low to no sexual dysfunction, low to no weight gain

a. Time course for response: a. 1-2 weeks: sleep and appetite improve b. 3rd week: energy level improves c. 4-6 weeks: mood improves b. Duration of therapy: a. Acute phase (6-8 weeks): full therapeutic doses b. Continuation phase (4-9 months): at full dose for all patients

c. Maintenance phase: varies i. 3+ episodes: 1-2 years at full dose ii. 3+ episodes in 5 years or over 65yo: lifetime treatment

Mood Stabilizer
Lithium for acute mania and bipolar depression

Benefits
Neuroprotective effects (less likely to relapse) Good for suicide prevention Enhances serotonin to help w/ depression

Adverse effects
toxic renal problems 1-3 onset of effect intentional tremor weight gain polyuria, polydipsia drug interactions (NSAID, caffeine can relapse weight gain sedation, lethargy drug interactions (aspirin, antacids)

Valproate for acute mania, mixed mania, and rapid cycling

Less risk of toxicity Quick onset of effect Low risk of intentional tremor

2. Differentiate 4 major antidepressant categories based on one prototype drug from each category a. See chart in #1 3. Explain the basic pharmacologic mechanisms associated with antidepressants and mood stabilizers (lithium and valproate) and link these mechanisms with their adverse effects Effect
Sedation Dizziness/orthostasis Dry mouth, constipation Weight gain

Mechanism behind effect

Inhibit: histamine 1 receptor; -1 Inhibit: -1 Inhibit: cholinergic or muscarinic receptor Increased appetite (multiple receptor effects on hypothalamus and feeding centers in the brain) inhibition of HISTAMINE Stimulate: serotonin 2 and 3 receptors Stimulate: serotonin 2 receptor Stimulate: serotonin 2 receptor

Nausea/diarrhea Headache Sexual dysfunction