Chapter 17:  Antidepressant Agents

 

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 Two types of depressive mood disorders (bipolar and unipolar) and their drug treatments.

Depression and Mania
Clinical depression is a syndrome that may include:
  •  sustained mood disturbances
  •  impaired memory and concentration
  •  disturbed sleep
  •  reduced energy level
  •  reduced libido
  •  impaired sleep.
Patient complaints suggestive of depression may include:
  •  Pain (headaches, body aches)
  •  A mood of apathy, anxiety, or irritability
  •  Sexual complaints
  •  low energy, excessive tiredness
  •  reduced capacity for enjoyment.

Definitive diagnosis of depression references the American Psychiatric Association Criteria for Diagnosis of Major Depression:

[Source: Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC; America Psychiatric Association, 1994]; Boyer, W., and Nemeroff, C.B., Mood Disorders: Depression and Mania, In, Medicine for the Practicing Physician, (Hurst, J.W., editor-in-chief) Appleton and Lange, 1996, pp. 22-23

Definitive diagnosis of mania references the American Psychiatric Association Criteria for Diagnosis of Mania

  1.   Inflated self-esteem or grandiosity.

  2.   Decreased need for sleep (e.g. feels rested after only 3 hours of sleep)

  3.   More talkative than usual or pressure to keep talking.

  4.   Flight of ideas or subjective experience that thoughts are racing.

  5.   Distractibility.

  6.   Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.

  7.   Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments.

 Mood disturbances must be sufficient to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

 

[Source: Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC; America Psychiatric Association, 1994]; Boyer, W., and Nemeroff, C.B., Mood Disorders: Depression and Mania, In, Medicine for the Practicing Physician, (Hurst, J.W., editor-in-chief) Appleton and Lange, 1996, pp. 22-23

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 Three classes of antidepressant Medications

 

Some Contemporary Agents (Second Generation)

Serotonin-Specific Reuptake Inhibitors and Atypical Antidepressants

Possible Mechanisms of Action of Antidepressant Drugs

[Baldessarini, R. J., Drugs and the Treatment of Psychiatric Disorders: Depression and Mania In, Goodman and Gillman's The Pharmacologial Basis of Therapeutics,(Hardman, J.G, Limbird, L.E, Molinoff, P.B., Ruddon, R.W, and Gilman, A.G.,eds) The McGraw-Hill Companies, Inc.,1996, pp.436-438.

The Medical Letter on Drugs and Therapeutics, vol. 39 (issue 998) April 11, 1997, The Medical Letter, Inc., New Rochelle, N.Y.

 

Clinical advantages of serotonin-selective reuptake inhibitors (SSRI).

Considerations

Boyer, W. and Nemeroff, C. Mood Disorders: Depression and Mania, In, Medicine for the Practicing Physician, (Hurst, J.W., editor-in-chief) Appleton and Lange, 1996, p. 25.

 

Antidepressants: Major Drug-Drug and Drug Food Interactions

  •   aged meats and cheeses
  •   alcohol
  •   anchovies
  •   liver
  •   protein extracts
  •   sausages
  •   overripe figs
  •   bananas
  •   avocadoes
  •   chocolate,
  •   sour cream
  •   soy sause
  •   bean curd
  •   natural yogurt
  •   fava beans

 

 

Shannon, M.T., Wilson, B.A., Stang, C. L. In, Govoni and Hayes 8th Edition: Drugs and Nursing Implications Appleton & Lange, 1995, p.617

 

Symptoms of overdose and the treatments

Antidepressants: Management of Overdosage

Tricyclic Antidepressants

Presenting symptoms

  • brief phase of restlessness/excitement

  • tonic-clonic seizures or dystonia

  • coma with depressed respirations

  • hypoxia, hypotension

Treatment:

  • Gastric lavage early

  • Activated charcoal may be somewhat useful

  • Dialysis and diuresis not useful

  • Supportive therapy with comatose state ending in one to three days

  • Phenytoin (Dilantin)may be useful in managing cardiac tricyclic antidepressant-induced arrthythmias and may also be useful in suppression seizures.

  • Lidocaine (Xylocaine)and beta-adrenoceptor blockers may be useful in arrhythmia suppression.

  • Diazepam (Valium): useful in suppression of seizures and myoclonic/dystonic symptoms.

 

MAO Inhibitors:  Conservative Supportive Treatment may be Successful

Presenting symptoms:

  • agitation

  • hallucinations

  • hyperreflexia

  • convulsions

  • hpotension/hypertension

  • peripheral neuropathies (hydrazines)

Toxicities involve: liver, brain, and cardiovascular systems.

Baldessarini, R.J., Drugs and the Treatment of Psychiatric Disorders: Depression and Manial In, Goodman and Gillman's The Pharmacologial Basis of Therapeutics,(Hardman, J.G, Limbird, L.E, Molinoff, P.B., Ruddon, R.W, and Gilman, A.G.,eds) TheMcGraw-Hill Companies, Inc.,1996, pp.442- 443.

Antidepressant Classification

Shannon, M.T., Wilson, B.A., Stang, C. L. In, Govoni and Hayes 8th Edition: Drugs and Nursing Implications Appleton & Lange, 1995, pp. 616-619

1. Eisendrath, SJ and Lichtmacher, JE, Psychiatric Disorders, in 2008 Current Medical Diagnosis & Treatment (McPhee, SJ, Papadakis, MA, eds, Tierney, LM, Senior editor) chapter 25, pp.  923-928.  47th edition, 2008.

2. Ascher, JA, Cole, JO, Colin, JN, et al. Buproprion: a review of its mechanism of antidepressant activity. J. Clin. Psychiatry 1995; 59:112-115.

3. Horst, WD. Preskorn, SH. Mechanism of action and clinical characteristics of three atypical antidepressants: venlafaxine, nefazodone, buproprion. J. Affect Disord.  1998; 51:237-254.

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