Antidepressants & Mood Stabilizers

Question 1

Antidepressant Treatment

Answer 1

• While SSRIs and SNRIs almost immediately block the reuptake of serotonin and norepinephrine, antidepressant effects take weeks to work
• ALL current pharmacological treatments target neurotransmitter systems
• ALL current treatments have a 4‐16 week delay before achieving antidepressant effect
• only about a third of patients treated initially with an SSRI will achieve remission
• All FDA‐approved antidepressants have comparable response rates in placebo‐controlled, double‐blindclinical trials.

Question 2

Types of Antidepressants

Answer 2

1) Selective serotonin reuptake inhibitors (SSRIs)
2) Serotonin‐Norepinephrine Reuptake Inhibitors (SNRIs)
3) Tricyclic antidepressants (TCAs)
4) Monoamine Oxidase Inhibitors (MAOIs)
5) Other (mixed actions).

Question 3

SSRIs

Answer 3

Block 5HT pre‐synaptic reuptake pump

Pros: Safe, effective, multiple indications
Cons: sexual side effects, drug interactions: P450
inhibition

Question 4

SNRIs

Answer 4

Block NE and 5‐HT reuptake pumps

Pros: better tolerated than TCAs

Cons: Sexual side effects, withdrawal syndrome (flu‐like, “electric shocks”)

Question 5

TCAs

Answer 5

Block reuptake of 5‐HT and NE, (and, to lesser extent, DA), as well as H1, muscarinic cholinergic receptors and alpha‐1

Pros: effective, time tested, more effective in severe depression, can monitor blood levels

Cons: Hypotension, orthostasis, anticholinergic side effects, weight gain, sexual side effects, dangerous in overdose (10 day supply can be lethal)

Question 6

MAOIs

Answer 6

Irreversibly inhibit MAO‐A and MAO‐B, increasing levels of 5‐HT and NE.

Pros: Can be very effective in non‐responsive patients, especially atypical depression, time‐ tested.

Cons: Hypotension, orthostasis, dry mouth, constipation, urinary retention, sexual side effects, weight gain, hypertensive crisis‐‐Tyramine reaction

Question 7

Buproprion

Answer 7

Increases whole‐body NE, weakly blocks reuptake of DA

Pros: No sexual side effects, weight neutral, activating

Cons: Increased anxiety, higher seizure risk (contraindicated in eating disorder patients and those with seizure disorder)

Question 8

Mirtazapine

Answer 8

Blocks 5‐HT2A, 5‐HT2C, 5‐HT3, ‐2‐adrenergic receptors

Pros: : Helpful with insomnia

Cons: weight gain

Question 9

Medications for Bipolar Disorder

Answer 9

• Lithium has best established evidence for preventing further episodes
• An ideal drug would be anti‐manic, anti‐depressive and prevent future episodes
• All atypical antipsychotics, lithium, divalproex and carbamazepine are anti‐manic agents.

Question 10

Lithium

Answer 10

Pros: Best studied, best proven drug

Cons: Narrow therapeutic window, toxic/lethal in overdose, renal effects, diabetes insipidus, hypothyroidism.

Question 11

Divalproex Sodium

Answer 11

Pros: rapid loading, safe and effective

Cons: Not proven as preventative agent

Question 12

Atypical Antipsychotics

Answer 12

Pros: All are anti‐manic, reasonably safe & effective

Cons: Weight gain, risk of metabolic effects/diabetes, risk of increased cholesterol/lipids, expensive