Antidepressants, mood stabilizers

Question 1

Classes of antidepressants

Answer 1

SSRIs, SNRIs, Tricyclics, MAOIs, other

Question 2

Tricyclic antidepressants

Answer 2

Pros:
Time-tested, very effective
More effective in severe depression
Blood levels

Cons:
Hypotension, orthostasis
Anticholinergic side effects, weight gain
Sexual side effects
Dangerous in overdose: 10 day supply can be lethal

Question 3

MAOIs

Answer 3

Rarely prescribed today (first ever discovered antidepressant)

Monoamine Oxidase Inhibitors

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 4

How long antidepressants take to have effect?

Answer 4

4-12 weeks for a pt with depression to get better after starting therapy

Probably due to alteration in gene expression and not just the neurotransmitter changes

Question 5

About what percent of pts respond to antidepressants?

Answer 5

67%

Question 6

SSRIs

Answer 6

Pro:
Safe, effective
Multiple indications: GAD, social anxiety, panic, OCD, PTSD, PMDD

Cons: 
Diarrhea
Nausea
Jitteriness/Anxiety
Sexual side effects
Drug interactions: P450 inhibition

Question 7

SNRIs

Answer 7

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

Pros:
Some evidence more effective
Safe, better tolerated than TCAs
Multiple indications

Cons:
Sexual side effects
Sweating
Increased diastolic blood pressure
Withdrawal syndrome
Flu-like, “electric shocks”

Question 8

Buproprion

Answer 8

Pros:
No sexual side effects
Weight neutral

Cons:
Increased anxiety, jitteriness, ineffective in panic
Insomnia
Higher seizure risk: contraindicated in eating disorder patients and those with seizure disorder

Question 9

Mirtazapine

Answer 9

Pros:
Helpful with insomnia
Rapid anti-anxiety effect
Low incidence of sexual side effects

Cons:
Daytime somnolence
Weight gain

Question 10

What are the most effective antidepressants?

Answer 10

All have comparable response rates

Question 11

Treatment of mania

Answer 11

VERY effective treatments

multiple medications effectively treat it

Mood stabilizers and atypical antipsychotics

Question 12

Treatment of bipolar depression

Answer 12

Very difficult to treat because have to stabilize mania, stabilize depression, and prevent future episodes; quetiapine, lurasidone, lithium and possibly lamotrigine are best treatments thus far

Hard to prevent recurrence of depression

Antidepressant use in bipolar disorder is controversial and not well proven.

Question 13

Prevention of future episodes

Answer 13

lithium, aripiprazole, olanzapine, lamotrigine

Question 14

Medications for bipolar disorders

Answer 14

Anti-manic, Antidepressant and Mood Stabilizing Drugs

quetiapine, lurasidone, lithium and possibly lamotrigine

Question 15

Lithium

Answer 15

Pros:
Best studied, best proven drug
Effective anti-manic, resonalbe preventative agent, some antidepressant effect
Anti-suicidal
Neuro-regenerative
Cheap

Cons:
Tremor, nausea, diarrhea, taste, thirst, cognitive dulling
Narrow therapeutic window (0.6-1.2 mEq/l)
Toxic/lethal in overdose
Renal effects
Decreased urine concentration (20-30% of pts)
Diabetes insipidus
5-10% Hypothyroidism

Question 16

Divalproex Sodium

Answer 16

Acute loading

Pros:
Individualized treatment (based on weight)
Rapid loading (20-30 mg/kg)
Safe and effective

Cons:
not proven as preventative
Weight gain, sedation
Not effective in bipolar depression

Question 17

Atypical/Second Generation Antipsychotics

Answer 17

Pros:
All are anti-manic
Reasonably safe & effective
Different routes of administration

Cons: 
Weight gain
Risk of diabetes
Risk of increased cholesterol/lipids
Expensive