Psychopharm Chapter 9

MAOIs

Clients must adhere to a careful diet while taking MAOIs to avoid toxic interactions. Avoid foods that have tyramine in them. Monoamine is present in body and metabolizes tyramine. If you don't have the monoamine in your body due to taking MAOI then it can have severe consequences. Because of this, generally TCAs or SSRIs are first and second line of treatment.

Exogenous depression

Also known as environmental or reactive depression. This type of depression is situational. Symptoms are linked to a precipitating event such as divorce, unemployment, medical diagnosis, etc. Medication intervention is often used though unwarranted in many cases.

Endogenous depression

Also known as melancholy. Symptoms of depressed mood are directly related to internal factors (neuron and neurotransmitter dysfunction). Often treated with medications or ECT. This type of depression is due to internal causes.

Monoamine Oxidase Inhibitors

Discovered in the late 1950s. Wasnt used in humans until after TCAs were though. Considered a third line treatment of depression (a very effective one at that). MAOIs block the action of the enzyme (monoamine oxidase) that deactivates certain neurotransmitters(stop from doing its destructive action). Side effects include weight gain, orthostatic hypotension, sexual dysfunction, insomnia, and nausea.

Atypical and Dual-Action Antidepressants

Duloxetine (Cymbalta): Also a dual-action antidepressant (newer on market). Used to treat physical pain in addition to depression. Reboxetine (Edronax) and Tianeptine (Stablon): Non-FDA approved antidepressants used in Canada and several European nations. May be bought online from there. Appear to affect norephinephrine selectively. Possible future direction for antidepressants.

Females tend to

Express anxiety, guilt and indecisiveness. Experience reverse neurovegetative symptoms such as hypersomnia and increased appetite.

Males tend to

Express self-criticalness Experience neurovegetative symptoms such a insomnia and decreased appetite.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Fairly new on the market (late 1980s). Specifically target serotonin (reuptake inhibition). Because of the decreased overdose (lethality) risk and absence of food interactions, SSRIs quickly became the first line of treatment for depression. Can interact with some antipsychotics, TCAs, and benzodiazepines.

Overview

Includes a broad class of drugs used to treat "unipolar" depression. Antidepressants are among the most commonly prescribed of ALL medicines. Despite their popularity, questions remain regarding their basic therapeutic efficacy, particularly with long-term use. Despite being legend drugs, abrupt cessation of virtually all antidepressants often creates a "discontinuation syndrome" (different from addictive drug withdrawal syndromes).

MAOIs

MAOIs have a 10-14 day "washout" period if a client is switching to one of the other classes of antidepressants. Hyperserotonergic syndrome (aka "serotonin syndrome") may occur if the transition is not carefully made. This syndrome can be fatal. The switch from Prozac (an SSRI) to an MAOI requires a 5-week washout period due to its extended half-life. Prozac has an extra long half-life. MAOIs interact with almost every other med that is available for any other condition.

SSRIs

May trigger a manic episode in those who are predisposed. Ex- if someone is predisposed to bipolar these may trigger it. In 2004, a "black box warning" was issued regarding increased suicide risk among children and adolescents taking SSRIs. Most common side effects include GI complaints, nausea, agitation, headaches, sexual dysfunction and weight gain. Used to treat premature ejaculation.

Atypical and Dual-Action Antidepressants

Mirtazapine (Remeron): effective antidepressant impacting norephinephrine. Extreme drowsiness and weight gain are most notable side effects. Trazadone (Desyrel) & Nefazodone (Serzone): very similar to one another in chemical structure. Serzone is well tolerated; but, has a rare side effect of fatal liver toxicity. It's a very small possibility but has been pulled from shelves. Trazadone is known for its sleep-inducing side effects (treatment for insomnia). A rare side effect of trazadone is priapism.

Antipsychotic Medications

Not covered in this chapter: The numerous neuroleptic (antipsychotic) medications that are being used in conjunction with antidepressants to treat depression: Abilify Seroquel Geodon Zyprexa Risperdal Invega These are antipsychotic meds. There are no blackbox warning label. They are being used more and more as a front line treatment for depression.

SSRIs

Prevents the reuptake of serotonin. Does not effect norephinephrine. No overdose risk like TCAs and no food risk like MAOIs. When SSRIs came on the market, most general practitioners felt comfortable enough to prescribe.

Tricyclic Antidepressants (TCAs)

TCAs were the mainstay of pharmacological treatment of depression in 1960s-1990s. Discovered in the 60s and lost favor in the 90s. Primary action: serotonin and norepinephrine reuptake inhibition (third line treatment). Blocks the recycling action. Overdoses on TCAs are very likely fatal. If its reached the small intestine then there's nothing that can be done. This was the 1st generation antidepressant and is very effective. Not on label anymore because its been around so long.

Side effects of TCAs

There are three categories of these: 1. Anticholinergic: dry mouth, eyes, nose, etc. Dries up your mucuos membranes. 2. Cardiovascular: cardiac arrhythmias; orthostatic hypotension. Interrupts heart rate, causes dizziness that is extreme. 3. Antihistaminic: drowsiness/weight gain. Contributes to dry sinus cavities, causes drowsiness like Benadryl. Slow, creeping weight gain.

Antidepressant Medications

This category includes: 1. Tricyclic antidepressants (TCAs) 2. Monoamine oxidase inhibitors (MAOIs) 3. Selective (specific) serotonin reuptake inhibitors (SSRIs) 4. Atypical and dual-action antidepressants (including non-FDA approved medications).

Atypical and Dual-Action Antidepressants

This loosely grouped category of drugs treat depression in a variety of unique ways. They don't fit into the TCA, MAOI or SSRI. Bupropion (Wellbutrin/Zyban): affects dopamine and norephinephrine reuptake. Causes less sexual dysfunction and can be combined with some SSRIs to counteract sexual side effects. Also used for smoking cessation and more recently ADHD treatment.

SSRIs

Used to treat numerous mental health disorders besides depression (a very marketable class of drugs): Anorexia and bulimia nervosa Obsessive compulsive disorder Body dysmorphic disorder PTSD GAD and Social Anxiety Disorder Panic disorder

Atypical and Dual-Action Antidepressants

Venlafaxine (Effexor) & Desvenlafaxine (Pristiq): chemically very similar, "dual action" antidepressants. Serve as serotonin and norepinephrine reuptake inhibitors (SNRIs). Has large side effect profile including dangerous elevations in blood pressure. Very commonly causes a disturbing discontinuation syndrome if not carefully tapered. Because it affects two neurotransmittersthe discontinuation syndrome is twice as bad. Both have extended release formations. Doctors prescribe tablets so they can be broken into smaller pieces to avoid this syndrome.