1. ANTIDEPRESSANTS &
Mood Stabilizers

2. Antidepressants
Actions:
Block the reuptake of serotonin and norepinephrine
(neurotransmitters) so that more are available in the
brain to transmit messages.

3. Antidepressants
Indications:
 Recurrent depressive disorders
 Psychomotor retardation
 Depression with no clear precipitating event
 Family history of depression
 Chronic pain
 Eneuresis

4. Antidepressants
 Have a long half life and can often be given once a
day.
 Therapeutic effects of some may not be seen until
3-4 weeks.

5. Three classifications
SSRIs/ SNRIs
Tricylcics
Mono-amine Oxidase Inhibitors

6. A. Selective Serotonin reuptake
Inhibitors (SSRIs)
Fluoxetine HCL (Prozac)
 Non-tricyclic, less sedation, fewer side effects
Sertraline HCI (Zoloft)
 Lower risk of toxicity in overdose, fewer side
effects, shorter half-life than prozac

7. SSRI Antidepressants (cont’d.)
Paroxetine HCI (Paxil):
Effectiveness comparable to Imipramine
(Tofranil), shortest half-life, safer for
elderly.
Fluvoxamine (Luvox)
Citalopram (Celexa)
Escitalopram oxalate (Lexapro)

8. SSRIs
 Block transport mechanism that returns
unbound serotonin left in synaptic cleft
into the presynaptic neuron
 Terminates transmission of the
message carried by that receptor
 When blocked, more serotonin is
available to the postsynaptic receptor

9. A. Serotonin & norepinephrine
reuptake inhibitor SNRIs
 Effexor (Venlafaxine)
 Inhibits serotonin & norepinephrine re-uptake
 Side effects include:
 dizziness, migraine, weight gain
Pristiq (Desvenlafaxine)
 Serzone (Nefazadone)
 Trazodone HCL (Desyrel)

10. Norepinephrine-Dopamine
Antagonist
Bupropion Hycrochloride
(Wellbutrin)
 Increases norepinephrine and dopamine
 Provides mild dopamine reuptake
 Blocks reuptake of norepinephrine
 Does not affect serotonin reuptake
 Does not inhibit monoamine oxidase

11. Side Effects SSRIs and SNRIs
 Weight gain
 Impotence and ejaculatory problems
 Arousal problems

12. B. Trycyclic Antidepressants
TCAs
Imipramine…….Tofranil
Desipramine……Norpramine, Pertofrane
Amitriptyline……Elavil, Endep
Nortriptyline……Pamelor, Aventyl
Protriptyline……Vivactil
Doxepin…………Sinequan

13. Trycyclic Antidepressants
 Affect norepinephrine, serotonin
acetylcholine and histamine receptors
 Increase availability of norepinephrine,
serotonin
 Inhibit transport back into the
presynaptic neuron

14. Side Effects: TCAs
Anticholinergic effects: Common and troublesome
in tricyclics: interfere with patient compliance.
 dry mouth  sweating
 constipation  drowsiness
 urinary hesitancy/retention  blurred vision
Cardiovascular: Postural hypotension, tachycardia,
heart conduction defects.

15. – TCAs Side Effects
Anticholinergic effects:
 Closed angle glaucoma worsened
 Toxic: confusion, psychosis
Other:
Weight gain, lowered seizure threshold, EPS
Overdose: 1000 – 4000 mg is fatal

16. TCAs Side effects
Managing Side Effects of Tricyclic Antidepressants
(Cont’d.)
If these dangerous side effects occur, advise the patient
either to call provider stop the medication, or reduce the
dosage.
 Orthostatic hypotension
 Marked, persistent sedation
 Atropine-like psychosis
 Cardiovascular conduction defect
 Seizures
 Severe anticholinergic effect: urinary retention, etc.

17. C. Mono-amine Oxidase
Inhibitors MAOIs
phenelzine….…………Nardil
isocarboxazide ……….Marplan
tranylcypromine………Parnate

18. MAO Inhibitors
Actions: Monamine oxidase is an enzyme responsible
for destroying epinephrine, norepinephrine and
serotonin. MAO inhibitors block this enzyme. The
effect is CNS stimulation and increased psychomotor
activity.
 symptoms relieved in 2-4 weeks
 Potential hypertensive crisis it certain foods or
medicines ingested

19. MAOIs
 Dietary restrictions necessary: foods high in
tyramine must be avoided: aged cheese, chicken
liver, beer, Chianti wine, cold or sinus medicines, diet
pills, blood pressure regulating meds. Severe
atypical headache is usually the first sign
Side effects: autonomic: orthostatic hypotention,
dizziness, increased appetite anticholinergic effects are
rare.

20. Other Antidepressant
Medications
Psychostimulants
Methylphenidate Hydrochloride (Ritalin)
Dextroamphetamine Sulfate (Dexedrine)
Pemoline (Cylert)
Source: Gomez (1993)

21. Serotonin Syndrome
 Occurs when serotonin excitement
occurs
 A second antidepressant is given before
the first has cleared-need 3 weeks
 Overdose of any classification

22. Serotonin syndrome
 Altered mental state
 Fever
 Tachycardia
 Tremors
 High or low blood pressure
 Clonus

23. Mood Stablilizers
 Lithium
 Antic-convulsants

24. Lithium
 Effective in manic excitement and preventative for
manic and depressive recurrences in bipolar 1 patients.
 Also used in other psychiatric disorders that do not
respond to other drug therapies. Can lead to toxic
reactions which may be fatal.
 Blood level monitoring is necessary to maintain in
therapeutic range.
 Therapeutic levels range from .7 to 1.5. Higher levels
are used to treat manic or psychotic excitement.

25. Lithium
Common Indications:
Acute Mania
Bipolar Prophylaxis
Possibly Effective:
Bulimia
Alcohol Abuse
Aggressive Behavior
Schizoaffective disorder

26. Lithium
Mechanism of Action Adverse Effects
Unclear
 Excessive drug levels
Dosing
Narrow therapeutic  Therapeutic drug levels
index Drug Interactions
Monitor blood levels
 q 2-3 days initially  Diuretics
then
 q 1-3 months  Anticholinergic drugs
 levels must be
below 1.5mEq/L

27. Lithium
Side effects:
Neuromuscular and CNS: tremor (fingers) cog wheeling
and mild parkinsonism possible. sluggishness and forgetfulness
treated by decreased dose.
GI: Chronic nausea, diarrhea, take with food.
Weight gain and endocrine effects: Increased appetite and
excessive thirst may cause weight gain - transitory
Decreased thyroid levels: Thyroid medication may be necessary.
Renal: polyuria and polydypsia may occur. Dose of drug
should be lowered.

28. Lithium
Allergic rashes – may be due to some ingredient in
the capsule. Drug form can be changed to liquid
citrate. Cause birth defects

29. Lithium
Common Causes for Increased Lithium Level:
Decreased sodium intake
Diuretic therapy
Decreased renal functioning
Fluid-electrolyte loss (sweating, diarrhea,
dehydration)
Medical illness
Overdose

30. Anti-convulsants
– used to promote mood stabilization
Carbamazepine (Tegratol): Used in patients who do not
respond to lithium. More effective for rapid-cycling
bipolar patients (4 or more affective episodes per year).
Blood levels should be monitored weekly for the first
eight weeks. Dose should be adjusted to maintain a serum
levels of 6-8 mg/L.

31. Anti convulsants
Side effects: sedation, mal coordination (common)
agranulocytosis, aplastic anemia (rare) regular
blood counts unnecessary . Watch for fever and
sore throat.
Can cause increased liver enzymes but serious
hepatic problems rare.
Associated with birth defects.

32. Anti convulsants
Valproate (Valproic acid) – Depakene, Depakote used in
manic and schizoaffective patients (treatment resistant)
Improvement occurs in 1-2 weeks. Blood levels should be
obtained every few days until 50 mg/l is reached.
Side effects – Major concern – severe hepatotoxicity (may
be fatal).
Liver function tests should be done every month.
Decreased platelet levels can occur.
Associated with neural tube birth defects.
Very toxic when taken in suicide attempt.

33. Anti-convulsants
 Lamitrogine- Lamictal
 Anit-convulsant used for type 2 BPD
 Side effect- rash, nausea, vomitting and
diarrhea.

34. Other Mood Stabilizers(cont’d.)
Clonazepam (Klonopin) – Benzodiazepine which is
useful in treating acute mania
Side effects: sedation, atoxia, disinhibition effect.