1. Drugs for Depressive Disorders
Kaukab Azim, MBBS, PhD

2. Drug List Antidepressants Tricyclics Atypicals MAO inhibitors SSRIs
SNRIs
Non Selective
Selective
Imipramine
Amitriptamine
Clomipramine
Trazodone
Bupropion
Mirtazapine
Phenelzine
Selegiline*
Fluoxetine
Paroxetine
Sertraline
Citalopram
Venlafaxine
* This drug will be covered in another lecture

3. Classification of Depressive Disorders (from DSM IV text revision)
Type
Features
Major depressive disorder
(endogenous depression – about 20% of all depressions)
Depression is autonomous and is unresponsive to changes in life. Biological factors seem important (family history).
It can occur as a single episode or may be recurrent.
Dysthymic disorder
A mood disorder with chronic (long-term) depressive symptoms that are present most of the day, more days than not, for a period of at least two years
Depressive disorder not otherwise specified
Any depressive disorder that does not meet the criteria of a specific disorder. Examples are
Minor depressive disorder
Recurrent brief depressive disorder

4. Pharmacology of Antidepressants
Mechanism of action
Short-term mechanisms
The molecular action of most antidepressants is an increase availability of NE and/or 5-HT in the synaptic cleft of brain neurons, or an altered response of these monoamine receptors. This is most likely due to the following mechanisms:
Tricyclic antidepressants (TCADs)
Blockade of reuptake of 5-HT and NE.
Monoamine oxidase inhibitors
Non selective inhibition of both MAO A and MAO B (Phenelzine).
Selective inhibition of MAO B. (Selegiline).

5. 3.Atypical ( also called heterocyclic) antidepressants (HEADS)
Mechanisms are often unclear but in most cases the final result is an effect on monoamines or monoamine receptors.
4.Selective serotonin reuptake inhibitors (SSRIs)
Selective blockade of the reuptake of 5-HT (at therapeutic doses about 80% of the activity of the transporter is inhibited)
5.Selective serotonin & norepinephrine reuptake inhibitors (SNRIs)
Blockade of the reuptake of 5-HT and NE.

6. Pharmacology of Antidepressants
Mechanism of action
Long-term mechanisms
Over time the increase availability of monoamines in the synaptic cleft likely causes a down-regulation of postsynaptic CNS receptors (mainly adrenergic and serotonergic). This occurs after 1-4 weeks of treatment when the therapeutic effect becomes evident.
Long term changes ultimately increase BDNF(Brain derived neurotrophic factor) which increases neurogenesis, mainly in the hippocampus.

7. Pharmacology of Antidepressants
Pharmacological effects
All available antidepressants are equally effective in the general depressed patient population.
All antidepressants have the same delayed onset (1-4 weeks) of therapeutic effects.
Some central and many peripheral effects of antidepressants result from blockade of serotonergic, adrenergic, cholinergic and histaminergic receptors.
Pharmacokinetics and administration
Variable oral bioavailability ( )
High or very high Vd.
Extensive metabolism by the liver (some metabolites are active).
Half-lives are long (8-36 hours). Fluoxetine has a half life of about 50 hours and an active metabolite with a half life of about 10 days.
Administration: PO, IM , IV, transdermal patch (selegiline).

8. Tricyclics SSRIs SNRIs Heterocyclics
Reuptake and Blocking Activity and Receptor Blocking Activity of Antidepressants
Drug
Amine pump block
Receptor Block
5-HT NE DA
5-HT2
Alpha-1 M H1
Tricyclics
Imipramine ++ +
0/+
Amitriptyline
+++
Clomipramine
Heterocyclics
Trazodone
Bupropion
Mirtazapine
Alpha2
SSRIs
Fluoxetine
Paroxetine
Citalopram
SNRIs
Venlafaxine

9. Heterocyclic (atypical) Antidepressant TRAZODONE
Mechanism of action
The drug is thought to act primarily as an antagonist at 5-HT2-A and 5-HT2-C presynaptic receptors, so increasing serotonin release.
Adverse effects
Drowsiness (up to 40%, likely related to blockade of 5-HT2 A, alpha-1 and H1 receptors).
Postural hypotension
Xerostomia (up to 30%)
Priapism(A persistent painful erection), sexual dysfunctions.
Therapeutic uses
Depression (as a second choice drug, mainly in patients with agitation and insomnia).
As an unlabeled hypnotic, since it is not associated with tolerance or dependence.

10. Heterocyclic (atypical) Antidepressant BUPROPION
Mechanism of action
It is still poorly understood. It stimulates the release and blocks the reuptake of NE and DE. The drug is closely related to diethylpropion (an amphetamine-like drug).
The drug has virtually no direct effects on the serotonin system.
Adverse effects
Insomnia (up to 30%), tremor (up to 20%),
Seizures (dose-dependent effect).
Appetite reduction, weight loss (up to 28 %)
Xerostomia, constipation (.10%)
Contraindications
Current or past epilepsy
Conditions predisposing to a low threshold for seizures (head trauma, alcohol misuse, diabetes, etc)
Use of certain drugs (theophylline, neuroleptics, glucocorticoids)
Therapeutic uses
Depression (second choice drug, or as an adjunct with other therapies)
Attention deficit hyperactivity disorder (second choice drug).
Smoking cessation (20-25% of success)

11. Heterocyclic (atypical) Antidepressant MIRTAZAPINE
Mechanism of action
Blockade of presynaptic alpha-2 receptors, which results in increased release of norepinephrine from noradrenergic nerve endings, and of serotonin from serotonergic nerve endings.
Blockade of 5-HT2A/C presynaptic receptors.
(It is not known which one of those two actions is more important for the antidepressant effect)
Blockade of H1 receptors (which likely mediates the sedative effects)
Adverse effects
Sedation and drowsiness (up to 40%), dizziness.
Constipation (10%), appetite stimulation, weight gain (up to 15%)
Therapeutic uses
Depression (second choice drug, but sometimes highly effective)

12. Adverse Effects of Antidepressants
All antidepressants increase the risk for suicide in patients 25 and under. Since failure to start treatment is also a risk for suicide, pharmacological and cognitive behavioral therapy are recommended with close supervision.

13. Adverse effects of tricyclic antidepressants
CNS effects
Drowsiness (the most common CNS effect), sedation, lassitude(Heaviness), fatigue, dysphoria, dizziness
Tremor, paresthesias, seizures (tricyclics lower the seizure threshold)
Pseudoparkinsonism (rare)
Autonomic effects
Anticholinergic effects (memory impairment, xerostomia, blurred vision, constipation, urinary retention)
Cardiovascular effects
Postural hypotension
Cardiac arrhythmias, due to antimuscarinic and quinidine-like actions [patients with long Q-T intervals are at greater risk]
Cardiomyopathy (after long-term use).

14. Adverse effects of tricyclic antidepressants
Other adverse effects
Weight gain (mainly with paroxetine). The mechanism is unknown
Sexual dysfunction
SIADH(Syndrome of inapropriate anti-diuretic hormone) secretion (rare)
Over dosage
Tricyclics have a narrow therapeutic index. Manifestations include agitation, delirium, hyperpyrexia, convulsions, coma, cardiac arrhythmias, circulatory collapse

15. Adverse effects of MAO inhibitors
Postural hypotension (common), edema.
Headache, insomnia, nightmares, nervousness.
Switch into mania ( about 10% of patients with bipolar disorders)
Weight gain
Sexual dysfunction (the highest rates of all the antidepressants).
Dangerous interactions with certain foods and with serotonergic drugs.
Hypertensive crisis is rare but can be lethal.

16. Adverse effects of SSRIs and SNRIs
GI effects
Anorexia, nausea and vomiting (these are the most common reason for discontinuation, but usually dissipated in a week),
Diarrhea (up to 20%) (due to increased serotonergic activity in the gut)
CNS effects
Sexual dysfunction (up to 50%)
Sleep disturbances (up to 30%) (insomnia, more vivid and memorable dreams, morning sleepiness).
Seizures (in patients at risk)
Extrapyramidal symptoms (tremor, akathisia(Involuntary movements), dystonias) (rare).

17. Adverse effects of SSRIs and SNRIs
Other adverse effects
Weight gain (mechanism unknown)
SIADH (rare)
Serotonin syndrome
SSRI (mainly fluoxetine and paroxetine) are inhibitors of the cytochrome P450 system and therefore can increase the effects of several drugs given concomitantly.
Discontinuation syndrome (abrupt discontinuation of an SSRI or SNRI can cause a variety of symptoms that can be quite distressing. These include dizziness, nausea and vomiting, flulike symptoms, irritability and anxiety.)

18. Antidepressant induced Sexual Dysfunction
Incidence
Overall frequency 30-50%.
Incidence seems the highest with SSRIs/SNRIs (mainly paroxetine and fluoxetine) and the lowest with bupropion and mirtazapine.
Pathophysiology
Serotonin is mainly an inhibitory neurotransmitter in the CNS
Symptoms and signs
In males: erectile dysfunction, priapism, delayed ejaculation
In females: decreased vaginal lubrication and clitoral congestion.
In both sexes: decreased libido, partial or complete anorgasmia(Excitement)
Therapy
Reduction to minimal effective dose (often difficult to find)
Changing antidepressant
Adding drugs which improve sexual function (sildenafil, dextroamphetamine, methylphenidate, amantadine, etc)

19. The Serotonin Syndrome
Clinical course and prognosis
Upon discontinuation of the offending drug most cases resolve within 24 hours, but the syndrome can be fatal (likely because of malignant hyperthermia).
Therapy
For mild cases: discontinuation of the offending drug.
For more serious cases:
Benzodiazepines for agitation and somatic effects.
Serotonin antagonists (cyproheptadine) or atypical neuroleptics with serotonin blocking activity (like olanzapine).
Beta-blockers for tachycardia and autonomic instability.
Dantrolene for hyperthermia.

20. Contraindications and Precautions of Antidepressants
Tricyclics and heterocyclics
Seizure disorders, Parkinson’s disease
Suicidal ideation
Cardiac disease ( Long Q-T intervals, arrhythmias, myocardial infarction, etc.)
Glaucoma
Gastroesophageal reflux disease, hiatal(opening OR aperture) hernia
Prostatic hypertrophy
Pregnancy (tricyclics are included in FDA pregnancy risk category D)
Children
Elderly (antimuscarinic effects may be greatly enhanced)

21. Contraindications and Precautions of Antidepressants
SSRIs, SNRIs
Seizure disorders
Suicidal ideation
Hepatic disease (liver clearance can be decreased)
Anorexia (SSRIs can decrease hunger)
Sleep disturbances
Concurrent therapy with other antidepressants, benzodiazepines, betablockers, methadone, etc.
Children (about 1 out of 50 children become more suicidal)
Pregnancy (only paroxetine is classified in FDA pregnancy risk category D)

22. Therapeutic Uses of Antidepressants
Most antidepressants are of equivalent efficacy in patients with major depressive disorder, when administered in comparable dose.
When one antidepressant is ineffective the addition of another antidepressant can be useful (so called augmentation therapy)
Drugs used effectively in augmentation therapy include lithium, bupropion, buspirone, lamotigrine and triiodothyronine.
A maintenance therapy with an antidepressant should be maintained for least 9-12 months.
Approximately 65-70% of patients with varying types of depression improve with drug therapy compared with 30-40% who improve with placebo.