1. Serotonin Syndrome SS life threatening emergency from excess CNS 5HT (serotonin) caused by combining 5HT enhancing drugs or giving SSRIs too close to discontinuation of MAOIs. Prozac is the SSRI most likely to cause the syndrome because of its long half-life

2. Serotonin Syndrome Confusion, disorientation, mania Autonomic dysfunction Neuromuscular activity – muscle rigidity – hyperreflexia – myoclonic jerking – Ataxia

3. Common side effects SSRI Insomnia, agitation Headache Weight loss Sexual dysfunction

4. Other side effects Priapism with trazodone (Desyrel) Prolonged penile erection. Hepatic failure with nefazodone (Serzone) – Jaundice, anorexia, GI complaints

5. Monoamine Oxidase Inhibitors (MAOI) diet restrictions tyramine-containing foods – cheese, fermented or aged protein, pickled or smoked fish – Chianti & vermouth wines, draft beer – Yeast, liver, sausages, pepperoni, salami, canned ham

6. MAOIs Hypertensive Crisis Sudden elevation of b.p. Explosive occipital headache Head & face flushed Palpitations, chest pain Sweating, fever, nausea, vomiting Dilated pupils, photophobia

7. Treatment of MAOI crisis Hold MAOI dose Do not lie down IM chlorpromazine (Thorazine) IV phentolamine --blocks norpinephrine

8. Mood Stabilizing Drugs Lithium (1.0-1.5) for acute mania) – Renal – Thyroid – Physical, ECG, fasting bl. Sugar, CBC (Diet adequate in salt)

9. Lithium side effects Drowsiness, dizziness, headache Dry mouth, thirst GI upset Fine hand tremors Hypertension Polyuria, dehydration Wt. gain

10. Mood Stabilizing Drugs Anticonvulsants – Carbamazepine (Tegretol) – Valproate (Depakote)

11. Tegretol, Depakote, and Klonapin inhibit kindling & enhance inhibitory neurotransmitter GABA kindling: brain becomes sensitized to stressors & responds without event – bipolar – panic – craving