Pharmacological therapy and ECT - antidepressants

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Author:
trincam2008
ID:
275453
Filename:
Pharmacological therapy and ECT - antidepressants
Updated:
2014-06-28 17:21:32
Tags:
psy pharm
Folders:
Psychiatry
Description:
History, classification, mech of action, side-effects, indications and CI
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  1. Psychotropic (mind-altering) meds can be divided into? (5)
    • - antidepressants
    • - mood stabilizers
    • - antipsychotics
    • - anxiolytics and hypnotics
    • - other
  2. MoA of antidepressants at synaptic cleft


    • 1. TCA - blockage of both presynaptic reuptake pumps, blockage of other receptors except the 2 - Seretonin & Noradrenaline
    • 2. SSRI - selective seretonin
    • 3. SNRI - both

    • 4. MAOI - monoamine oxidase inhibitor
    • 5. RIMA - reversible inhi monoamin oxidase A

    • 6. NARI - selective NorA
    • 7. SARI - seretonin 2A/seretonin 
    • 8. NaSSA - NorA and spec serotonergic anti
  3. Monoamine synthesis
    a) seretonin (5-HT)
    b) Noradrenaline
    • a) Tryptophan -> Seretonin (5-HT)
    • b) Tyrosine - DOPA - Dopamine - Noradrenaline
  4. Classification & MoA of antidepressants
    (at least 8 & common actions)
    • - at least 8: TCA, SSRI, SNRI, MAOI, RIMA, NaSSA, NARI, SARI
    • - common action is to elevate the levels of one or more monoamineneurotransmitters in the synaptic cleft
  5. * Antidepressants
    1. Tricyclic antidepressant (TCA) & egs
    Tip: TCA -> A, C

    • - amitriptyline
    • - clomipramine
    • - imipramine
    • - lofepramine
  6. * Antidepressants
    1. Tricyclic antidepressant (TCA) & MoA
    • - presynaptic blockade of both
    •   + noradrenaline
    •   + serotonin reuptake pumps (to a lesser extent – dopamine)
    • - also blockage of muscarinic, histaminergic anda-adrenergic receptors
  7. * Antidepressants
    2. SSRI & egs
    (serotonin selective reuptake inhibitor)
    • - fluoxetine (1st arrived, 'Prozac')
    • - paroxetine
    • - citalopram
    • - sertraline
    • - fluvoxamine

    (sờ sori - bị fluox, xí ta cả lô (citalopram), sertraline)
  8. * Antidepressants
    2. SSRI & MoA
    Selective presynaptic blockade of serotonin reuptake pumps
  9. * Antidepressants
    3. SNRI & eg
    (serotonin - noradrenaline reuptake inhibitor)
    - venlafaxine

    (sunrise, vén lá fax)
  10. * Antidepressants
    3. SNRI & MoA (serotonin - noradrenaline reuptake inhibitor)
    • - Presynaptic blockade of both
    •    + noradrenaline
    •    + serotonin reuptake pumps(also dopamine in high doses)

    - but with negligibleeffects on muscarinic, histaminergic ora-adrenergic receptors (in contrast to TCAs)
  11. * Antidepressants
    4. MAOI & eg
    (monoamine oxidase inhibitor)
    • - phenelzine
    • - tranylcypromine
    • - isocaboxazid

    (mao mao, phe nào zì (phenelzine), tra nyl(on) cypro 
  12. * Antidepressants
    4. MAOI & MoA
    (monoamine oxidase inhibitor)
    • Non-selective and irreversible inhibition of monoamine oxidase A and B
    • (break down seretonin, NorA)
  13. * Antidepressants
    5. RIMA & e.gs
    (reversible inhibitor monoamine oxidase A)
    - moclobenide

    (mở clo bên này - reversible)
  14. * Antidepressants
    5. RIMA & MoA
    (reversible inhibitor monoamine oxidase A)
    ctive and reversible inhibition of monoamineoxidase A
  15. * Antidepressants
    6. NaSSA & e.gs
    (Noradrenergic and specific serotonergic antidepressant)
    - mirtazapine

    (nasa mỉa ta da (za) đầy lông (pine)
  16. * Antidepressants
    6. NaSSA & MoA
    (Noradrenergic and specific serotonergic antidepressant)
    • Presynaptic alpha 2 receptor blockade
    • (results in increased release of
    • + noradrenaline
    • + serotonin
    • from presynaptic neurons)
  17. * Antidepressants
    7. NARI & e.gs
    (selective noradrenaline reuptake inhibitor)
    - reboxetine

    (cái ná bị rỉ - cất vô hộp rebox)
  18. * Antidepressants
    7. NARI & MoA
    tive presynaptic blockade of noradrenaline(norepinephrine) reuptake pumps
  19. * Antidepressants
    8. SARI & e.gs
    (Serotonin 2A antagonist / serotonin reuptake inhibitor)
    - Trazodone

    (xa ri, tra rọi zô đồn)
  20. * Antidepressants
    8. SARI & MoA
    Which action is important in sedative andanxiolytic effect is unclear
  21. * Antidepressants
    9. Others
    • - Tetracyclic antidepressants: miansetrin
    • - Dopaminergic and noradrenergic antidepressants: bupropion, pramipexole
  22. Common side effects of SSRIs
    • - Gastrointestinal disturbance (nausea, vomiting,diarrhoea, pain) – early*
    • - Anxiety and agitation – early*
    • - Loss of appetite and weight loss (sometimes weight gain)
    • - Insomnia
    • - Sweating
    • - Sexual dysfunction (anorgasmia, delayed ejaculation)

    *Gastrointestinal and anxiety symptoms occur on initiation oftreatment and resolve with time
  23. Common side-effects of TCAs (1/4):
    - Anticholinergic:muscarinic receptor blockade
    • Dry mouth
    • Constipation
    • Urinary retention
    • Blurred vision
  24. Common side-effects of TCAs (2/4):
    a-Adrenergic receptor blockade
    Postural hypotension (dizziness,syncope)
  25. Common side-effects of TCAs (3/4):
    Histaminergic receptor blockade
    • Weight gain
    • Sedation
  26. Common side-effects of TCAs (4/4):
    Cardiotoxic effects
    QT interval prolongation, STsegment elevation, heart block,arrhythmias
  27. Why antidepressants should be used with caution in pt with epilepsy?
    Tend to lower the seizure threshold
  28. Discontinuation syndrome of antidepressants
    • - The abrupt withdrawal of any antidepressant 
    • - symptoms such as gastrointestinal disturbance, agitation,dizziness, headache, tremor and insomnia.
    • - SSRIs with short half-lives (e.g. paroxetine, sertraline) and venlafaxine are particular culprits.
    • - all antidepressants (with the exception of fluoxetine,which has a long half-life and many active metabolites)should be gradually tapered down before being withdrawn completely.
    • - Although certain antidepressants may cause a withdrawal syndrome, they do not cause a dependence syndrome or‘addiction’
  29. Drugs and food that may precipitate a hypertensive crisis in combination with MAOIs
    - the combination of MAOIs and antidepressants or opiates(especially pethidine) may result in the serotonin syndrome

    • - Tyramine-rich foods
    • - Cheese – especially mature varieties (e.g. Stilton)
    • - Degraded protein: pickled herring, smoked fish, chicken liver, hung game
    • - Yeast and protein extract: Bovril®, Oxo®, Marmite®
    • - Chianti wine, beer
    • - Broad bean pods
    • - Soya bean extract
    • - Overripe or unfresh food
    • - Drugs

    • - Adrenaline, noradrenaline
    • - Amfetamines
    • - Cocaine
    • - Ephedrine, pseudoephedrine, phenylpropanolamine(cough mixtures, decongestants)
    • - L-dopa, dopamine
    • - Local anaesthetics containing adrenaline
  30. CI of
    a) all antidepressants
    b)TCAs
    • a) mania
    • b) TCAs
    • - recent MI, arrhythmias
    • - severe liver disease
    • - high risk of overdose - cardiotoxic effects
    • - mania
  31. CIs of MAOI
    • - phaechromocytoma
    • - cerebrovascular disease
    • - hepatic impairement
    • - mania
  32. Indications of SSRIs/TCAs
    • - Depression
    • - Anxiety disorders
    • - OCD
    • SSRIs: Bullimia nervosa (fluoxetine)
    • TCAs: chronic pain, nocturnal enuresis, narcolepsy

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