Antidepressant

Aka: Antidepressant, Depression Medication

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II. Mechanism

  1. Biogenic Amine Hypothesis
    1. Depression is associated with decreased monoamine (Serotonin, Norepinephrine and Dopamine) neurotransmission
    2. Antidepressants that increase synaptic Neurotransmitter concentrations appear to improve Major Depression
    3. Delayed Antidepressant effects may be related to postsynaptic monoamine receptor downregulation
    4. In contrast, mania occurs when there is excessive monoamine neurotransmission

III. Types

  1. See Medical Management of Depression
  2. Serotonin Norepinephrine Reuptake Inhibitors (SNRI)
    1. Tricyclic Antidepressants
      1. Tertiary amines: Amitriptyline (Elavil)
      2. Secondary amines: Nortriptyline (Pamelor)
    2. Other
      1. Venlafaxine (Effexor)
    3. Tetracyclic: rarely use
  3. Serotonin Norepinephrine Reuptake Inhibitors (SNRI)
    1. Venlafaxine (Effexor)
    2. Desvenlafaxine (Pristiq)
    3. Duloxetine (Cymbalta)
    4. Levomilnacipran (Fetzima)
  4. Selective Serotonin Reuptake Inhibitors (SSRI)
    1. Paroxetine (Paxil)
    2. Fluoxetine (Prozac)
    3. Sertraline (Zoloft)
    4. Fluvoxamine (Luvox)
    5. Citalopram (Celexa)
    6. Escitalopram (Lexapro)
    7. Vortioxetine (Brintellix)
      1. New in 2013, similar to generic SSRIs, with more Nausea at 10x the cost
  5. Norepinephrine Dopamine Reuptake Inhibitor (NDRI)
    1. Bupropion (Wellbutrin, Zyban)
  6. Serotonin Antagonist and Reuptake Inhibitor (SARI)
    1. Nefazodone (Serzone)
    2. Trazodone (Desyrel)
  7. Norepinephrine Antagonist Serotonin Antagonist (NASA)
    1. Mirtazapine (Remeron)
  8. Monoamine Oxidase Inhibitor (MAO Inhibitor)
    1. Isocarboxazid (Marplan)
    2. Phenelzine (Nardil)
    3. Tranylcypromine (Parnate)

IV. Efficacy

  1. Number Needed to Treat for significant improvement of Major Depression
    1. Tricyclic Antidepressants (TCA): 7-16
    2. Selective Serotonin Reuptake Inhibitors (SSRI): 7-8
    3. Arroll (2009) Cochrane Database Syst Rev (3): CD007954 [PubMed]

V. Management

  1. See Medical Management of Depression

VI. Adverse Effects

  1. See Antidepressant Adverse Effects
  2. See Antepartum Depression

VII. Complications

  1. Serotonin Syndrome
  2. Antidepressant Withdrawal

VIII. Resources: Patient Education

  1. Information from your Family Doctor
    1. http://www.familydoctor.org/handouts/012.html

IX. References

  1. Kovich (2015) Am Fam Physician 92(2): 94-100 [PubMed]
  2. Bhatia (1997) Am Fam Physician 55(5):1683-94 [PubMed]

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