Antidepressants+in+Psychiatric+Disorder

Antidepressants in Psychiatric Disorders

Antidepressants? Are drugs that relieve the symptoms of depression

Were first developed in the 1950s

There are approx. 30 different kinds of antidepressants available today and are of 5 main types:

− MAOIs (Monoamine oxidase inhibitors)

− Tricyclics

− SSRIs (Selective Serotonin Reuptake Inhibitors)

− SNRIs (Serotonin and Noradrenaline Reuptake Inhibitors)

− NASSAs (Noradrenaline and Specific Serotoninergic Antidepressants)

2medicalquery@torrentpharma.com

Classes of Antidepressants SNRIs: newer form of antidepressant that work on both

norepinephrine and 5-HT. They typically have similar side effects to the SSRIs.− Desvenlafaxine, Duloxetine, Milnacipram, Venlafaxine

SSRIs: work by preventing the reuptake of serotonin by the presynaptic neuron, thus maintaining higher levels of 5-HT in the synapse − Citalopram, Escitalopram, Fluoxetine, Fluvoxamine,

Paroxetine, Sertraline,

Tricyclics: block the reuptake of certain neurotransmitters such as norepinephrine (noradrenaline) and serotonin − Amitriptyline, Clomipramine, Imipramine, Nortriptyline

MAOIs: work by blocking the enzyme monoamine oxidase which breaks down the neurotransmitters dopamine, serotonin, and norepinephrine (noradrenaline).

− MAOIs can be as effective as tricyclic antidepressants, although they can have a higher incidence of dangerous side effects (as a result of inhibition of cytochrome P450 in the liver

− Isocarboxazid, Phenelzine

map of TCAs and SNRI pharmacological properties

Advantages Disadvantages / Side Effects

• Often effective in reducing panic attacks and elevating depressed mood. • Well researched. • Usually a single daily dose

Anticholinergic : dry mouth, blurred vision constipation, urinary retensionAntihistaminergic : SedationAlpha blockade : Postural hypotension

Action of antidepressants and other drugs at serotonergic synapses

Uses of Antidepressants Moderate to severe depressive illness (Not

mild depression)

Schizophrenia

Severe anxiety and panic attacks

Obsessive compulsive disorders

Post-traumatic stress disorder

Chronic pain

Eating disorders

Depression A common mental disorder that presents with

− Depressed mood − Loss of interest or pleasure − Feelings of guilt or low self-worth − Disturbed sleep or appetite− Low energy and − Poor concentration.

Major Types:− Major depressive disorder,

− Dysthymic disorder

− Bipolar disorder

− Cyclothymic

Prevalence− 20 – 25% of women (35 – 45 years)− 7-12 % of men (after 55 years)− 50 – 75 % remain undiagnosed & untreated.

Aaron M. Koenig; First line pharmacotherapies for depression – what is the best choice?;‑ POLSKIE ARCHIWUM MEDYCYNY WEWNĘTRZNEJ 2009; 119 (7-8)

Frequently prescribed antidepressants for Depression

Schizophrenia Is a psychiatric diagnosis that describes a

mental disorder characterized by abnormalities in the perception or expression of reality

Characterized by psychosis, hallucinations, delusions, cognitive defects, occupational and social dysfunction

Onset in late teens or early 20s in males; sometime later in females

Incidence : 1 - 3 %

Gender : Affects males and females equally

• Males in the early 20’s• Females in early 30’s

SchizophreniaEtiology and Pathophysiology

− Etiology Genetic predisposition Intrauterine, birth or postnatal

complications Viral CNS infections Environmental stressors (biochemical or

social)

− Pathophysiology Increased dopamine in mesolimbic

pathways causes delusions and hallucinations

Dopamine deficiency in mesocortical and nigrostriatal pathways causes negative symptoms (apathy, withdrawal)

Hallocinogens produce effect through action on 5-HT2 receptors

Schizophrenia

Positive symptoms−Hallucinations−Delusions−Disordered thinking−Disorganized

speech−Combativeness−Agitation−Paranoia

Negative symptoms−Social withdrawal−Emotional

withdrawal−Lack of motivation−Poverty of speech−Blunted affect−Poor insight−Poor judgement−Poor self-care

Antidepressants in Schizophrenia Studies show that depressive symptoms are common in

all phases of Schizophrenia

In one study, improvement in treatment scores was significantly greater in 58 schizophrenics given the neuroleptic Perphenazine after a two-week washout than in the 29 patients given placebo. Half the Perphenazine-treated group also had Amitriptyline; these showed a significantly greater improvement than the placebo group as regards flatness of effect and in other sub-scores on the Wing scale, but they did not improve significantly more than patients given perphenazine alone

Reference: Use of antidepressants in schizophrenia; BRITISH MEDICAL JOURNAL; 103715medicalquery@torrentpharma.com

Study of 35 outpatient schizophrenics who had developed true depressive symptoms showed that depressive symptoms responded better in the group given Amitriptyline together with perphenazine, but three-quarters of those receiving combined treatment had an increase in blood pressure and body weight. In another study of schizodepressives chlorpromazine alone appeared to be as good as chlorpromazine combined with amitriptyline. Thus the value of antidepressants even for schizophrenics with definite depression has yet to be firmly substantiated.

Reference: Use of antidepressants in schizophrenia; BRITISH MEDICAL JOURNAL; 1037

Antidepressants in Schizophrenia

Anxiety Anxiety disorders are extremes of normal

anxiety.

Occur when normal anxiety system becomes dysregulated - excessive, inappropriate or deficient

Causes− Genetic linkage− Structural abnormalities in the brain

− Neurochemical dysfunction

Generalized Anxiety Disorder (GAD)

Is an anxiety disorder characterized by chronic anxiety, exaggerated worry and tension, even when there is little or nothing to provoke it

Worries are accompanied by physical symptoms, especially fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, and hot flashes

Usually begins at an earlier age and symptoms may manifest themselves more slowly than in most other anxiety disorders

Reference: NPS News; ISSN 1441-7421 October 2009

Drug Therapy for GAD

Reference: NPS News; ISSN 1441-7421 October 200921medicalquery@torrentpharma.com

Antidepressant as a Generalized Anxiolytics

Recently, Venlafaxine XR became the first agent approved to treat both mood in depression and anxiety in GAD

Antidepressants are more effective than benzodiazepines for treating the uncontrollable worry associated with GAD

They do not produce tolerance or dependence

Panic Attacks Sudden, unexpected attacks –

overwhelming anxiety

Physical symptoms− Palpitations, chest pain, choking

sensation, dizziness, breathlessness, tingling in the hands and feet, sweating, faintness, nausea or abdominal distress

Emotional and behavioral symptoms− Fear of dying, losing control, going

mad, feeling of unreality

Panic Attacks

Panic attacks -Management SSRIs - Paroxetine, Citalopram

Benzodiazepines - good short term relief but high risk of dependency - Alprazolam

TCAs - Imipramine, Clomipramine

MAOIs - especially in mixed panic depressive states

Obsessive Compulsive Disorders

Repetitive unwanted obsessions or compulsive acts

Obsession is recurrent and intrusive thought, feeling, idea, image or impulses−Usually distressing−Extreme need for

orderliness−Persistent doubts

Obsessive Compulsive Disorders

Pharmacotherapy•SSRIs, Clomipramine•Augmentation with Quetiapine or Risperidone•Clonazepam

Post-Traumatic Stress Disorder

Typically occur after a traumatic event (especially crimes, war)− Symptoms : re-experiencing trauma

(dreams, flashbacks), avoidance of anything associated with trauma, and constant state of hypervigilance

Causes: Major Negative events in life− War− Childhood abuse− Accidents− Earthquakes− Floods

PTSD - management

Serotinergic TCAs

Zoloft (sertraline) has FDA approval for this indication

Phobias Intense, irrational fear of

a specific object or situation

Types of phobia:− Agoraphobia− Social phobia− Specific phobias

Antideperssants for Anxiety

Psychological therapies should be the first choice for most anxiety disorders to control symptoms and improve functioning.

If these do not provide sufficient benefit and drug therapy is needed, an antidepressant may be added− Serotonin Selective Reuptake Inhibitors (SSRIs) -

E.g. : Fluoxetine− Serotonin-Norepinephrine Reuptake Inhibitors

(SNRIs) - E.g. : venlafaxine− Atypical Antidepressants− Tricyclic Antidepressants (TCAs)− Monoamine Oxidase Inhibitors (MAOIs)

Why Antidepressants for Anxiety??

Reference: Stephen M. Stahl; Mergers and Acquisitions among PsychotropicsClinical Neuroscience Update; J Clin Psychiatry 60:5, May 1999 32medicalquery@torrentpharma.com

Antidepressants for Anxiety??

Reference: Stephen M. Stahl; Mergers and Acquisitions among PsychotropicsClinical Neuroscience Update; J Clin Psychiatry 60:5, May 1999

Eating disorders

An eating disorder is a condition which affects an individuals eating habits, either as a result of their own doing (self-inflicted), or as a bodily reaction to the consumption of food

Types:− Anorexia Nervosa (It is an obsessive fear of

gaining weight )− Bulimia Nervosa (A person with bulimia eats

a lot of food in a short amount of time)− Binge Eating (A binge eating disorder is

characterized primarily by periods of uncontrolled, impulsive, or continuous eating beyond the point of feeling comfortably full)

Epidemiology Primarily affect women and girls, boys and men are

also vulnerable

Lifetime prevalence− Anorexia nervosa: 1%− Bulimia nervosa: 1-2%− Binge-eating disorder: 2.6%

5-10% of the obese population

Women vs. men− Anorexia and bulimia nervosa

10x more common in women

− Binge eating disorder 33% of those diagnosed are men

Median age onset: − Anorexia & bulimia: 18-21 years old

Antidepressant for eating disorder

Role of Antidepressant ineating disorders

Trials have shown that binge eating and purging in people with bulimia nervosa can be reduced with antidepressant medicines

They can also improve a person’s perception about their body and weight

National Prescribing Service Limited; Australian Prescriber; 2 august 2005

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Antidepressants+in+Psychiatric+Disorder

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