Antidepressants

class
dose
indication
1. Selective Serotonin Reuptake inhibitors (SSRIs)
Fluoxetine
20-60mg po mane

1st line for MDD

Paroxetine
20-50mg po mane
Citalopram
20-40mg po mane
Escitalopram
10-20mg po mane
Sertraline
50-200mg po mane
Fluvoxamine
50-150mg po bd
2. Serotonin and noradrenaline reuptake inhibitors (SNRI)
Venlafaxine
75-300mg po mane

2nd line MDD

augmentation
Duloxetine
60-120mg po mane

resistant MDD

MDD w/ pain sx
3. Selective Noradrenaline reuptake inhibitors (NRIs)
Reboxetine
4-5mg po bd

Ineffective alone as
antidepressant

Augmentation
in
MDD

4. Noradrenaline Dopamine receptor inhibitors (NDRIs)

bupropione
150-300mg po mane

2nd line MDD

augmentation

MDD + fatigue +
hypersomnia

Pt w/ sexual dysfx on
other rx

Smoking cessation
5. Tricyclic antidepressants/tetracyclic antidepressants (TCA /TTAD)
TCA

2nd
line
antidepressant
d/t
amitriptyline
30-200mg po nocte
S/E
clomipramine
10-250mg po nocte

lethal
arrhythmia
Imipramine
10-200mg po nocte
with
overdose
Trimipramine
30-300mg po nocte

effective
lofepramine
140-210mg po nocte
antidepressant
TTADs
Maprotiline

75-200mg po nocte

6. Monoamineoxidase inhibitors/ reversible inhibitors of MAO (MAOI/ RIMA)

MAOI

Powerful
antidepressant
Tranylcipromine
5-100mg po bd

Not 1st line

RIMA
moclobemide
75-300mg po bd
7. Noradrenalin & specific serotonin antagonists (NASSAs)
mirtazapine
15-45mg po nocte

1st/2nd line Rx MDD

augmentation MDD

MDD+insomnia
8. Serotonin antagonist/reuptake inhibitor (SARI)
trazodone
75-300mg po bd

NOT 1st line MDD rx

ineffective MDD rx
alone

Side effect

Sexual dysfx (decreased

libido, anorgasmia)
N/V/D
Headache
insomnia

GI discomfort
Sexual dysfx
Sedation
Hypotension + tachy
Dry mouth

Urinary hesitancy
Constipation
Headache
Nasal congestion
Perspiration
Dry mouth
Dizziness
Decreased libido
insomnia

Headache
Insomnia
nausea

Anticholinergic
S/E,
often
severe
(constipation,
urinary
retention, dry mouth,
blurred vision)
Sedation
Orthostatic hypotention
Cardiac
arrhythmia
(more with TCA)

Orthostatic hypertension
Insomnia
Weight gain
Oedema
Sexual dysfunction

Sedation
Weight gain
Increased appetite
Dry mouth

Sedation
Orthostatic hypotension
Dizziness

Misc.

Mostly used
Hardly used

Tyramine
induced
HTN crisis

9. Melatonin antagonist (MAs)

agomelatine
25-50mg po nocte
10. other
vortioxetine

class
1. Classic
Lithium

5-20mg po daily

2. Anticonvulsants
Valporate
250-1250mg po
bd

carbamazepine

Starting:
200mg po bd
Titrate
200mg at a time
Maintenance:
300-600mg po bd

MDD + insomnia

Headache
nausea

Not 1st line MDD

MDD + insomnia

Dizziness
nausea

MDD
New drug

constipation
N/V
hyponatraemia
Serotonin syndrome
Abnormal bleed

Mood stabilizers
indication

dose
Safe starting dose
500mg po mane

1st line Bipolar ds +

maintenance phase
Rx+Pre manic episode
Mixed + rapid cycling
(not 1st line)
?Rx not Prevention of
BP depression

Before starting Rx
UKE
Creatinine
FBC (leucocytosis)
TSH
bHCG
ECG

Side effect

N/V/D

Weight gain, oedema

Postural tremor
Renal:

Polyuria + polydipsia

hypoK+ (flat T wave or

inversion; sinus
dysrhythmia, heart
block, sycope episode)

non-specific interstitial
fibrosis (>10 years use)
Thyroid:

hypothyroidism

hyperthyroidism

goiter & exophthalmos

teratogenic

ebsteins anomaly
Toxicity

tremor, dysarthria, ataxia

N/V/D

CV changes, renal dysfx

Myoclonus, fasciculation

Seizure, LOC, coma

Rx: stop lithium, push IV

fluids EMERGENCY!

1st line BP (&maintenance)

Rx + px manic
ToC mixed & rapid cycling
Not depressive BPD
Advantage: can rapid
titrate

Sedation
Weight gain
Thrombocytopaenia
Hair loss at high dose
Tremor
PCOS
Teratogenic - neural
tube

Fallen out of favour

no longer routine use
only specific cases
same use profile as
valproate but less effective

exfoliative dermatitis
Hyponatremia & SIADH
GI S/E
Hepatitis
Rarely Agranulocytosis/
aplastic anaemia (BM
suppression)
Teratogenic - neural

monitoring

Dose according to
trough levels of
lithium in blood
(before next dose)
Start low dose
increase slowly
Narrow therapeutic
index:
0.5-0.9
maintenance
~1.5 Rx acute
manic
< = ineffective
> = toxic/lethal

Monitoring
UKE (1 , 6 )
FBC ()
TSH(1 , 6 )
bHCG ()
ECG(1 , )
Lithium levels (4 , 3-6
)

LFT (before starting Rx

to check for imparired
liver fx since
metabolized. Then 6
monthly to check for
fatal hepatotoxicity
(paeds)
bHCG
Pelvic sonar
LFT (impaired liver fx,
hepatitis)
UKE (hypoNa+, SIADH
FBC (BM)
bHCG


lamotrigine

3. Atypical
Olanzapine

tube
Interfere with other drug
metabolism
Dizziness, ataxia
Blurred vision, diplopia
Headache
Sedation
N/V
SJS ( if rash develops,
stop immediately)

Starting:
25mg po nocte
titrate:
25mg / 2 weekly
(decreased SJS)
maintain:
100-200mg po
nocte

1st line BP depression

effective Rx depressive ep
TOC px depressive ep
Effective px manic ep
NOT rx manic ep
? rapid cycling & mixed

10-20mg po nocte

Effective:

Manic ep

Px manic ep

Rx depressive
NOT effective Px
depressive ep
Consider cycling/mixed

severe MS, sedation,

dizziness, dry mouth,
constipation, dyspepsia,
akathasia
MS, severe sedation,
dizziness, postural
hypotension
Headache, sedation,
akathasia, agitation, anxiety,
nausea, dyspepsia, NOT MS

Quetiapine

300-800mg po
nocte

Aripiprazole

10-30mg po nocte

fasting glucose +
lipogram, BP, waist
circumference, weight:
baseline
1month
6 monthly
more regular for
olanzapine if sings of
metabolic sd (MS)

SEROTONIN SYNDROME

Medical emergency potentially fatal

Raised plasma serotonin concentrations secondary to co-administration of antidepressants

Usually: SSRI + MAOI/lithium

Sx appear in specific order as condition worsens

o Diarrhoea
o Restlessness
o Extreme agitation, hyperreflexia, autonomic instability
o Myoclonus, seizures, hyperthermia, uncontrollable shivering, rigidity
o Delirium, coma, status epilepticus, cardiovascular collapse, death

Rx
o Transfer to ICU
o Stop causative drug
o Supportive care + cooling blanket
o Nitroglycerin, cyproheptadine, chlorpromazine, dantrolene, BZ, anticonvulsants
o Muscle relaxant + mechanical ventilation
ANTIDEPRESSNAT DISCONTINUATION SYNDORME

Can occur following abrupt discontinuation of antidepressants

Commonly SSRIs and medication with short t1/2 (e.g. paroxetine)

Sx
o Dizziness, weakness, nausea
o Rebound depression, anxiety, insomnia, poor concentration
o Headache, migraine like sx, paraesthesias
o Upper respiratory sx
o Usualy appear about 6 weeks after antidepressant discontinuation
o Usually resolve spontaneously after 3 weeks

Prevention
o Taper slowly before discontinuation

Rx
o Restart medication at appropriate dose > taper > discontinue
o If patient was on SSRI, start fluoxetine (because long half life) > taper > stop slowly to minimize chance of sd
o Rx symptomatically
TYRAMINE
INDUCED
caused by intake of tyramine containing foods whilst on medication

HYPERTENSIVE

CRISIS

Aged cheeses, fish, biltong, marmite, sauerkraut, beer, chiati wine, liquor