ANTIDEPRESIVOS
TRICCLICOS (HETEROCCLICOS) INHIBIDORES DE LA RECAPTACIN DE SEROTONINA INHIBIDORES DE LA MONOAMINO OXIDASA (MAO) ESTABILIZANTES DEL HUMOR TRIAZOLOBENZODIACEPINAS
ANTIDEPRESIVOS
AGONISTAS PARCIALES DEL RECEPTOR 5-HT1A INHIBIDOR DE LA RECAPTACIN DE SEROTONINA Y ANTAGONISTA DEL RECEPTOR 5-HT2 INHIBIDOR NO SELECTIVO DE LA RECAPTACIN DE NEUROTRASMISORES AMINERGICOS TERAPIA ELECTROCONVULSIVA (TEC)
INHIBIDORES DE LA M.A.O EFECTO DE LOS TRICCLICOS EFECTO DE LAS ANFETAMINAS REACCIONES PSICTICAS EFECTO DE LA RESERPINA
Norepinephrine
Alpha Receptors
Serotonin
Serotonin
Serotonin (5-HT) cells are mostly located in the gut (98%) with only 2% of serotonin cells in brain Serotonin cell bodies are located in brainstem raphe nuclei and project to cortex Serotonin systems:
D system originates in the dorsal raphe nucleus but does not form synapses (5-HT as a neuromodulator) M system originates from the median 4.11 raphe nucleus and these varicosities form synapses
NEUROVEGETATIVOS: Trastornos del sueo Trastornos del apetito Trastornos de la volicin Trastornos sexuales Ritmos diurnos anormales 10 dias a 2 semanas
PSICOMOTORES:
AGITACIN O LENTIFICACIN 3-4 SEMANAS (MEJORIA 7-14 DIAS)
AFECTIVOS
TRISTEZA (MELANCOLIA) INCAPACIDAD DE EXPRESIN LENTAMENTE Y POR ETAPAS
COGNOCITIVOS:
CONCENTRACIN MEMORIA ATENCIN APRENDIZAJE
DIMENSIN EXISTENCIAL
ESTABLECER DIFERENCIAS
DUELO:
CULPA/REPROCHE SINT SOMATICOS MENOS DE SEIS MESES FUNCIONAL NO SUICIDIO
DEPRESIN
CULPA/REPROCHE SINT SOMATICOS MAYOR A SEIS MESES DEBILITAMIENTO PROGRESIVO POTENCIALMENTE SUICIDA
ESTABLECER DIFERENCIAS
DEMENCIA
INSIDIOSA PROLONGADA AFECTO VARIABLE DEF COGNITIVAS CONSISTENTES RESP ERRONEAS EN EVAL NEUROL AFASIA, APRAXIA, AGNOSIA
DEPRESIN
ABRUPTA* CORTA* AFECTO DEPRESIVO DEF COGNITIVO NO PERSISTENTES NO DEFICIT NEUROLOGICO
Ludiomil
FARMACODINAMIA
EFECTOS SECUNDARIOS
LOS EFECTOS SECUNDARIOS SE CORRELACIONAN MEJOR CON EL PERFIL FARMACODINAMICO QUE STE CON LOS EFECTOS CLNICOS
EFECTOS SECUNDARIOS
ANTICOLINERGICOS
SEQUEDAD DE LA BOCA VISIN BORROSA CONSTIPACIN RETENCIN URINARIA CONFUSIN
EFECTOS SECUNDARIOS
ANTIHISTAMNICOS
SEDACIN
SEROTONINRGICOS
SEDACIN Y/O ACATISIA
ADRENRGICOS
TEMBLOR, EXCITACIN PALPITACIONES GANANCIA DE PESO
INDICACIONES
Enfermedad cardiaca concomitante Intolerancia a los efectos secundarios anticolinrgicos Alto riesgo de sobredosis voluntaria Aumento de peso excesivo La sedacin no es aconsejable Trastorno obsesivo-compulsivo asociado
EFECTOS SECUNDARIOS
Gastrointestinales: nausea, flatulencia, diarrea S.N.C: insomnio, inquietud, irritabilidad, euforia, agitacin, temblores, distona* Sexuales: eyaculacin retardada, anorgasmia
SINDROME SEROTONINERGICO
INHIBIDORES DE LA MAO
NO SELECTIVOS
ISOCARBOXAZI DA TRANILCIPROMI NA
SELECTIVOS
MOCLOBEMIDA BROMFAROMINE
EFECTOS SECUNDARIOS
Autonmicos: boca seca, mareo, estreimiento, dificultad en la miccin, hipotensin postural Centrales: cefalea, temblores, parestesia Otros: edema en tobillos, hepatotoxicidad
Trazodone (Desyrel)
Strong 5-HT2A antagonist, relatively weak 5-HT reuptake inhibitor Also an 1-adrenergic and H1 antagonist
Highly protein bound, metabolized by 3A4, to mCPP (active metabolite), overall halflife < 24 hours.
Bottom Line:
Almost always used for insomnia. Watch for orthostatic hypotension Caution about priapism Remember, its an antidepressant!
NEFAZODONE
Nefazadone (Serzone)
Approved in 1995, developed to improve upon trazadone: no priapism and less sedating. Unfortunately, cases of liver failure 1:200,000-300,000 has limited its use. A generic still available.
Time to liver injury 2 weeks to 6 months. Check LFTs
Strong 5-HT2A antagonist, relatively weak 5-HT reuptake inhibitor Weaker alpha 1 adrenergic and H1 antagonist compared to trazadone.
Mirtazapine (Remeron)
Approved for MDD (may work faster than SSRIs) Also used for SSRI augmentation, anxiety, nausea Moderately protein bound, metabolized by 1A2, 2D6, 3A4. Half-life 20-40 hours. Eliminated primarily via urine
Bottom Line:
Can be good inpatient choice (helps sleep, depression, appetite, no drug interactions) Not popular first choice for outpatients (oversedation, weight gain). Avoids sexual dysfunction. Used for augmentation
NDRI (norepinephrine, dopamine receptor inhibitor) Inhibits reuptake of NE, lesser extent DA but exact mechanism controversial. Initial release of IR delayed due to seizures, re-released in 89(rarely used). In 96 SR released (now generic) and in 03 XL form released. FDA approved for MDD, smoking cessation (Zyban) Also used for ADHD, SSRI induced sexual dysfunction, SSRI augmentation Highly protein bound, bupropion and its active metabolites metabolized by 2B6. Half life approx 21 hours. Mild 2D6 inhibitor.
Bottom Line:
Activating so caution for depression with comorbid panic/anxiety disorders. Can be useful for anergic depression or when you wish to avoid sexual dysfunction. Relatively ineffective for anxiety disorders. Commonly used to augment SSRIs. Screen for seizure history.
VENLAFAXINE
SNRI (serotonin, norepinephrine reuptake inhibitor) At low doses (75 mg-150 mg), primarily SSRI At moderate/high doses, also NE reuptake inhibitor FDA approved for MDD, social phobia and GAD At higher doses, some evidence of higher remission rate for MDD compared to SSRIs. Some evidence: chronic pain, panic disorder, ADHD, OCD Poorly protein bound, XR formulation slows absorption but half-life still only about 15 hours. Metabolized by 2D6 to active Odesmethylvenlafaxine (ODV) Primarily eliminated in urine.
Bottom Line:
Potentially modestly more efficacious antidepressant at high doses but inconsistent. Watch for discontinuation syndrome. Consider checking BP at doses > 225 mg qd Commonly used after initial trial of SSRI.
cymbalta (Duloxetine)
Approved for MDD and diabetic peripheral neuropathy Some evidence for chronic pain, anxiety disorders, urinary stress incontinence. Highly protein bound, metabolized by 2D6 and 1A2, Half life 12 hours Moderate inhibitor of 2D6
Bottom Line:
Newest antidepressant (04) Marketed for physical symptoms of depression but not unique: tertiary TCAs, venlafaxine Some evidence for improved remission vs SSRIs but jury still out.
TERAPIA ELECTROCONVULSIVA
INDICACIONES
RIESGO SUICIDA SINTOMAS CATATNICOS
Remission
Relapse
Recovery
Recurrence
Response Relapse
65 to 70% STOP Rx
Acute Continuation Maintenance Phase (3 months+) Phase (6-12 months) Phase (years) Time
Gastrointestinal Urogenital
Erectile dysfunction, ejaculation disorder, anorgasmia, priapism
45
TRIAZOLOBENZODIACEPINAS
ALPRAZOLAM ADINAZOLAM
GEPIRONA IPSAPIRONA
Dysphoric or Negative Mood and Behavior Depression Anxiety Irritability Hostility Violence or suicide Cognitive Symptoms
Racing thoughts Distractibility Disorganization Inattentiveness
Delusions Hallucinations
Bipolar I, Classic Mania Borderline Personality Disorder The Bipolar Spectrum Bipolar I, Depressed
Cyclothymic Disorder
Bipolar II Disorder
Bipolar I
Mania + Major Depression
Bipolar IV
Anti-depressantinduced Hypomania
Bipolar II
Hypomania + Major Depression
Bipolar V
Recurrent Major Depression with a Family History of Bipolar Disorder
Bipolar III
Cyclothymia
Bipolar VI
Unipolar Mania
Lifetime prevalence: 0.81.6% Gender influence: men = women Recurrent illness in >90% of patients Factors :episode frequency and severity of residual symptoms between episodes Number of episodes may affect subsequent treatment response 25-50% of patients attempt suicide > 1 time
Any medication that stabilizes acute manic symptoms, does not induce depression, and prevents against future relapses into (mania or depression)
Mood-Stabilizing Agents
Valproate (Depakene, Depakote*, Depakote ER) Carbamazepine(Tegre tol)/ Oxcarbazepine(Trilept al) Gabapentin (Neurontin) Topiramate (Topamax) Lamotrigine (Lamictal)
Novel antipsychotics
Risperidone (Risperdal) Ziprasidone (Geodon) Olanzapine (Zyprexa)* Clozapine (Clozaril) Quetiapine (Seroquel)
*FDA approved for acute mania.
Typical antipsychotics
CARBONATO DE LITIO
EVIDENCIA CLINICA USO CLINICO FARMACODINAMIA PROBABLE
EFECTOS SECUNDARIOS
TEMPRANOS
sequedad de la boca sed diuresis temblor pirosis, sabor metlico debilidad, fatiga
EFECTOS SECUNDARIOS
TARDIOS temblor leve polidipsia, poliuria aumento de tamao del tiroides hipotiroidismo alteraciones de memoria cambios en el EKG
TOXICIDAD
Vmito Diarrea Temblor intenso Ataxia, disartria Calambres musculares, hiperreflexia Confusin, coma Insuficiencia renal Shock cardiovascular
INTERACCIONES
Haloperidol Diurticos tiazdicos Relajantes musculares AINES metronidazol, estreptomicina iECAS, metildopa antipsicticos, ISRS, TECAR
No neurological impairment No substance abuse Relatively few illness episodes (i.e., no rapid cycling, mixed, other novel features)
Predictors
of response