ANTIDEPRESSANTS

INTRODUCTION
Antidepressant drugs are primarily used in the treatment of major depressive
illness, anxiety disorders, the depressed phase of bipolar disorder, and psychotic
depression. Off- label uses of antidepressants include the treatment of chronic pain,
migraine headaches, peripheral and diabetic neuropathies, sleep apnea,
dermatologic disorders, panic disorder, and eating disorders. Although the
mechanism of action is not completely understood, antidepressants somehow
interact with the two neurotransmitters, norepinephrine and serotonin, that regulate
mood, arousal, attention, sensory processing, and appetite.
Antidepressants work by balancing brain neurotransmitters level to ease
depression. Generally speaking, it takes about 2 weeks for the drugs to start
working and about 6-9 months for the whole therapy, or depend on the severity of
illness as some people will need to take them longer.

CLASSIFICATION OF ANTIDEPRESSANTS
1. Tri cyclic antidepressants (TCAs)
2. Tetra cyclic antidepressants
3. Selective serotonin re-uptake inhibitors (SSRIs)

4.
5.
6.
7.

Serotonin and nor epinephrine re-uptake inhibitors (SNRIs)

Serotonin receptor modulators (SRMs)
Monoamine oxidase inhibitors (MAOIs)
Lithium salts

The cyclic compounds became available in the 1950s and for years were the first
choice of drugs to treat depression even though they cause varying degrees of
sedation, orthostatic hypotension (drop in blood pressure on rising), and
anticholinergic side effects. In addition, cyclic antidepressants are potentially lethal
if taken in an overdose. During that same period, the MAOIs were discovered to
have a positive effect on people with depression. Although the MAOIs have a low
incidence of sedation and anticholinergic effects, they must be used with extreme
caution for several reasons:
A life-threatening side effect, hypertensive crisis, may occur if the client
ingests foods containing tyramine (an amino acid) while taking MAOIs.
Because of the risk for potentially fatal drug interactions, MAOIs cannot be
given in combination with other MAOIs, tricyclic antidepressants, meperidine
(Demerol), CNS depressants, many antihypertensives, or general anesthetics.

 MAOIs are potentially lethal in overdose and pose a potential risk in clients with
depression who may be considering suicide.
The SSRIs, first available in 1987 with the release of fluoxetine (Prozac), have
replaced the cyclic drugs as the first choice in treating depression because they are
equal in efficacy and produce fewer troublesome side effects. The SSRIs and
clomipramine are effective in the treatment of OCD as well. Prozac Weekly is the
first and only medication that can be given once a week as maintenance therapy for
depression after the client has been stabilized on fluoxetine. It contains 90 mg of
fluoxetine with an enteric coating that delays release into the bloodstream.
INDICATIONS
Mainly relieve the symptoms of depression or bipolar disorder such as
depressed mood, worthlessness, lack of motivation or concentration.
Antidepressants are also used for anxiety disorder, phobic disorder (such as social
phobia or agoraphobia), panic attack, obsessive-compulsive disorder, bulimia
nervosa, nocturnal enuresis, chronic pain, neuropathic pain and post-traumatic
stress disorder.
MECHANISM OF ACTION OF ANTIDEPRESSANT
The precise mechanism by which antidepressants produce their therapeutic
effects is not known, but much is known about their action on the CNS. The major
interaction is with the monoamine neurotransmitter systems in the brain,
particularly norepinephrine and serotonin. Both of these neurotransmitters are
released throughout the brain and help to regulate arousal, vigilance, attention,
mood, sensory processing, and appetite. Norepinephrine, serotonin, and dopamine
are removed from the synapses after release by reuptake into presynaptic neurons.
After reuptake, these three neurotransmitters are reloaded for subsequent release
or metabolized by the enzyme MAO. The SSRIs block the reuptake of serotonin, the
cyclic anti- depressants and venlafaxine block the reuptake of norepinephrine
primarily and block serotonin to some degree, and the MAOIs interfere with enzyme
metabolism. This is not the complete explanation, however; the blockade of
serotonin and norepinephrine reuptake and the inhibition of MAO occur in a matter
of hours, whereas antidepressants are rarely effective until taken for several weeks.
The cyclic compounds may take 4 to 6 weeks to be effective, MAOIs need 2 to 4
weeks for effectiveness, and SSRIs may be effective in 2 to 3 weeks. Researchers
believe that the actions of these drugs are an initiating event and that eventual
therapeutic effectiveness results when neurons respond more slowly, making
serotonin available at the synapses (Lehne, 2006).
According to the monoamine hypothesis of depression postulates a deficiency
in serotonin or norepinephrine neurotransmission in the brain. Most of the currently
used antidepressants work by slowing the removal of both norepinephrine and
serotonin from the brain, thus increasing the availability of these neurotransmitters.

As a result, they are efficacious for patients whose depression is caused by the
imbalance of either norepinephrine or serotonin.
ADVERSE EFFECTS
Side effects of different antidepressants are as follows:
1) Tricyclic & tetracyclic antidepressants: Dizziness, headache, sweating,
tremor, somnloence, palpitation, dry mouth, constipation, blurred vision, difficulty
passing urine, and orthostatic hypotension. Other less-common adverse effects
include seizure, liver dysfunction, ECG changes and abnormal blood count.
2) SSRIs: Nausea, vomiting, gastrointestinal discomfort, somnolence, dry mouth,
tremor, headache, sweating, sexual dysfunction and weight loss, etc. Occasionally,
some patients may experience excitement, anxiety, insomnia, restlessness or
seizure.
3) SNRIs: Similar to SSRIs. May cause hypertension at high doses.
4) SRMs: Somnolence, tremor, headache, constipation, weight gain and
hypotension. Some patients may develop seizure, abnormal liver function tests and
blood disorder, etc.
5) MAOIs: Dizziness, headache, nervousness, gastrointestinal disturbance, etc.
May interact with tyramine-rich food or drinks, as a consequence inducing sweating,
vomiting and hypertensive crisis. E.g. pigeon, alcoholic beverages, cheese, chicken
and beef liver, chocolate or cheese, etc.
6) Lithium salts: Bitter taste, dry mouth, tremor, polyuria, fatigue and weight gain.
Other less-common side effects include hyperthyroidism, hypothyroidism, ECG
changes, raised anti-diuretic hormone concentrations, renal failure or leucocytosis.

COMMONLY-USED ANTIDEPRESSANTS
1) TCAs:

Amitriptylin
Imipramine
Clomipramine
Nortriptyline
Desipramine
Dothiepin
Doxepin
Trimipramine
Melitracen

2) Tetracyclic antidepressants:

Mianserin
Maprotiline

3) SSRIs:

Fluoxetine
Paroxetine
Sertraline
Fluvoxamine
Citalopram
Escitalopram

4) SNRIs:

Venlafaxine/ Venlafaxine XR
Duloxetine

5) SRMs:

Mirtazapine

6) MAOIs:

Moclobemide
Phenelzine
Isocarboxazid
Tranylcypromine

7) Lithium salts:

Lithium carbonate.

CAUTIONS WHEN TAKING ANTIDEPRESSANT

1) Patients with or have a history of suicidal behavior should avoid taking SSRIs.
2) Do not expect the antidepressants to work right away. It usually takes about 2
to 3 weeks for the antidepressants to start working.
3) To avoid side effects. Do not drink alcohol when taking these medications.

DRUG INTERACTIONS
An uncommon but potentially serious drug interaction, called serotonin
syndrome (or serotonergic syndrome), can result from taking an MAOI and an SSRI
at the same time. It also can occur if the client takes one of these drugs too close to
the end of therapy with the other. In other words, one drug must clear the persons
system before initiation of therapy with the other. Symptoms include agitation,
sweating, fever, tachycardia, hypotension, rigidity, hyperreflexia, and, in extreme
reactions, even coma and death (Krishnan, 2006). These symptoms are similar to
those seen with an SSRI overdose.
Client Teaching Clients should take SSRIs first thing in the morning unless
sedation is a problem; generally, paroxetine most often causes sedation. If the client
forgets a dose of an SSRI, he or she can take it up to 8 hours after the missed dose.
To minimize side effects, clients generally should take cyclic compounds at night in
a single daily dose when possible. If the client forgets a dose of a cyclic compound,
he or she should take it within 3 hours of the missed dose or omit the dose for that
day. Clients should exercise caution when driving or performing activities requiring
sharp, alert reflexes until sedative effects can be determined. Clients taking MAOIs
need to be aware that a life- threatening hyperadrenergic crisis can occur if they do
not observe certain dietary restrictions. They should receive a written list of foods to
avoid while taking MAOIs. The nurse should make clients aware of the risk for
serious or even fatal drug interactions when taking MAOIs and instruct them not to
take any additional medication, including over-the-counter preparations, without
check- ing with the physician or pharmacist.

FOODS (CONTAINING TYRAMINE) TO AVOID WHEN TAKING MAOIS

Mature or aged cheeses or dishes made with cheese, such as

lasagna or pizza. All cheese is considered aged except cottage
cheese, cream cheese, ricotta cheese, and processed cheese
slices.
Aged meats such as pepperoni, salami, mortadella, summer
sausage, beef logs, meat extracts, and similar products. Make
sure meat and chicken are fresh and have been properly
refrigerated.
Italian broad beans (fava), bean curd (tofu), banana peel,
overripe fruit, and avocado.
All tap beers and microbrewery beer. Drink no more than two
cans or bottles of beer (including nonalcoholic beer) or 4
ounces of wine per day.

Sauerkraut, soy sauce or soybean condiments, or marmite

(concentrated yeast).
Yogurt, sour cream, peanuts, Brewers yeast, and monosodium glutamate (MSG).

SERTRALINE
Brand and Generic Names:
Brand name = Zoloft
Tablets: 25 mg, 50 mg, 100 mg
Liquid: 20 mg/ml
Generic name = Sertraline

USES
Sertraline is an antidepressant medication that works in the brain. It is
approved for the treatment of Major Depressive Disorder (MDD), Posttraumatic Stress Disorder (PTSD), Premenstural Dysphoric Disorder (PMDD),
as well as Obsessive Compulsive Disorder (OCD) in adults and children.
MDD occurs when a person experiences several of the following symptoms
concurrently, for at least two weeks: "low" or depressed mood (for example,
sad, empty, tearful); decreased interest in most or all activities; changes in
appetite (usually decreased); changes in sleep (usually poor sleep); loss of
energy; feeling worthless/guilty/ hopeless/ helpless; psychomotor agitation or
retardation (i.e. thoughts/movements speeding up or slowing down); difficulty
concentrating, and thoughts of death (suicidal thinking).
PTSD occurs when a person experiences a traumatic event (e.g. assault,
combat experience) and then later experiences flashbacks, nightmares, feels
on edge and avoids situations that remind them of the event.
PMDD occurs when a woman experiences symptoms including irritability,
mood changes, bloating, tension, breast tenderness and sadness in
association with the menstrual cycle.
OCD occurs when a person experiences the following symptoms at the same
time: obsessions (unwanted, recurrent and disturbing thoughts) and
compulsions (repetitive, ritualized behaviors that the person feels driven to
perform in order to lessen the anxiety produced by the obsessions).
IMPORTANT INFORMATION

After starting sertraline, symptoms gradually decrease over a period of

weeks. Sleep and other physical symptoms may improve before there
is noticeable improvement in mood or interest in activities. Once
symptoms are under control, MDD usually requires longterm treatment

to help prevent the return of depressive symptoms. Only your

healthcare provider can determine the length of generic name
treatment that is right for you.
Do not stop taking sertraline or change your dose without talking to
with your healthcare provider first.
Stopping sertraline abruptly may result in one or more of the following
withdrawal symptoms: irritability, nausea, dizziness, vomiting,
nightmares, headache and paresthesias (prickling, tingling sensation
on the skin).
Because depression is also a part of Bipolar illness, people who take
antidepressants may be at risk for "switching" from depression into
mania. Symptoms of mania include "high" or irritable mood, very high
self esteem, decreased need for sleep, pressure to keep talking, racing
thoughts, being easily distracted, frequently involved in activities with
a large risk for bad consequences (for example, excessive buying
sprees).

SPECIAL CONSIDERATIONS

Sertraline is usually taken once daily (at the same time each day). It
may be taken with food to minimize stomach upset. If a dose is taken
twice a day, take one in the morning and the second dose at noon.
While the dose usually ranges from 50mg to 200 mg, your healthcare
provider will determine the dose that is right for you based upon your
response.
When used for PMDD, paroxetine may be taken continuously (every
day) or intermittently (usually starting 14 days prior to the anticipated
onset of menstruation through the first full day of menses and
repeating with each cycle). Your healthcare provider will determine the
regimen that is right for you.
If you are taking the sertraline oral concentrate, mix your prescribed
dose with 4 ounces (oz) of water, ginger ale, lemon-lime soda,
lemonade or orange juice. Take it immediately after mixing it with your
beverage. Do not mix it with anything other than the liquids listed. Do
not mix your dosage in advance. A slight haze may appear after
mixing; this is normal.
Note that caution should be exercised with latex sensitivity, as the
dropper dispenser provided with sertraline oral concentrate contains
dry natural rubber.
If you miss a dose of sertraline, take it as soon as you remember
unless it is close to when your next dose is due. If you missed a dose of
medication and it is close to the time of your next dose, skip the

missed dose and take your next dose at the regularly scheduled time.
Do not double your next dose or take more than your prescribed dose.
Avoid drinking alcohol or using illegal drugs while you are taking
antidepressant medications because the beneficial effects of the
medication may be decreased and adverse effects may be increased
(e.g. sedation).

OVER DOSAGE
If an overdose occurs, whether intentional or accidental, immediate medical
attention may be necessary. Call your doctor or emergency medical service (911).
You may also contact the poison control center (1-800-222-1222).
Symptoms of overdose include

Drowsiness
Nausea
Vomiting
abdominal pain
tremor
slow heart rate
seizures

A specific antidote does not exist.

POSSIBLE SIDE EFFECTS
Side effects with sertraline are generally mild and are similar to those
reported with other SSRI antidepressants. The most commonly reported side effects
are increased sweating, sleepiness, insomnia, nausea, diarrhea, tremor, dry mouth,
loss of strength, headache, weight loss or gain, dizziness, and restlessness. If you
experience side effects after starting sertraline they will often improve over the first
week or two as you continue to take the medication. Sexual side effects such as
problems with ejaculation may also occur, and often do not diminish over time.
TIME OF ACTION
While depressed mood and lack of interest in activities may need up to 4-6
weeks to improve, disturbances in sleep, energy, or appetite may show some
improvement within the first 1-2 weeks. Improvement in these physical symptoms

can be an important early signal that the medication is working. Like other
medications used for anxiety disorders (e.g. panic disorder, GAD and social anxiety
disorder) sertraline may take several weeks before it is fully effective. It is important
to give the medication sufficient time before judging whether or not it will work for a
given person.
DRUG INTERACTIONS
o

o
o

Sertraline should not be taken with or within two weeks of taking

monoamine oxidase inhibitors (MAOIs). These include phenelzine
(Nardil), tranylcypromine (Parnate), isocarboxazid (Marplan) and
selegeline (Emsam).
Although rare, there is an increased risk of serotonin syndrome when
sertraline is used with other medications that increase serotonin such
as other antidepressants, migraine medications called triptans (e.g.
Imitrex) and the analgesic tramadol (Ultram).
Always let your doctor know what other prescription, over-the-counter,
and herbal medications you are taking.
Sertraline Oral Concentrate should NOT be taken in combination with
disulfiram (Antabuse) due to the alcohol content of the concentrate.

Conclusion
So far we discussed about the Antidepressants and the drug of choice
SERTRALIN. I hope you all understood the topic and gained good knowledge
regarding Antidepressants.

BIBLIOGRAPHY
1. Mary C Townsend (2013), Psychiatric mental health Nursing, eight
edition, FA Davis Publications.
2. R.Sreevani(2007), Mental Health and Psychiatric Nursing, Second
edition, Jaypee medical Publishers.
3. Niraj Ahuja(2006), A Short text book of psychiatry, seventh edition,
Jaypee Brothers Medical Publishers.
4. K.Lalitha (2010), Mental Health Psychiatric Nursing, Second Edition,
CBS publishers.
5. Bimla Kapoor (2012), Text Book of Psychiatric Nursing, student edition,
KPH publishers.
6. Sujatha Sethi (2008), Textbook of Psychiatry, third edition, Elseiver
Publishers.

7. Norman. L. Keltner (2010), Textbook of Psychiatric Nursing, sixth

edition, Mosby Publishers.

Net reference

www.scribd.com
www.slideshare.net
www.authorstream.org
www.wikipedia.net
www.mayoclinic.net

DRUG
PRESENTATI
ON
ON

SUBMITTED TO:

SR.JOSEPHINE
M.Sc.,(N), LECTURER
OLH COLLEGE OF NURSING

SUBMITTED BY:

R.SUBI MOL
M.Sc.,(N) I YEAR
OLH COLLEGE OF NURSING

SUBMITTED ON:

19/06/15