Maryam Tabatabaee M.DAssistant professor of psychiatry

No one drug is certain to produce clinical improvement in all patients.

All drugs have side effects

Side effects are unavoidable

Be familiar with the more common and serious adverse effects

Side effects cause :

compliance and QOL

HARM

Duration of side effects:

Nausea with SSRIs is transient

Dry mouth with TCAs is persistent

Patient related factors:

past treatment responseresponse in family memberconcurrent medical or psychiatric

disorder

Dosing

time of dosingmaximum dosageduration of treatment

Combination

Monotherapy is ideal

Special population

childreneldery: start low, go slow, full dosagemedically ill patients

Antidepressant Mood stabilizer Anxiolytics Antipsychotics

TCAs

SSRIs

MAOIs

Other

FIRST CHOISE

Least preferred usage: Sexual dysfunctions secondary refractiveness consistent insomnia agitation

Fluoxetine Cap 10 , 20

Citalopram Tab 20 , 40

Sertraline Tab 50 , 100

Fluvoxamine Tab 25, 50 , 100

Adverse effects :HeadacheYawning Agitation Sexual dysfunction GI disturbanceInsomnia or hypersomnia

Imipramine 150-300 Amitriptyline Clomipramine 130-250 Trimipramine Doxepine Nortriptyline 50-150 Desipramine

Least preferred :

cannot tolerate sedation, constipation ,over weight,

Dementia suicidal patients cardiac patients

Preferred usage:

Pain migraine fibromyalgia severe depression sedative hypnotics

Adverse effects :

Dry mouthOther anticholinergic effectsSedationCardiacHematologic

Preferred usage:

second line atypical refractory compliant patient with panic attacks

Least preferred:

noncompliant first line for

insomniac agitated

A.RENAL IMPAIREMENT

TCA level monitoring ↦

Fluoxetine and Serteraline no adjustment↦

B.HEPATIC IMPAIREMENT

TCA level monitoring↦

SSRI safe, but lower dosage,1/2 in cirrhosis↦

C.EPILEPSY

TCA lower seizure threshold,SSRI lower risk,↦

Bupropione contraindicated,fluvoxamine and carbamazpine↦

D.ENDOCRINE

treatment then antidepressant,fluoxetine improve insulin act

E.IATROGENIC DEPRESSION:

Anti HTN,sedative,steroid,antiulcer,digitals,antiparkinson

First remove offending agent then antidepressant

• Venlafaxine - fewer side effects than TCAs( clean amitriptyline)

• Mirtazapine - causes sedation, weight gain

• Reboxetine - minimal side effects

• Bupropion

Bipolar disorder

For individual with more pure or euphoric mania

(0.8_1.2)

It is also helpful in depression but less effective in mixed episodes and rapid cycling

Lithium clearance decrease in elderly ,peurperium ,increase in pregnancy

ADVERSE EFFECT : Thirst , polyuria ,gastric

distress ,tremor ,nausea ,vomiting ,diarrhea , thyroid effect, cardiac effect, dermatologic effect

• It has been used as an anticonvulsant• Valproate is equally effective in both euphoric and

mixed episodes, and effective in rapid cycling, substance disorder

• Adverse effects:

nausea ,vomiting ,diarrhea , tremor, weight gain, alopecia

CARBAMAZEPINE: It is effective in both euphoric and mixed episodes bone marrow suppression and liver inflammation periodic blood testing is also needed during carbamazepine

treatment.LAMOTRIGINE

It can act as a mood stabilizer and may be especially useful for depressed phase of bipolar disorder.

0.3 % taking the medication develop a serious rash. Overly trend to have fewer troublesome side effect.

GABAPENTIN It has become popular as a mood stabilizer. It is unlikely to interact with other

medication. Fatigue ,sedation ,dizziness

TOPIRAMATE This new anticonvulsant may be helpful in mania. It does not appear to cause weight gain Sedation ,dizziness ,and cognitive slowing

Alpearzolam 0.5 , 1 Lorazepam 1, 2 Oxazepam 10,20 Clonazepam 1 , 2 Chlordiazepoxide 5, 10, 20 Diazepam ???

DependencyAbuse

Zolpidem Zolpidem Buspirone Buspirone

Indicationpsychosismaniasevere agitationdelirium …

P.r.n (haloperidol)

Depot (flupentixol, fluphenazine,haldol)

Adverse effectsEPSNMSSedationCardiac, weight gain, liver, hematologic,orthostatic hypotention, reduce seizure thereshold…

Typical HaloperidoleTrifluperazinePerphenazineChlorpromazineThioridazine…

Atypical Risperidone 1,2,4Olanzapine 5,10Clozapine…