Now treating major depression, because
of their tolerability and safety,
SSRIs are actually the
most common agents used,
probably second to them are
the atypical antidepressants.
Your treatment choice should be
based on the patientâ€™s symptoms,
their risk for suicide, previous
response to medication,
side effects and also
So there are a lot of different
indications other than depression
for using an antidepressant.
Things like anxiety disorders,
OCD, panic, also eating disorders,
dysthymia, social phobia, PTSD,
irritable bowel syndrome, enuresis,
neuropathic pain, migraines,
autism, premenstrual dysphoric disorder,
depressive phase of a manic
episode, and also insomnia,
so keep in mind thereâ€™s this
whole list of other reasons
why a patient might be put
on an antidepressant.
Now, a group of symptoms can occur
when SSRIs, SNRIs and MAOIs,
any serotonergic agent basically is
being combined or used in excess.
So Iâ€™ve mentioned this phenomenon called
the serotonin syndrome several times now.
And thatâ€™s because this is a very important
concept to remember for your boards.
This serotonin syndrome
is going to manifest
as autonomic instability
in your patient.
So you may look for high
body temperature, agitation,
increased reflexes, so
they may have a tremor, sweating,
dilated pupils, and diarrhea.
So this can often occur again
through drug-drug interactions
and when it come to the initial
phase of serotonin syndrome,
a patientâ€™s going
to look lethargic.
Theyâ€™re going to be
have facial flushing, diaphoresis,
and a tremor or myoclonus.
Important things to
stay attuned to.
Then, this can progress
convulsions and actually
coma and death.
So this is why serotonin syndrome
is such an important side effect
to look out for in patients.
And therefore, they often like
to quiz about it on the boards.
So when it comes to
sometimes itâ€™s a bit of trial
and error in patients.
So you do have to switch from
one medicine to another,
but of course, youâ€™re concerned about
giving your patient too much serotonin
and causing this potentially deadly
reaction called serotonin syndrome.
So when youâ€™re switching agents,
you really want to wait two weeks
before switching from an SSRI to MAOI
to avoid serotonin syndrome.
However, an important point
to note is that fluoxetine,
one of the most commonly prescribed
SSRIs has a very long half-life.
And therefore, when youâ€™re
switching from that
agent over to an MAOI
or something else,
you want to do a five-week
Now, I mentioned bupropion earlier which is an NDRI.
This is actually commonly used to help people quit smoking.
So, that's something to keep in mind and also, it's indicated for ADHD.
It's most significant advantage is actually its lack of major side effects.
So, and it can also be used for the treatment of sexual dysfunction
when somebody incurs that side effect from an SSRI.
One side effect to note, however, with bupropion, and very important to know for your boards,
is that it can really lower a patient's seizure threshold
and so, any patient who has a history of seizure disorder
should not be put on Wellbutrin or bupropion, its generic name.
The other thing to note is that particularly,
patients who have a history of an eating disorder should never be prescribed buproprion.
SARIs are a typical antidepressants.
It can be useful in the treatment of major depression and also, anxiety disorders
and because they are so sedating, they can actually be used to treat insomnia.
So, another example of an atypical antidepressant is mirtazapine
and this is useful as well on the treatment of depression.
It has two major side effects: one being weight gain and the other is sedation.
So, this can be a nice choice of medication in your patient who's so depressed
that they're not eating, they're losing weight, they're not sleeping,
and often, we'll see that constellation of symptoms in an elderly individual
so you might think of using mirtazapine to target their depression.
And coincidentally, the side effects of mirtazapine would be just the thing that helps the patient.
So, one last point to keep in mind about antidepressants,
although there are many to choose from and there are considerable side effects
in drug-drug interactions to keep in mind,
about 70% of patients with major depression will actually respond to antidepressant treatment.
So, it's very important to know about them and to keep that in mind in your treatment.
That summarizes our discussion of the highlights of antidepressant medications.