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 patient’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 there’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 I’ve mentioned this phenomenon called
the serotonin syndrome several times now.
And that’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 patient’s going
to look lethargic.
They’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 it’s a bit of trial
and error in patients.
So you do have to switch from
one medicine to another,
but of course, you’re concerned about
giving your patient too much serotonin
and causing this potentially deadly
reaction called serotonin syndrome.
So when you’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 you’re
switching from that
agent over to an MAOI
or something else,
you want to do a five-week
A quick note about an
this is also useful for treatment
And there’s a low drug
but be aware of the serotonin syndrome.
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.
Its most significant advantage is
actually its lack of major side effects.
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 bupropion.
SARIs are atypical antidepressants,
can be useful in the treatment of
major depression and
also anxiety disorders
and because they’re so sedating, they
can actually be used to treat insomnia.
So another example of an atypical
antidepressant is mirtazapine
and this useful as well in
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
may 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 and
drug-drug interactions to keep in mind,
about 70% of patients
with major depression
will actually respond to
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.