Maryam Tabatabaee M.D Assistant 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 response response in family member concurrent medical or psychiatric disorder

 Dosing time of dosing maximum dosage duration of treatment

 Combination Monotherapy is ideal

 Special population children eldery: start low, go slow, full dosage medically ill patients

 Antidepressant  Mood stabilizer  Anxiolytics  Antipsychotics

 TCAs  SSRIs  MAOIs  Other

Serotonin Specific Reuptake Inhibitors (SSRIs) FIRST CHOISE Least preferred usage: Sexual dysfunctions secondary refractiveness consistent insomnia agitation

SSRIs  Fluoxetine Cap 10, 20  Citalopram Tab 20, 40  Sertraline Tab 50, 100  Fluvoxamine Tab 25, 50, 100

 Adverse effects : Headache Yawning Agitation Sexual dysfunction GI disturbance Insomnia or hypersomnia

 Imipramine  Amitriptyline  Clomipramine  Trimipramine  Doxepine  Nortriptyline  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 mouth Other anticholinergic effects Sedation Cardiac Hematologic

MAOIs MAOIs 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 ???

Dependency AbuseZolpidemBuspirone

 Indication psychosis mania severe agitation delirium …

 P.r.n(haloperidol)  Depot (flupentixol, fluphenazine,haldol)

 Adverse effects EPS NMS Sedation Cardiac, weight gain, liver, hematologic, orthostatic hypotention, reduce seizure thereshold …

 Typical Haloperidole Trifluperazine Perphenazine Chlorpromazine Thioridazine …

 Atypical Risperidone1,2,4 Olanzapine5,10 Clozapine …