Monoamine hypothesis of depression
Depression occurs as a result of deficiency of 1 or all 3 monoamine NT
-occurs due to too little positive affect or too much negative affect
(mania will occur from excess of all 3)
What are the three monoamine NT
NE, DA, 5HT
Too little positive affect
-DA/NE dysfunction
-DA levels low = loss of pleasure, interest, alertness, self-confidence
-DA levels high = hallucinations seen in schizo
-NE (fight or flight) high = antsy, nervous, affects focus ability
-depressed mood, loss of joy, lack of interest, loss of energy, decreased alertness,
decreased self-confidence, appetite changes
Too much negative affect
-5HT = relaxation, comfort, decreases stress, regulates libido, arousal, sleep,
aggression, pain perception
-5HT/NE dysfunction
-depressed mood, guilt, fear/anxiety, hostility, irritability, loneliness, appetite changes
Prescribing considerations
-client preference
-prior treatment response
-anticipated adverse effects
-comorbidities
,-half-life interactions
-cost
Client preference
If no contraindication, then prescribe that med to improve adherence
Prior treatment response
If patient had success with a previous med, prescribe that one first
Anticipated adverse events
-consider age, family planning, and anticipated adverse effects.
-use adverse effects to pt’s advantage (choose a known activating medication for a pt
with atypical depression or choose a sedating medication for a patient with sleep
disturbances)
Comorbidities
Clients with comorbid anxiety may experience worsening symptoms when taking
medications that target NE (SNRIs)
-fluoxetine is known to activate clients and cause panic attacks in clients with comorbid
anxiety
Half-life interactions
-choose a medication with a longer half life to avoid discontinuation syndrome if your
client forgets to take it
-many antidepressants have significant interactions with other meds due to CYP450
enzyme involvement
Cost
,If client cant afford medication, they will not benefit. Keep cost, insurance benefits, and
pharmaceutical assistance programs in mind
Goal of antidepressant medications
Complete remission of symptoms
Antidepressant prescribing schedule
-start on a single drug for 4-8 weeks
-if not working:
1. increase dose gradually until efficacy occurs
2. switch to different drug within same drug class after adequate trial which included
higher dosing and a minimum of 8 weeks
3. switch to a drug in a different class after adequate trial and higher dosing
4. add a second med as adjunct
SSRI MOA
Inhibit 5HT reuptake
First line of treatment for depression
SSRI s/e
7 S’s of SSRIs
1. Stomach
2. sexual dysfunction
3. serotonin syndrome
4. sleep difficulties
5. suicidal thoughts
6. stress
, 7. size (weight)
Serotonin s/e
Head, red, fed
Head = decreased anxiety, impulsivity, sex drive
Red = platelets and bleeding
Fed = gi motility and nausea
SSRI pt education
Most adverse affects will subside after 4-5 days once body adjusts to increased
serotonin levels
SSRI drugs
Citalopram
Fluoxetine
Paroxetine
Sertraline
Fluvoxamine
Bupropion
Citalopram
*has a mild antihistamine effect
*causes QT prolongation
Citalopram = celexa, think of cel LEXUS (car) = car – get an electrocardiogram if on this
drug
Escitalopram
Depression occurs as a result of deficiency of 1 or all 3 monoamine NT
-occurs due to too little positive affect or too much negative affect
(mania will occur from excess of all 3)
What are the three monoamine NT
NE, DA, 5HT
Too little positive affect
-DA/NE dysfunction
-DA levels low = loss of pleasure, interest, alertness, self-confidence
-DA levels high = hallucinations seen in schizo
-NE (fight or flight) high = antsy, nervous, affects focus ability
-depressed mood, loss of joy, lack of interest, loss of energy, decreased alertness,
decreased self-confidence, appetite changes
Too much negative affect
-5HT = relaxation, comfort, decreases stress, regulates libido, arousal, sleep,
aggression, pain perception
-5HT/NE dysfunction
-depressed mood, guilt, fear/anxiety, hostility, irritability, loneliness, appetite changes
Prescribing considerations
-client preference
-prior treatment response
-anticipated adverse effects
-comorbidities
,-half-life interactions
-cost
Client preference
If no contraindication, then prescribe that med to improve adherence
Prior treatment response
If patient had success with a previous med, prescribe that one first
Anticipated adverse events
-consider age, family planning, and anticipated adverse effects.
-use adverse effects to pt’s advantage (choose a known activating medication for a pt
with atypical depression or choose a sedating medication for a patient with sleep
disturbances)
Comorbidities
Clients with comorbid anxiety may experience worsening symptoms when taking
medications that target NE (SNRIs)
-fluoxetine is known to activate clients and cause panic attacks in clients with comorbid
anxiety
Half-life interactions
-choose a medication with a longer half life to avoid discontinuation syndrome if your
client forgets to take it
-many antidepressants have significant interactions with other meds due to CYP450
enzyme involvement
Cost
,If client cant afford medication, they will not benefit. Keep cost, insurance benefits, and
pharmaceutical assistance programs in mind
Goal of antidepressant medications
Complete remission of symptoms
Antidepressant prescribing schedule
-start on a single drug for 4-8 weeks
-if not working:
1. increase dose gradually until efficacy occurs
2. switch to different drug within same drug class after adequate trial which included
higher dosing and a minimum of 8 weeks
3. switch to a drug in a different class after adequate trial and higher dosing
4. add a second med as adjunct
SSRI MOA
Inhibit 5HT reuptake
First line of treatment for depression
SSRI s/e
7 S’s of SSRIs
1. Stomach
2. sexual dysfunction
3. serotonin syndrome
4. sleep difficulties
5. suicidal thoughts
6. stress
, 7. size (weight)
Serotonin s/e
Head, red, fed
Head = decreased anxiety, impulsivity, sex drive
Red = platelets and bleeding
Fed = gi motility and nausea
SSRI pt education
Most adverse affects will subside after 4-5 days once body adjusts to increased
serotonin levels
SSRI drugs
Citalopram
Fluoxetine
Paroxetine
Sertraline
Fluvoxamine
Bupropion
Citalopram
*has a mild antihistamine effect
*causes QT prolongation
Citalopram = celexa, think of cel LEXUS (car) = car – get an electrocardiogram if on this
drug
Escitalopram
