An Update on
The mechanism of action ofantidepressants involves inhibiting thereuptake of monoamines (such asserotonin, noradrenaline, anddopamine), blocking monoaminereceptors, or inhibiting the monoamineoxidase enzyme.
Older classes ofantidepressants include monoamineoxidase inhibitors (MAOIs) and tricyclicantidepressants (TCAs). Medicationsin these two classes generally affecta wide range of neurotransmittersystems and cause many undesirableside effects. Newer antidepressantsinclude the selective serotonin reuptakeinhibitors (SSRIs), serotonin andnoradrenaline reuptake inhibitors(SNRI), mirtazapine, and bupropion.These antidepressants usually targetsingle or dual neurotransmitters.
MONOAMINE OXIDASE INHIBITORS
Traditional monoamine oxidaseinhibitors (MAOIs) are non-selectiveand irreversible inhibitors of bothmonoamine oxidase A (MAO-A) and B(MAO-B) enzymes. By inhibiting bothMAO-A and MAO-B, they inhibit thefirst-pass metabolism of exogeneoustyramine, resulting in an accumulationof tyramine which may causehypertensive crisis.
Patients takingMAOIs should be counselled abouttheir potential drug-drug and drug-food interactions. Patients takingMAOIs may experience hypertensivecrisis if they consume tyramine-richfoods, such as aged cheese, soyproducts or yeast extracts (such asMarmite). They are also oftenassociated with side effects such asorthostatic hypotension, headache,insomnia, weight gain, sexualdysfunction, edema, drowsiness andsedation.
Newer MAOIs, such as moclobemide,is a reversible inhibitor of monoamineoxidase A, an enzyme that actsselectively on noradrenaline andserotonin. Unlike irreversible MAOIs,moclobemide is less likely to causehypertensive crisis with tyramine-richfood but caution should still beexercised when titrating dosesupwards.
Common side effects ofmoclobemide include dizziness,insomnia and nausea. No dosageadjustment is required in renalimpairment but dosages should bereduced to half to a third in liverimpairment. Use of moclobemide withother medications that can increaseserotonin levels can lead to the
According to the World Health Organization (WHO), it is estimated that 5 to 10 per cent of the population at anygiven time is suffering from depression needing psychiatric or psychosocial intervention, but only 30 per cent ofthese received appropriate care.
With advances in pharmacotherapy and a better knowledge of the biochemicalbasis of depression, many medications have been developed for the treatment of depression and prevention ofrelapses. The treatment of depression in patients with appropriate agents, at an appropriate dose over an appropriatelength of time, together with non-pharmacologic therapies, has been shown to be cost-effective.
This article coversthe pharmacotherapy of depression in adults.