Huppert’s Notes: Pathophysiology and Clinical Pearls for Internal Medicine >Key Medications
&Interventions in Psychiatry
Laura A. Huppert, Timothy G. Dyster, (Lead Contributing Editor)+
TABLE 13.3Antidepressant Medications
Class
Selective serotonin reuptake inhibitor
(SSRI)
Serotonin-norepinephrine reuptake
inhibitor (SNRI)
Tricyclic antidepressant (TCA)
Drug: Generic (Trade Name)
fluoxetine (Prozac) sertraline (Zoloft)
escitalopram (Lexapro)
venlafaxine (Effexor) duloxetine
(Cymbalta) desvenlafaxine (Pristiq)
amitriptyline (Elavil) clomipramine
(Anafranil) nortriptyline (Pamelor)
imipramine (Tofranil) doxepin
(Sinequan)
Mechanism of Action
Serotonin-specific reuptake inhibitor
Serotonin + norepinephrine reuptake
inhibitor
Serotonin + norepinephrine reuptake
inhibitor
Use
Depression, OCD, panic, anxiety,
PTSD
Depression, anxiety. Venlafaxine also
used for fibromyalgia and chronic pain
Depression
Amitriptyline and nortriptyline also
used for chronic pain; imipramine also
used for enuresis and panic disorder;
clomipramine also used for OCD (1st
line)
Side Effects
•Nausea, diarrhea, sexual dysfunction,
GI bleeds (platelet inhibition),
hyponatremia (especially in the
elderly), possible initial increase in
anxiety
•Withdrawal symptoms when stop
(especially fluoxetine, which has a
long half life)
•Fluoxetine/sertraline: CYP450
inhibitors
•Nausea, sexual dysfunction,
hypertension at higher doses
•Desvenlafaxine = active metabolite of
venlafaxine
•Anticholinergic: Sedation,
hypotension, dry mouth, constipation,
urinary retention
•May slow the electrical conduction in
the heart and cause a prolonged
QTc. Check ECG before initiating
treatment.
•Overdose = lethal 3Cs: Convulsion
(seizure), Coma, Cardiotoxicity.
Treatment: IV sodium bicarb

Monoamine oxidase inhibitors (MAOI)
Atypical Antidepressants
Date of download: 12/29/22 from AccessMedicine: accessmedicine.mhmedical.com, Copyright © McGraw Hill. All rights reserved.
phenelzine (Nardil) isocarboxazid
(Marplan) tranylcypromine (Parnate)
selegiline (Emsam)
bupropion (Wellbutrin)
mirtazapine (Remeron)
trazodone (Desyrl)
vilazodone (Viibryd)
vortioxetine (Trintellix)
MAO Inhibitor (↑serotonin,
norepinephrine, dopamine)
↑norepinephrine, dopamine
Blocks multiple receptors: serotonin, α
receptors, histamine
Blocks serotonin reuptake
Depression in patients who had a poor
response to at least 2 other
antidepressants.
Atypical depression (overeating,
oversleeping, often in younger
patients), phobias
Atypical depression
Depression, anxiety
Most often used as non-addictive
sleep aids, although sometimes also
for depression
Hypertensive crisis: Can occur within
30 minutes of ingesting tyramine
containing foods (aged cheese, aged
meats, wine, fava beans). Treatment:
Phentolamine, nitroprusside
Serotonin syndrome:
•Risk factors: Increased risk with >1
serotonergic agent. Often occurs
when MAOI is combined with an
SSRI, SNRI, linezolid, or antiemetic.
•Onset: Acute, typically within 24
hours of ingestion
•Symptoms: Autonomic dysfunction
(increased HR, increased
temperature, sweating, diarrhea),
neuromuscular excitation (clonus,
hyperreflexia, hypertonicity, rigidity),
altered mental status, catatonia. In
severe cases, can lead to
rhabdomyolysis and renal failure.
•Treatment: Stop the offending
medication. Provide supportive
treatment. Can consider the use of
anticonvulsants and benzodiazepines
for agitation/muscle rigidity.
•Overstimulation, insomnia, dry mouth
•Lowers seizure threshold: Avoid in
epilepsy, eating disorders
•Sedation, weight gain (good for
elderly and cancer patients where
weight gain is desired)
•Priapism, sexual dysfunction
•Orthostatic hypotension
•Dizziness
•Nausea, vomiting, constipation
Inhibits serotonin reuptake + has
partial 5-HT1A agonism
Inhibits serotonin reuptake + has full
5-HT1A agonism, partial 5-HT1B
agonism + 5-HT3 antagonism