Affective disorders( 情感疾病 )

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憂鬱症名人

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 Affective disorders
憂鬱症和躁鬱症
單極性 (unipolar)
雙極性 (bipolar or manic-
depressive)

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 What is Bipolar Disorder?
Bipolar disorder is a cyclic brain disorder
with recurrent fluctuations in mood, energy,
and behavior.
It differs from major depression in that
Bipolar not only has a depressive state, but
also includes
– Manic
– Hypomanic or
– Mixed episode
Also known as manic-depressive illness
– Genetically based
– Influenced by the environment 6
 Biology of Bipolar Disorder
Brain Structural Abnormalities

Brain function Abnormalities

Abnormalities of Biochemical mechanisms

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Pathophysiology of Bipolar Disorder
Neurotransmitter theory:
– Alteration of NT concentration in the CNS
Excess norepinephrine and dopamine Mania
Deficit in NE, DA, and/or 5-HT Depression
– Norepinephrine and dopamine disregulation may
produce a cyclic disturbance in the CNS
Imbalance of these NT plays an important role in mania
– Switch phenomenon:
Decrease in Norepinephrine (in depression), causes
Dopamine to predominate hypomania or mania
– Increase in Dopamine psychosis and hyperactivity
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– Decrease in Dopamine depression
Pathophysiology of Bipolar Disorder
Neurotransmitter theory, con’t
– γ- Aminobutyric acid (GABA) is the main inhibitory
neurotransmitter in the brain
Inhibits norepinephrine and dopamine activity
Deficit in GABA mood disorders
– Low levels of GABA in CSF and plasma have been
found
Bipolar patients
Major depressive patients
Alcoholics
– Excitatory AA such as Glutamate and Aspartate may
also be involved in mood disorders. 9
 陽光殺人 ？　 5 月天憂鬱
症易自殺
記者 : 張舜芬   報導

5 月份春夏交替，是自殺率最高的月份，而增加的陽
光會刺激憂鬱症患者體內「血清素」的分泌，使得
憂鬱症患者更容易有自殺的衝動？﹗

科學家發現了憂鬱基因，這種 5-HHT 基因有長短兩型

，會影響人腦的灰質分佈，協助血清素的循環，科學
家也強調 80% 的憂鬱症都是可以治癒的。

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 憂鬱症簡介及治療方法
憂鬱症的病因、 症狀、 區別診斷與治療藥物及病患諮詢
大綱 :
憂鬱症的定義與流行病學
憂鬱症的病因學病態生理學
憂鬱症的臨床檢查與診斷症狀
憂鬱症的治療藥物 :
TCA & MAO inhibitors
SSRI & SNRI
Miscellaneous
憂鬱症的病患照顧與藥物諮詢

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 流行病學
憂鬱症終生盛行率 (prevalence) 約為 15% , 女性
高達 25% ；老年人 10-15%
美國護理之家住民大約有 50-55% 有精神方面問
題而憂鬱症佔最高約 25-30% ，臨床上 15-32%
須長期照護
住院老人發生頻率 25-45%
衛生署統計資料顯示，每十萬人口自殺 / 自傷的標
準化死亡率從民國八十七年的 9.97 增加到民國九
十三年的 15.31 。自殺死亡率隨年齡增加而增加
，六十歲以上老人，死亡率為 25 以上 ( 以每十萬
人計 ) 。
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 精神疾病 ? 短路 ?
DSM-IV （ Diagnostic and Statistical Manual of Ment


Disorder, 4th Edition, DSM-IV ）

重鬱症
(Major Depressive Disorder, MDD)
輕鬱症
(Dysthymic Disorder)
廣泛性焦慮症 Generalized anxiety
disorder
社交畏懼症 Social phobia
自殺
恐慌症 Panic disorder 13
 重憂鬱疾患 (major depressive
disorder) 的診斷準則 DSM-IV
A. 要有兩週以上的下列五項或五項以上的症狀且呈
現由原先功能的改變但其中一定要包括第一項
( 憂鬱情感 ) 或第二項 ( 無快樂感及無生趣 ):
1. 憂鬱情感，幾乎整天都有，幾乎每日都有，可
由主觀報告 ( 如感覺悲傷或空虛 ) 或由他人觀察
( 如看來含淚欲哭 )
2. 在所有或幾乎所有的活動無快樂感及無生趣，
幾乎整天都有，幾乎每日都有
3. 體重減輕或增加 ( 每月有 5% 的變化 )
4. 幾乎每日睡眠不足或過多
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 重憂鬱疾患 (major depressive
disorder) 的診斷準則 DSM-IV
5. 幾乎每日躁動不安或行動遲緩
6. 幾乎每日疲勞或去活力
7. 幾乎每日無價 感或過分不合宜的罪惡感
8. 幾乎每日思考混淆、注意力不能集中或猶豫
不決
9. 重覆性的自殺或死亡念頭 ( 不只是怕死 ) ，有
過自殺 試或已有實行自殺的特別計
劃

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 重憂鬱疾患 (major depressive
disorder) 的診斷準則 DSM-IV
B. 沒有混有躁症症狀 ( 一星期內 )
C. 臨床上重大痛苦或在社會、職業或其他重
要領域造成一些損害
D. 此障礙並非由某種物質濫用的直接生理效
應、藥物或治療的副作用、或暴露於某種毒
素所造成或一般性醫學狀況 ( 如甲狀腺功能
低下症 ) 的直接生理效應所造成

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 重憂鬱疾患 (major depressive
disorder) 的診斷準則 DSM-IV
E. 若症狀在所愛的人過世兩個月之內開始且未
超過這兩個月則一般只算是傷慟反應，除非
這些症狀造成顯著功能損害，或包含病態地
專注於無價值感、自殺意念、精神病性症狀
或精神運動性遲滯
重憂鬱與輕憂鬱區分輕憂鬱不但沒有準則
A 的症狀數目且不須要準則 C

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DSM IV Criteria for Manic Episode
(American Psychiatric Association 1994)
A) A distinct period of abnormally and persistently
elevated, expansive or irritable mood, lasting at
least 1 week (or any duration if hospitalization is
necessary)
B) During the period of mood disturbance, three
(or more) of the following symptoms have
persisted (four if the mood is only irritable) and
have been present to a significant degree:
1) inflated self-esteem or grandiosity
2) decreased need for sleep (e.g., feels rested
after only 3 hours of sleep)
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DSM IV Criteria for Manic Episode
(American Psychiatric Association 1994)
3) more talkative than usual or pressure to keep talking
4) flight of ideas or subjective experience that thoughts are
racing
5) distractibility (i.e., attention too easily drawn to
unimportant or irrelevant external stimuli)
6) increase in goal-directed activity (at work, at school, or
sexually) or psychomotor agitation
7) excessive involvement in pleasurable activities that have
a high potential for painful consequences (e.g., engaging in
unrestrained buying sprees, sexual indiscretions, or foolish
business investments)

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DSM IV Criteria for Manic Episode
(American Psychiatric Association 1994)
C) The symptoms do not meet criteria for a
Mixed Episode
D) The mood disturbance is sufficiently
severe to cause marked impairment in
occupational functioning or in usual social
activities or relationships with others, or to
necessitate hospitalization to prevent harm
to self or others, or there are psychotic
features.
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DSM IV Criteria for Manic Episode
(American Psychiatric Association 1994)
E) The symptoms are not due to the direct
physiological effects of a substance (e.g., a
drug of abuse, a medication or other
treatment) or a general medical condition
(e.g., hyperthyroidism) Note: Manic-like
episodes that are clearly caused by
somatic antidepressant treatment (e.g.,
medication, electroconvulsive therapy, light
therapy) should not count toward a
diagnosis of Bipolar I disorder
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 憂鬱症之臨床症狀
持續的悲傷、焦慮、或頭腦空白 
睡眠過少或過多 
體重減輕，食慾減退 
失去活動的快樂和興趣 
心神不寧或急躁不安 
注意力難以集中，記憶力下降，
決策困難 
疲勞或精神不振 
感到內疚、無望或者自身毫無價值 
出現自殺或死亡的想法

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誘發因子 (precipitating factor)
基因 ( 老年人較不重要
)
人格
工作壓力、情感因素
藥物
身體因素

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 神經傳導物質
Neurotransmitter Functions Associated
Disorders
Dopamine Posture and movement Parkinson’s disease
Psychoses, depression

Acetylcholine Motor activity Parkinson’s disease

Learning/memory Alzheimer’s disease

Serotonin Broad homeostatic Depression/suicide,

functions psychoses, obsessive
Sensory processing compulsive disorder,
anxiety

Norepinephrine Learning/memory Depression

GABA Anxiolytic Anxiety
Anticonvulsant Seizures
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 憂鬱症病程與預後
單極性憂鬱症 (unipolar depressive disorder)
自青春期至老年皆可能發病 , 平均每次治療療程
約
2 到 3 個月 , 未治療者病情會持續約 6 個月至數年
雙極性情感障礙症 (bipolar
disorder)
90% 病人於 50 歲前發病 . 常見病
程是完全復原 , 但一段時間又復發 ,
如此反覆發生 , 每次發病約持續數個
月 , 平均約是 3 個月 , 大多數一生中
憂鬱和躁症同時出現 , 但少數只有躁 25
 憂鬱症之
Monoamine Hypothesis
單胺神經介質：
– Dopamine (DA)
– Norepinephrine (NE)
– Serotonin (5-HT)
reserpine 會耗竭腦中單 胺神經介質 ，並導致
憂鬱症 狀出現
– TCAs 及 MA OI s 均可提高單胺神經介質的作用

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憂鬱症之單胺神經介質假說

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 單胺神經介質與
憂鬱症狀之關係

NE 5-HT
anxiety
vigilance irritability impulsiveness
energy suicidal ideas
mood
interest cognition sex
emotion appetite
motivation sleep
aggression
drive
psychomotor activity
DA
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 Depression
Depression ( 憂鬱症 )
憂鬱症與婦女更年期障礙是屬於情感性之精神疾
病 , 與環境因素不一定有關 , 病人有心情沉重 , 做
事無興緻 , 失助無用感 , 注意力無法集中 , 自卑等
精神症狀 ;
血液及尿液中常有 Norepinephrine 及 Serotonin
(5-HT) 濃度下降的現象 .

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 Major Depression
Up to 30% of patients-seen by physicians
About 5 million women and 2.5 million men
(4% and 2%) of the general population
respectively
But often goes undetected

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Depression and Suicide
Suicide risk is great among untreated
depressed person
Studies suggest that more than 50% of
suicides saw a physician during the month
before death

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 History-Talking
Point to check
1.previous psychiatric episodes.
2.family history of depression
3.alcohol or drug abuse, suicide
attend
4.continuing or recurrent illness, long
recover times

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 History-Talking:
the most important steps
1.make patient feel comfortable
2.assure privacy
3.let patient guide somewhat
4.note patient’s and convert behavior
5.elicit information relevant to know
diagnostic criteria

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Most common presenting symptom
of depression
1.sleep disturbances
2.fatique
3.pain
4.anxiety, irritability
5.gastroinstestinal disorders

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 High-Risk groups
1.substance abusers
(ex.alcoholics)
2.drug withdrawal
3.severe chronic disease

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Common predisposing factors
1.prior depressive episodes
2.family history of depression
3.female gender
4.postpartum state
5.severe or unanticipated stress

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 Mental status examination
ask about the patient’s
1.mood
2.appetite
3.sleep
4.libido
5.concentration
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 Patient’s personal history
1. birth 6. work
2. parents 7. marital status
3. Siblings 8. family life
4. upbringing 9. interests
5. education 10. habits

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 Family history of depression
1. indicates patient at increased
risk
2. often difficult to elicit

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Basis for differential diagnosis
Physical examination
review of system
Psychiatric examination
personal and family history
mental status examination

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 Depression may be ...
Caused by another illness
Concomitant with another illness
A treatment result of another
illness

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 Physical examination
Assess fuctioning of systems
Look for other cluses
--anxiety --organic disease.
--malnutrition --vitamin deficiency
--drug abuse

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 Physical examination

Do further diagnostic testing

If somatic symptoms, history, and
examination suggest organic disease
Try an antidepressant if organic disease
is not suspected and complaints are
consistent with depression

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Other illnesses can cause
depressive symptoms (1)
Endocrine disorders : Cushing's disease,
Addison's disease, diabetes mellitus.
hypothyroidism, hyperthyroidism
Collagen disease : Rheumatoid arthritis,
temporal arteritis, polymyalgia rheumatica
Chronic infections : Infectious
mononucleosis, hepatitis, herpes zoster,
tuberculosis
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Other illnesses can cause
depressive symptoms (2)
Neoplastic : Cancer of lung, brain, or head
or pancreas.
Neurologic : Parkinsonism, cerebrovascular
accident, multiple sclerosis, Alzheimer's
disease.
Pharmacologic : Steroids, beta blockers,
reserpine, alcohol, alpha-methyldopa,
barbiturates.

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Selected Medical Conditions Which
May Mimic Depression
Central nervous system
Alzheimer’s disease, Brain tumor
Cerebrovascular accident.
Huntington’s disease, HIV-infection,
Myasthenia gravis,, Trauma, Parkinson’s
disease
Pulmonary Chronic bronchitis, Emphysemia
Cardiovascular CHF, MI, Arteriosclerosis,
Dysrhythmias

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Selected Medical Conditions Which
May Mimic Depression
Infectious diseases
Endocrine Cushing's disease, Diabetes
mellitus. Hyperparathyroldism,
Hypothyroidism
Malignancies
Metabolic abnormalities Hepatic
encephalopathy, uremia
Malnutrition, Pernicious anemia, Chronic
pain syndrome
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 DEPRESSION DEMENTIA
Neurologic None Dysphasia,
deficit
apraxia,
Memory Decreased attention agnosia memory
Decreased
and concentration for recent events;
patient may attempt
cover-up
Orientation Relatively minor Patient maybe
confusion disoriented as to
time and place
Affect Depressed, anxious; Labile; patient can
patient not influenced be influenced by
suggestions
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MAJOR GRIEF REACTION
DEPRESSION
Guilt and self- Guilt and self-
blame
More than six blame
Less than six
months' duration month's duration
Patient may be Patient can
incapacitated function
May be suicidal Usually not
suicidal
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Depression and Anxiety
Many patients with major depression have
some anxiety symptoms
Treatment of depression with
antidepressants should be strongly
considered, even if the symptom of anxiety
is present.

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Features distinguishing Depression
from Primary anxiety disorders (1)

Depression Anxiety
Suicidal ++ X
ideation
Guilt ++ X

Fatigue ++ X

Sad affect ++ X

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Features distinguishing Depression
from Primary anxiety disorders (2)

Depression Anxiety
Apathy ++ X
Anxiety ++ +
Insomnia All the time Early
Lack of ++ x
interest in
daily activity
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 Manic-depression
Manic-depression ( 躁鬱症 )
躁鬱症 : Manic 及 depression 交互出
現的症狀 , 病人有時 有運 動過度 , 誇大妄
想 , 胡言 亂語 等行為 . 但有 時又 變成退 縮
與鬱悶 , 甚有自 殺傾 向 .
此症狀可 能與 患者中 樞之
Catecholamine 過多 及不 足相關 .
臨床上在 狂躁 期 常以 鋰鹽 (Lithium) 治
療. 53
 Target Symptoms for
Depression
S: Sleep problems
A: Appetite or weight change
D: Dysphoria or bad mood
A: Anhedonia or lack of interest in pleasure
F: Fatigue or loss of energy
A: Agitation /psychomotor retardation a
C: Concentration problems
E: Esteem problems
S: Suicide thoughts
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 憂鬱症量表
以下列舉的問題是人們對一些事物的感受，在過去一星期內，
你是否曾有以下的感受，如有的話，請圈（是）；若無的話，
請圈（否）。
1 你基本上對自己的生活感到滿意嗎 ? 是∕否 ( )
2 你是否已放棄了很多以往的活動和嗜好 ? 是∕否 ( )
3你是否覺得生活空虛 ? 是∕否 ( )
4 你是否常常感到煩悶 ? 是∕否 ( )
5 你是否很多時感到心情愉快呢 ? 是∕否 ( )
6 你是否害怕將會有不好的事情發生在你身上呢 ? 是∕否 ( )
7 你是否大部份時間感到快樂呢 ? 是∕否 ( )

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 憂鬱症量表（續）
8 你是否常常感到無助 ?( 覺得沒有人能幫自己 ) 是∕否 ( )
9 你是否寧願晚上留在家裡，而不愛出外做些有新意的事情 ?
( 例 : 和家人到一新開酒樓吃晚飯 ) 是∕否 ( )

10 你是否覺得，你比大多數人，有多些記憶的問題呢 ? 是∕否
( )
11 你
認為現在活著是一件好事嗎? 是∕否 ( )
12 你是否覺得自己現在是一無是處呢 ? 是∕否 ( )
13 你是否感到精力充足 ? 是∕否 ( )
14 你是否覺得自己的處境無望 ? 是∕否 ( )
15 你覺得大部份人的境況比自己好嗎 ? 是∕否 ( )
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 憂鬱症量表（續）
總分： ( )
計分方法：
．第 2,3,4,6,8,9,10,12,14,15 題答
案‘是’得 1 分。
．第 1,5,7,11,13 題答案‘否’得 1 分。
．若得 8 分或以上，則有憂鬱之傾向。

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 Depression in family
practice
Up to 60% of depressed persons
are treated by family physicians
Many patients find a diagnosis
of depression difficult to accept

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 Common patient
misconceptions
Depression is not a treatable
disease
Depression is a weakness of
character
Antidepressant drugs may
cause dependence
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Patients must be taught that
Major depression is not the same as a
depressed mood over a life event
Major depression is treatable
Pharmacotherapy is the treatment of choice
for major depression of moderate severity
Psychotherapy may be helpful for specific
symptoms or concerns in combination with
pharmacotherapy

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 Enhancing compliance
Involve one family member in
patient's treatment if possible
Instruct both this person and
patient about depression,
suggesting reading materials and
informing about common side
effects
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 Pharmacotherapy of
depression
65% to 70% of depressed
outpatients receiving an
antidepressant show marked
improvement

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Current hypotheses of the
biological etiology of
depression
Neurotransmitter depletion at limbic
system synapses
Alteration of receptor sensitivity to
neurotransmitters

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 Amine Theory of Mood
Depression results from a deficiency of
transmitter amines [e.g. Norepinephrine (NE) /or
Serotonin] at certain central synapses.
[Evidence]:
Reserpine depletes amine storage-
depression
Neuroleptics block central amine receptors
— depression

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 MAO inhibitors can increase amine
conc.
Antidepression
TCAs block uptake of amines —
Antidepression
Some depressed patients have been
shown to have low conc. of cerebral
amines.
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 Commonly used
Antidepressants
Tricyclics
Heterocyclines
Serotonin reuptake inhibitors (SSRI)
Serotonin-Norepinephrine reuptake
inhibitors (SNRI)
MAO inhibitors

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67
Tertiary amines
Amitriptyline
Doxepin
Imipramine
Secondary amines
Desiprami
Nortriptyline
Clomipramine
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Common side effects of
Tricyclics
Dry mouth
Blurred vision
Constipation
Sedation and drowsiness
Dizziness
Weight gain
Postural hypotension
Cardiac effects
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70
Dosing guidelines for tricyclics
and heterocyclics
Under-dosage is common
Increase dosage as tolerated
until depressive symptoms
disappear or maximum dosage
is reached

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 Precautions of tricyclics
1500 mg of tricyclics can be lethal
Prescribe a one-week supply or less than
1000mg
Remain alert for suicidal ideation
Discuss risks with patient and family member
Consider referral and patients receiving
multiple medications and/or experiencing
unstable medical problems

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Available heterocyclics
Amoxapine
Maprotiline
Trazodone
Mianserin

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Available MAO inhibitors
Phenelzine
Tranylcypromide
Moclobemide ( Aurorix 150mg)

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 Specific Serotonin reuptake
inhibitor (SSRI)
Citralopram (Celexa) 10-20 mg qd
Fluoxetine (Prozac) 10-20mg qd
Fluvoxamine
Paroxetine (Paxil) 10-20mg qd
Sertraline (Zoloft) 25-50mg qd
Venlafaxine (Effexor) 25-50mg bid
Mirtazapine (Remeron) 15mg hs
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Serotonin reuptake transporter

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Specific Serotonin reuptake inhibitors (SSRI)

1.serotonin 5-HT reuptake blocker

2.specific action
3.fewer tricyclic-like side effects
4 most have q.d. dosage regimen
5.tends not to cause weight gain
6.wide margin of safety

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Serotonin reuptake inhibitors
(SSRI)
As clinical experience has been gained,
serotonin reuptake inhibitors appear to be
effective in patients with anxiety or
insomnia
Sedation is not a necessary feature of
antidepressants
As the depression is alleviated, other
symptoms tend to resolve
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 Precautions of SSRIs
Discontinue if rash appears
Avoid concomitant use with MAO
inhibitors
Allow washout period prior to or
following administration of MAO
inhibitor
Sleep disorders
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 Sleep abnormalities in
depression
Hyposomnia
Hypersomnia
Loss of sleep continuity
Decreased sleep efficiency

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 Sleep abnormalities in
depression
Decreased deep sleep
Shorter Rapid Eye Movement (REM)
latency period
Shift of REM sleep to early cycles

81
 Management of sleep
disturbances in depression
Sleep complaints and the other
symptoms tend to resolve as
depression improves.
Individual symptoms are not reliable
predictor of overall antidepressant
effectiveness.

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Management of sleep disturbances in
depression
Sedating drugs are no more effective in
treatment of depression in activated
patients
Compliance may be complicated by long-
term side effects
Under-dosing or drug discontinuation
increases the risk of relapse

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 Relative Potential Clinical Consequences Of
Receptor Blockade
Antidepressant Receptor Affinity
Tricyclics Heterocyclics Newer agents

Cholinergic High Low Low

(Dry mouth,
constipation,
blurred vision)
Histaminergi High Variable Low
c
(Sedation,
drowsiness,
Alpha-
weight gain) High High Low
adrenergic 84
 REUPTAKE INHIBITION RECEPTOR AFFINITIES

Compound Noradrenaline Serotonin Muscarinic Histaminergic Adrenergic

TCAs + + + + +
SSRIs +
EFEXOR + +

TCAs 對與副作用 相關之接受體具有親和力

SSRIs 只作用於 5-HT 的再吸收機制
85
 Common Adverse
Effects of
Antidepressants
TCA: Sedation, orthostatic
hypotension, dry mouth, blurred
vision, constipation, urinary
retention, weight gain, slow AV
conduction, tremor, seizures,
sexual dysfunction.

86
MOAI : orthostatic hypotension, dry
mouth, constipation, drowsiness,
insomnia, agitation, over
stimulation, edema, weight gain,
dizziness, hypertensive crisis.

87
SSRIs : nausea, anxiety, insomnia,
nervousness, diarrhea, anorexia,
dizziness, weight loss, dry mouth,
headache, tremor, sweating,
sexual dysfunction.

88
 CYP 1A2 CYP 2C19 CYP 2D6 CYP 3A4

Fluoxetine ++ ++ ++ +
Fluvoxamine ++ ++ - ++
Paroxetine - ++ -
Sertraline + + +
Venlafaxine - - - -
Remeron - - - -
Capacity of newer antidepressants for inhibition of CYP450 activity (modified from Sussman 1996)

89
Factors affecting choice of
antidepressant

Drug response may be familial

Side effects
If previously treated, consider:
# Prior response
# Switching to new drug if
possible additional benefits
90
Patient-management
considerations
Treat syndrome, not
symptoms
Length of treatment
Therapeutic dosage

91
 Other therapies for
depression
Psychotherapy
MAO inhibitors
SRRI, SNRI
Electro-convulsive therapy

92
 When to involve
A specialist must consider when patient
Persistent suicidal ideation or plan on action
Development of psychotic or manic
symptoms
Poor or partial response to antidepressants
Refusal of pharmacotherapy
Complicating illness or concurrent medication

93
Patient follow-up
Regular monitoring of mental state
Inform patients that improvement may
not be apparent for 2 weeks on
antidepressants
Clear instructions regarding
medication and importance of
compliance
94
 Monitoring early
improvement
Physician's observations and
impressions of global change
Family members' observations
Patient's self-assessment

95
Answers to frequently asked
questions
Sleep disturbances may resolve
relatively quickly with some agents
Somatic complaints may resolve in a
few weeks
Other symptoms may take several
weeks to resolve
Compliance is essential
96
Psychotherapy may be
indicated
As an adjunct to drug therapy but is not
a substitute for it
In patients with milder depression who
do not need or do not want drugs

97
 Life style changes
Suggestions for life-style changes are
not useful while patients are
significantly depressed
Patients should avoid alcohol and
substances with potential for abuse
while being treated

98
Pharmacology of Bipolar Disorder

Lithium salts
Valproate
Antipsychotic agents: typical and second-
generation drugs
Newer anticonvulsants: lamotrigine,
gabapentin, topiramate, oxcarbazepine,
zonisamide

99
Rational Selection of Antidepressants
Depression & insomnia
– Remeron (mirtazapine)
– Paxil (Paroxetine) (SSRI)
Depression & obesity
– Wellbutrin SR (Bupropion) or
XL
– SSRI
– Effexor XR (venlafaxine)
100
Rational Selection of Antidepressants

Depression & sexual dysfunction

– Remeron
– Wellbutrin SR (Bupropion) or XL
– Effexor XR
Depression & sedation
– Wellbutrin SR or XL
– Prozac (SSRI)

101
102
憂鬱症的 治療

103
憂鬱症的 治療

104
憂鬱症的 治療

105
憂鬱症的治療

106
107
108
 Core symptoms of major
depression (1)
Depressed mood
Diminished interest or pleasure in
daily activities
Significant change in appetite and/or
weight
Insomnia or hypersomnia 嗜睡症

109
 Core symptoms of major
depression (1)
Psychomotor agitation or retardation
Fatigue or loss of energy
Lack of concentration or indecision
Thoughts of death or suicide

110
 CYP450 drug-drug interactions

1A2 2C9/19 2D6 3A4

Citalopram ++ + + +
Escitalopram + + ++ +
Fluoxetine ++ + +/ + + + ++++ + +/ + + +
Fluvoxamine ++++ + + +/ + + + + ++ +++
Paroxetine ++ ++ ++++ ++
Sertraline + +/ + + + +
Examples of drug affected

Theophylline Phenytoin Tramadol Carbamazepin

e
Warfarin Warfarin Codeine Cisapride
Olanzapine Amitriptyline Zolpidem Corticosteroids
Acetaminophen Captopril Trazodone Cyclosporine

Caffeine Celecoxib Risperidone Nifedipine

Propranolol Haloperidol Atprazolam 111
 Antidepressants & Drug
interactions
Cytochrome P-450 1A2
Fluvoxamine & Theophylline, caffeine, warfarin, haloperodol,
acetaminophene, TCAs, dozapine
Cytochrome P-450 isoxyme 2D6
Fluoxetine, Paroxetine, Sertraline & Pronpranolol, timolol,
metoprolol, nortriptyline, resperidone, codeine,
phenothiazines, encainide, bupropion
Cytochrome P-450 isoxyme 3A4
Fluvoxamine, nefazodone & Tefenadine, astemizole,
cisapride, steroids, alprazolam, triazolam, erythromycin,
nifedipine. diltiazem, verepamil, zolpidem, cyclosporin,
tamoxifen, ritonavir, warfarin.

112
Classification of mood disorders
Bipolar disorder: depressed or manic &
mixed
Major depression : single episode or
recurrent 精神抑鬱
Cyclothymia 循環情緒病
Dysthymia 心情惡劣

113
Symptoms of major depression
1.depressed mood most of every day
2.marked depressed interest or pleasure in
most all activities. (anhedonia)
3.appetite or weight change(>5% of weight
in a month)
4.insomnia or hypersomnia
5.psychomotor agitation or retardation

114
Symptoms of major depression
6.fatigue or loss of energy
7.worthlessness, excessive guilt
8.decreased ability to think,
concentrate, indecisiveness
9.recurrent thought of death, suicidal
ideation or attempt

115