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Many noncyclic antidepressants are available. These can be classified as selective serotonin reuptake inhibitors (SSRIs), including fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil), and fluvoxamine (Luvox); serotonin-norepinephrine reuptake inhibitors (SNRIs), including venlafaxine (Effexor), desvenlafaxine (Pristiq), and duloxetine (Cymbalta); norepinephrine-dopamine reuptake inhibitors (NDRIs), including bupropion (Wellbutrin); and others, including trazodone (Desyrel) and mirtazapine (Remeron), the latter a tetracyclic antidepressant. Bupropion is also marketed under the brand name Zyban for smoking cessation. In general, these drugs are much less toxic than the tricyclic antidepressants (See Anticholinergics) and the monoamine oxidase (MAO) inhibitors (See Monoamine Oxidase Inhibitors), although serious effects, such as seizures, hypotension, and serotonin syndrome, occasionally occur. Noncyclic and tricyclic antidepressants are described in Table II–7.

Table II-7 Antidepressants

  1. Mechanism of toxicity

    1. Most agents cause CNS depression. Bupropion is a stimulant that can also cause seizures, presumably related to inhibition of reuptake of dopamine and norepinephrine.

    2. Trazodone and mirtazapine produce peripheral alpha-adrenergic blockade, which can result in hypotension and priapism.

    3. Serotonin reuptake inhibitors, such as fluoxetine, citalopram, sertraline, paroxetine, fluvoxamine, venlafaxine, and trazodone, may interact with each other, with chronic use of an MAO inhibitor (See Monoamine Oxidase Inhibitors), or with dextromethorphan (See Dextromethorphan) to produce the “serotonin syndrome” (see below and "Hyperthermia").

    4. None of the drugs in this group has significant anticholinergic effects.

    5. Pharmacokinetics. These drugs have large volumes of distribution (Vd = 12–88 L/kg), except for trazodone (Vd = 1.3 L/kg). Most are eliminated via hepatic metabolism (see also Table II–61). Fluoxetine ...

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