3Factors Influencing Choice Features of illness, e.g. agitation, hypersomiaSuicide riskOther therapyOther illness.Side effectsCostSpecial problems e.g. Age, driving, pregnancy
4Drug Failure Non compliance. Inadequate dosage. Other drugs e.g. alcohol, caffeine.Unresolved outside problems.Up to 25% failure even if above don’t apply.
5Tricyclics Amitryptyline Potent sedative Weight gain ++ Anticholinergic ++Most researched150mg / day(Therapeutic in 95% of adults)ClomipramineSimilar side effects to amitryptyline.Said to be best for obsessional symptoms.150mg / day
6Tricyclics Dothiepin Sedative Same side effects as amitryptyline. By far and away the most toxic antidepressant.150 mg / dayImipramineStimulantAnticholinergic ++150 mg/ day
7Tricyclics Lofepramine Least toxic TCA. Minimal sedative side effects. Anticholinergic +Doubts about efficacy.210 mg / dayProtriptylineStimulant.Anticholinergic +40mg / day
8Tetracyclics Maprotiline Similar side effect profile to amitryptyline. Seizures severe in overdose.150 mg /dayMianserinGood safety in overdose.Few sedative or anticholinergic properties.? Agranulocytosis risk90 mg / day
9? SSRI First choice in elderly. First choice if heart disease. First choice if suicide risk.More expensive.Side effectsLike TCA reduce with time.Gut problems predominate.Flat dose response curve – so no need to titrate dose upwards.?
11SSNRIVenlafaxineSelective Serotonin and noradrenaline reuptake inhibitor – like amitryptyline.Few other effects – unlike amitryptyline.75-150mg / day minimumDry mouth, somnolence, high BP, nausea, headache and dizziness.
12MAOIThe old ones block peripheral MAOI ( B ) and central MAOI (A) so a low tyramine diet is needed. ? Obsolete.Moclobemide.Only MAOI-A.? Role.? Special place in anxiety disorder.mg / day.
13Oddities Trazodone. Unique structure. Low cardiotoxicity, few anticholinergic side effects.Drowsiness +.Nausea.150 mg /day.
14Oddities Tryptophan Natural amino acid - Serotonin precursor. Eosinophilia-myalgia syndrome, Hospital initiation only.Adjuvant to others ?FlupenthixolSome doubts as to efficacy.Fast action1 mg / day
15Adjuvants and Combinations Realm of specialistsLithium, carbamazepineMixtures i.e. SSRI and TCADangerous – need expert supervision
16Anxiety Usually worth trying a antidepressant. May be useful to avoid the stimulant ones !May need higher doses.Initiation may lead to paradoxical increase in symptoms. ? Cover with short course of anxiolytic.
17Anxiety ? Role of benzodiazepines. ? Beta-blockers. Buspirone. Some efficacy, but small.Slow onset, 2-4 weeks.
18DSM - IV Duration > 2 weeks Depressed mood or Marked loss of interest or pleasure in normal activitiesPlus 4 of:Significant change in weightSignificant change in sleep patternAgitation or retardationFatigue or loss of energyGuilt / worthlessnessCan’t concentrate or make decisionsThoughts of death or suicide
19Incidence Of Depression : 2000 Patients 100 - major100 - minor200 - subclinicalDepression. In 50% of patients it may not be acknowledged.
20ICD - 10 Patient has low mood: How bad is it and how long has it been going on?Have you lost interest in things?Are you more tired than usual?If the answer is yes to these, then:Have you lost confidence in yourself?Do you feel guilty about things?Concentration difficulties?Sleeping problems?Change in appetite or weight?Do you feel that life is not worth living any more?
21ICD - 10 Mild Two criteria from 1-3 and 2 others. Moderate Two criteria from 1-3 and 3-4 others or a yes to question 5.SevereMost of the criteria in severe form especially questions 5 & 9.
22BUT BUT BUT But there is a lot more than the drugs. The use of other therapies is equally important.The doctor may be the best drug.Availability is often the limit to other treatment methods.
23Based OnBNF June 2000.Depression in General Practice. Tylee, Priest & Roberts. Pub. Martin DunitzGP Psychotropic Handbook. S Bazire. Quay BooksBasic Notes in Psychiatry. Michael Levi. Kluwer Books