Case study Which antidepressant Dr. Matthew Miller

Aims You should be able to: Decide upon the best antidepressant for different clinical situations Explain about using the antidepressant to the patient

Choosing antidepressants Experience with medication Side effect profile Patients symptoms Risks Medical history Compliance Cost

Antidepressants: general advice for patients They wont always work; they're good at getting people better but excellent at keeping them better They take a while to work They have to be taken every day You must continue to take them after you feel better Always discuss stopping with your GP Aren't addictive

Other questions Do they return my serotonin level to normal? Will I get a buzz off them? Can I drink? What happens if I use drugs? Are they safe with other prescribed drugs? Are some better than others?

General advice for GPs Use antidepressants you are familiar with (suggestions below) Give advice about side effects, risks – Ask about sexual side effects Limit availability of patients self harming Tell patients not to stop suddenly Always offer psychotherapy

26 year old woman. First presentation to GP with depression. Feels low in mood, anhedonic, tired all the time Sleep remains normal, appetite normal Some suicidal ideas, non specific Treatment Which antidepressant?

SSRIs SSRI, e.g. Sertraline, Citalopram Well tolerated, safe, effective, Cause nausea, headaches, more expensive than TCAs

SSRIs Headache Nausea, gastric upset, reduced appetite Reduced interest in sex, anorgasmia, erectile dysfunction Sleep disturbance Sweating and yawning Dry mouth, dizziness

SSRIs May cause increased anxiety in first 2 weeks Are associated with increased risk of GI bleeds Can cause the serotonin syndrome

26 year old woman. Moderate depression with poor sleep; initial insomnia and early morning wakening Patient has occasional suicidal ideas but no plan or intent Experiencing reduced appetite, nausea which got worse on Citalopram Which antidepressant?

NASSA Mirtazapine – Safe, sedative, good for nausea Constipation, Sleepiness Increased appetite, weight gain Dizziness, dry mouth Very rarely: bone morrow suppression

46 year old man Moderate to severe depression sleep disturbed, low appetite no suicidal ideas, chronic pain, poor response to SSRIs Which antidepressant

TCA Tricyclic antidepressant, e.g. Amitriptyline – Effective at the right dose – Sedative – Licensed for neuropathic pain – cheap – Very dangerous in overdose – Lofepramine is safer in overdose

TCAs Sedation Anticholinergic symptoms Tachycardia, cardiac dysrythmias Weight gain Increased seizure threshold Hepatitis Death in overdose

19 year old woman, second presentation with depression, but variable compliance with medication Which antidepressant

Fluoxetine – SSRI, safe, effective, long half life – Can be difficult to cross taper antidepressants

34 year old man, second episode of depression. Very low energy levels Previous good response to SSRI, but developed anorgasmia Which antidepressant

NARIs Reboxetine – NA reuptake inhibitor, little serotonergic activity – Lowest rates of sexual dysfunction, good for energy Causes nausea, reduced appetite dry mouth, dizziness, blurred vision Tachycardia Some concerns about research

40 year old woman, third episode of depression, didn’t respond to SSRI or TCA prominent anxiety symptoms normal blood pressure Which antidepressant

– Venlafaxine – Similar to SSRIs. ?more effective, indicated in resistant depression, anxiety – Can cause hypertension – Side effects are SSRI plus blurred vision, tachycardia, increased likelihood of hypomania, rashes

Which antidepressant 35 year old man, long term depression Didn't respond to 3 antidepressants at a good dose for an extended period of time. Low risk and good compliance.

Psychology! But a psychiatrist might try: – Lithium – Olanzapine – Combinations, esp Mirtazapine/ Venlafaxine – Quetiapine – MAOI

Which antidepressant

Any questions Thanks!