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NAME: Generic / TRADE


Prepared by Brent Jensen, Loren Regier




ACH. + 0 SED. + 0 OTHER SSRIs SE in General

(Bold indicates official indication in Canada) fewest drug interactions ?benefit heart dx pts11 most anorexic & stimulating long half-life (5 wk washout) 90mg weekly avail. in USA most nauseating, constipating & sedating SSRI; ↑ DI's most anticholinergic of SSRIs
most official anxiety indications
↑weight, D/C reaction possible 14 & ↑ sexual dysfunction



Citalopram CELEXAg

ς ς ,20, 40mg scored tabs) abr=CC S(+)citalopram 10 -20 mg od ~$60

escitalopram CIPRALEX ⊗



mg cap & 4mg/ml soln) abr=F


(50,100mg scored tabs)





(10ς,20ς, 30mg tab) {Paxil CR 12.5,25,37.5mg tab




(blocks dopamine at high doses:P,S)



nausea {21%(F) - 36% (X)}, anxiety, insomnia {~14%}, agitation,anorexia,tremor somnolence {11-26%}, sweating, dry mouth, headache, dizziness, diarrhea {12% (F,P)-17% (S)}, constipation {13-18%}, EPS sexual dysfx. >30%8,9, SIADH
Toxicity can→depression 10 {D/C Syndrome →flu-like

Therapeutic Uses: √ OCD (esp. F, P,S,X)

10-20mg am

10-20mg od

√ GAD (P,ES);?others √ Bulimia nervosa (F) √Diabetic neurop.(CC) & deter use of EtOH

√ Panic(esp. P,S;F,CC,X)

25-50mg hs

10-20mg am

√Social Phobia (P,S) √ Pediatric (F,S,X)

(25,50,100mg cap)



+ +++ ++++

Sx's 'FINISH' flu,insomnia,
nausea,imbalance,sensory dist., hyper.}

Nefazodone Trazodone Amitriptyline
(10, 25,50mg; 75mg (10, 25, 50mg tab)



SARI 5HT Selective
SSRI+5HT2 rec. antagonism

+ 0

As for SSRIs +: ↓ BP
Rare: hepatotoxicity17

most diarrhea & male sexual dysfx of SSRIs ?benefit heart dx pts15,few drug interactions16 least stimulating serotonergic less wt gain;less sex dysfx,DI's √dementia 50mg hs (insomnia, sundowning, aggression); less cardiac effects than TCAs often 10-30 mg hs for sleep, IBS & chronic pain Cp esp. effective for OCD≥10yrs Most serotonergic TCA; Cp higher risk of seizures Most histamine block; Cp √ psychoneurotic/anxious dep. Cp √ Childhood enuresis (age 6+) Most NE activity Least ACH side effects Cp (used in IBS irritable bowel syndrome) Least hypotensive TCA. √IBS Cp (response may be higher at low end ≈50mg of dose range23) initial nausea; “clean TCA” side effects similar to SSRIs;
low wt gain; few drug interactions

+ve effect on headache? flat dose response (majority of depressed pts respond at the lowest effective dose)

25-50mg am

50-100mg bid

(50;75 ;100mg scored tabs) (150mg Dividose tab:50/75/100/150mg

↓↓ BP, dizzy, headache, nausea; (α1 blockade); priapism 1/6000, (Tx epi)

↓anxiety/insomnia {Still avail. in USA} √ Panic, chronic pain √ Sleep disorders: 50-100mg hs Therapeutic Uses 19 √ IBS, Pain Syndromes20 & sleep disorders21 (amitriptyline; but ° nortriptyline 2 TCA useful & less SE) √ Neuropathy √ Agitation & insomnia √ Panic→ imipramine √ Migraine prophylaxis22
(esp. amitrip./nortriptyline) √ Smoke D/C→nortrip. √ ADD(ie. desipramine) √Generalized,Panic & social anxiety disorder √for BPAD depressed;
relapse prevents & ↓ recurrence
→D/C smoking;

50mg bid

10-25mg hs

20mg po od 27 27 40mg po od Star*D~40-60mg/d (10mg po od) 41 20mg po od am 30 53 40mg po od am 100mg po hs 39 54 150mg po hs 50mg am & 150mg hs 70 44-32 10-20mg po od am 33 30mg po od am 57 40mg po od am 61-64 12.5-25mg CR od am ⊗ 100mg po od cc 34 59 50mg am &100mg pmStar D 100mg po bid cc 61 100mg po bid DISCONTINUED 150mg po bid Canada NOV03 50mg po hs 14 100mg po bid pc 27 200mg po bid pc 48 50 mg po hs 200mg po hs 50 mg po hs 150mg po hs 200mg po hs 50 mg po hs 200mg po hs 50 mg po hs 150-200mg po hs 50 mg po hs 150mg po hs (3x50mg) 200mg po hs (4x50mg) 25mg po hs 50mg po hs 100mg po hs
75-100mg/d for neuropathic pain


5HT & NE
tertiary (3°) amine TCA's



Clomipramine ANAFRANILg Doxepin Imipramine
(10, 25, 50; 75


++++ ++++ +++ ++

mg tab)

(10,25,50,75,100,150mg cap)

+++ +++

General TCA SE: ↑HR, ↓BP (Tx: fluid+/Florinef), weight gain, sexual dysfx, sweating, rash, tremors, ECG abnormalities, seizures fatal in overdose 18 (≥2gm) due to cardiac & neurologic toxicity.
rare: anticonvulsant hypersensitivity cross reactions

10-25mg hs

10-25mg hs

10-25mg hs

10-25mg hs



(10,25,50,75,100mg tab) –imipramine derivative

(50mg tabs better price in SK)

NE > 5HT
secondary (2°) amine TCA's


(10, 25mg cap)

–amitriptyline derivative



2° amines generally better tolerated then 3° amines (less dry mouth,
dizziness & weight gain)

10mg hs

15 34 22 51 65 22 61 18 40-51 22 51 66 17 25 43 28 g /37 49 g /66 51 g /71

Star*D <200mg/d



(Reg 37.5,75mg scored tabs-Co D/C Jul04) (XR 37.5mg, 75mg, 150mg caps) g (contents of XR caps may be sprinkled)

5HT & NE
(also some DA) ++ +

As dose↑: ↑BP&HR, agitation, tremor,sweating,nausea~37%, headache, sleep disturbances caution:withdrawal effects


↓renal fx adjust dose; overdoseconcern
↑’d risk of seizure ~0.4% 400mg/d

100mg od am

37.5mg XR po od 75mg XR po od 150mg XR od Star*D ~200mg/d 225mg XR od (if 2-3 cap) 100-150mg bid 150-300mg XL po od

(100,150mg tab) (150,300mg XLtab)




↓appetite, GI upset, psychos.

less sex dysfx, low wt. gain
↑appetite&weight ;↓sexual dysfx;
rare neutropenia; RD if difficulty swallowing

√ BPAD & Seasonal ADUSA

Star*D <60mg/d

48-68 26-44

MAOIs: non-selective & irreversible;

atypical/refractory depression; enzyme effect ~10days; many DIs & food cautions (tyramine-hypertensive crisis);phenelzine NARDIL 15mg tab bid-tid; tranylcypromine PARNATE 10mg tab bid-tid +++ ++++
Dry mouth,sedation,DI-clonidine

Mirtazapine REMERONg

15ς,30ς,45mg tabs (RDg 15,30,45mg tab )

√Anxiety,Somatization √Atypical, √Anxious-phobic, √Co-morbid anxiety

15-30mg po hs(RD & reg)
Generic RD Novo-mirtaz OD is ↓$

17-35 26 36 58



Selective & Reversible + 0

(100,150,300mg scored tabs) (2x150mg tabs cheaper than 300mg tab)

Dry mouth, dizzy, headache, nausea, tremor, restless, less sex dysfx

no dietary tyramine precaution enzyme effect lasts ~24hrs DI:meperidine,sympathomimetics,DM…

100mg bid


150mg po bid pc 300mg am&150pm pc 300mg po bid pc

dose for renal dysfx ς=scored tab EDS non-formulary in SK =prior approval NIHB =covered by NIHB ⊗=not NIHB COST=total cost 5HT=serotonin ACH=anticholinergic effects (dry mouth,constipation,urinary hesitancy,blurred vision) ADD =attention deficit disorder BP =blood pressure Cp =plasma levels avail DA =dopamine D/C =discontinuation DI =drug interactions epi =epinephrine GI =gastro-intestinal HR =heart rate MAOI =monoamine oxidase inhibitors NE =norepinephrine OCD =obsessive compulsive disorder RIMA reversible inhibitor of MAO-A SE =side effects SED =sedation SSRI =selective 5HT reuptake inhibitor Sx =symptoms TCA =tricyclic antidepressant Tx =treatment wk =week wt =weight INITIAL DOSE -Lower initial dose rec for elderly/sensitive pts. =initial dose lower than usual effective dose. Pregnancy: C agents: fluoxetine (most clinical experience), sertraline & bupropion but less clinical experience. Not in :Duloxetine CYMBALTA (20,30,60mg cap) an SNRI 40-60mg/d Max 120mg. SE: insomnia, somnolence, headache, nausea, diarrhea, ↓appetite, fatigue, ↑sweating,↑BP, ↑LFTs,↑DI's & dry mouth. √adult depression, diabetic peripheral neuropathic pain & ?effective for stress incontinence.

Augmentation→if partial responder: some evidence ECT,(esp. with TCA + lithium ~600-900mg/d or l-thyroxine ≤100ug/d; for buspirone Star*D, pindolol, olanzapine & tryptophan with SSRI). Combo's bupropion Star*D or mirtazapine (with SSRI or venlafaxine). 79

bupropion LOW→amitripyline. cimetidine. metronidazole. broad bean pods.50.57 Neonates may experience withdrawal 58 & pulmonary hypertension with SSRIs. isoniazid. GI upset. lithium.47. SSRI’S.X. MAOI. history of urinary retention. irritability.tryptophan. bulimia or anorexia nervosa Pediatric Issues: Safety & efficacy not well established 45. select pts modafinil or methylphenidate Peripheral anticholinergic effects tolerance may develop over several weeks. post-MI acute recovery phase. venlafaxine Drug citalopram fluoxetine fluvoxamine paroxetine sertraline CYP450 1A2 0 + +++ + + CYP450 2C9 0 ++ ++ + + CYP450 2C19 0 + to ++ +++ + + CYP450 2D6 + +++ + +++ + to ++ CYP450 3A4 0 + to ++ ++ + + Antidepressant Drug Interactions: page 80 Drug induced depression: ACEI.tremor. med dose: start low & go slow Relative Seizure Risk:64 HIGH→ maprotiline. aged unpasteurized meats.63 Cardiac Condition SSRIs (citalopram. physostigmine. start 2nd new drug at a low dose. HIGH → Unpasteurized cheese (cheddar. moclobemide.delirium. amantadine. D/C serotonergic meds. Brent Jensen Feb 07 Table 3: Switching Antidepressants: Washout periods in DAYS for outpatients 67.33 SSRI(CC.31 stop or reduce offending agent (see bottom) Elderly 32.SSRIs. Imipramine desipramine.tramadol. MAOI. Comorbid Atypical* Bipolar SSRIs.69 The more critical recommendations are in bold. restlessness. taper first drug. diarrhea .clonus.nefazodone.nortriptyline. sleep disturbance. Haldol. amoxapine.5-15mg 30min prior to intercourse impaired erection → bethanechol 10mg po tid anorgasmia → amantadine. bupropion Chronic Pain/Neuropathy29 TCAs: amitriptyline. Pregnancy: Consider risk vs benefit! ECT & psychotherapy are non-drug options. levodopa. wine. less common with fluoxetine) 43 Bleeding: Prepared by: Loren Regier. carbamazepine adverse effects. tetracycline & thiazides. Psychotherapy. FROM # 1 1-7 amitriptyline 1* 1-7 7 1 # 1 7-14 1* 7-14 clomipramine 7 1 # 1 1-7 doxepin 1* 1-7 7 1 # 1 1-7 imipramine 1* 1-7 7 1 # 1 1-7 desipramine 1* 1-7 7 1 # 1 1-7 nortriptyline 1* 1-7 7 1 3 3 mirtazapine 3 1 7 1# # 7 7 venlafaxine 7 7 7 7 ! ! ! ! fluoxetine 35 35 7 35 35! 7! # 1 1+ fluvoxamine 7 1-7 7 1 7 7+ 7 paroxetine 7 10 7# # 1 1+ citalopram/sertraline 1-7 7 10 1 # 1 1+ nefazodone 3 1-3 7 1 2 1+ trazodone 7 1-7 7 1# phenelzine 10-14 14 10-14 14 2## 14 ## tranylcypromine 10-14 14 10-14 14 2 14 bupropion 1-3 1 1 7 3 moclobemide 2 2 2 2 2 Table 2: Precautions 38. fluoxetine & venlafaxine: ↑ breast milk level). venlafaxine↓ dose).nd maintain dietary restriction for 10d. clomipramine. TCA)42. ethambutol. methylphenidate. methysergide. NSAIDs. aggression & agitation). hyperphagia. dapsone. arrhythmias) SSRIs: hepatic dysfunction (↑ levels & half-life). MAOIs. meperidine. insomnia.St. digoxin.↑temp.P. cognitive behavioral therapy & ECT may be effective. nitrofurantoin.Antidepressants – Supplementary Tables Table 1:Adverse Effects: Management Options 24. hypersomnia. propranolol (for akathisia) as necessary. clonidine.55. 59 Breast feeding: consider risk vs benefit.imipramine.venlafaxine trazodone.52.adjust dose dry mouth .g. insomnia. acetazolamide. methyldopa. fluvoxamine. nausea. ethanol. bulk forming laxatives Weight gain modify & monitor diet & activity. cardiovascular disease.g. steroids. mirtazapine. distilled spirits. MODERATE→ avocado. chocolate}. griseofulvin. Bupropion: avoid if hx of seizures. moclobemide. meat extract. treatment options for some Sx: blurry vision-pilocarpine eye drops. gradual dose titration) Elderly: extra caution required. MDMA.g. LOW→ fruit.antidepressant) e. levels often <10% of maternal dose. TCAs & SSRIs: most clinical safety data. efavirenz.25mg tid Insomnia & anxiety (5HT related) ↓dose. (Pregnancy: some C agents may be preferable: fluoxetine (most experience. chemotherapy some.62.39. mirtazapine. Less37 moclobemide.68. isotretinoin. ## taper if high dose.53. withdrawal syndrome: dizziness. switch to alternative agent. nortriptyline. procainamide. benzos. SIADH (syndrome of inappropriate antidiuretic hormone secretion esp in elderly): associated with hyponatremia 27 Contraindicated: cerebrovascular/heart disease. DRUG INTERACTIONS: Various cytochrome P450 inhibition65 by SSRI's. longer tapering (up to 8 week) may be required for high dose fluoxetine paroxetine & venlafaxine tapered slowly ↓discontinuation rxs. irritable bowel syndrome. use equivalent dose. reserpine. anticonvulsants. nortriptyline Obsessive Compulsive SSRI (high dose). nausea. opiates. camembert. psychotherapy.methylcellulose drops for dry eyes urinary hesitancy .moclobemide.venlafaxine. Tx: TAPER off original antidepressants slowly over several days or give benztropine(for cholinergic rebound→nausea/vomiting. Response ~50%.anxiety. SSRI’s & also nortriptyline used (sertraline. Other: ↓ libido→ neostigmine 7. MAOI’S. esp. hydration. General: Remission ~30%. SSRIs. sweating). ! use lower doses of 2 new drug initially.sugarless gum. mirtazapine.ORAL balance Gel) constipation .sumatriptan. progestins. mefloquine. propranolol.54. BCPs. cholinergic rebound upon withdrawal from high doses (dizziness. psychomotor agitation & hypersensitivity to rejection. Florinef 0. MAOIs. Phobic Psychotic Seizure History Sleep Disorders35 Smoking Cessation36 Weight Gain. ↓ dose or switch agent. interferon. venlafaxine.RxFiles.Z). switch to alternate agent © www. valproic acid. sensory disturbances & hyperactivity) may occur.adequate hydration. amantadine. paroxetine & fluvoxamine:↓ levels & no reported . blue). Imipramine for enuresis kids≥6 yrs.clomipramine.sertraline). bromocriptine.5% 44 MAOIs: hypertensive crisis can occur secondary to foods containing tyramine {e.56. * no washout required. cardiac conduction delays. cream & cottage cheese. uncorrected angle closure glaucoma. Eventually ~80% respond to drug tx (2-4 wks some & 6-8wks for substantial improvement). Johns Wort. risks of toxicity are greater with higher dosage regimens and inadequate washout period. lorazepam (for agitation/insomnia).desipramine. paroxetine? + antipsychotic (or amoxapine).46.40 Dizziness TCAs: benign prostatic hypertrophy. mirtazapine. ? buspirone moclobemide. Tx: Periactin 4mg po q4h.but ?↑harm51). nortriptyline 25-75mg/d bupropion. desipramine. administer in am. ondansetron. SSRIs (ambulation. sertraline & bupropion but less clinical experience). + short course of trazodone 50-100mg hs.diaphoresis. sulfas. amitriptyline bupropion ZYBAN 300mg/d. fluid restriction (1 liter/d) Serotonin Syndrome : excitement. give single dose 1-2 hr prior to bedtime. lithium.nortriptyline mirtazapine. Some urgent cases may necessitate shorter delays in switching. 2° TCA Migraine34 amitriptyline.↑HR&BP. switch to: (bupropion. imbalance. diazepam Discontinuation syndrome with abrupt withdrawal eg. reassess dose/levels.S. seizure history.clomipramine doxepin. barbiturates.48 (Concern→suicide ideas<25yr. nausea. clomipramine Orthostatic Hypotension venlafaxine(↑BP). FDA:Fluoxetine depression (49) & OCD. CNS overstimulation (e.sertraline. caffeine. headache.moclobemide. activity. encourage adequate fluid intake & avoid excessive salt restriction. mild symptoms may attenuate over several weeks.rigidity. adjust dose. mirtazapine moclobemide. paroxetine & venlafaxine a flulike syndrome x~10day(FINISH: flu.1mg po od & titrate Sedation/foggy may attenuate over 1-2weeks. paroxetine (no active metabolites. certain ales & beer. sertraline & venlafaxine. bupropion 78 Table 4: Individualizing Therapy Considerations28 citalopram.g. or history of severe headache. nortriptyline Drug Induced 30.silbutramine. yeast extract.bethanechol 25-50mg po tid-qid abdominal cramps. streptomycin.25 check BP for orthostatic hypotension. paroxetine DC causative agent.trazodone fluoxetine. herring. 60.61.doxe LOWEST→ trazodone. ECT trazodone. amphetamine/ cocaine withdrawal. geriatric or debilitated. finasteride. agitation/restlessness (usually mild & transient. # taper first drug over 3-7day prior to initiating 2nd new drug. saliva substitutes(e.mirtazapine. RIMA. diarrhea. SSRIs * mood stabilizer (+/. ↑reflexes.venlafaxine tranylcypromine moclobemide phenelzine Anxiety/Panic Anxiety. RIMA. hydralazine. clonazepam 0. dextromethorphan. Use lowest dose & try to taper off 5-10 days before delivery. serotonin syndrome) 41 especially if used in combination with other serotonergic drugs (buspirone. by degree of serotonin reuptake inhibition & risk of bleeding<0. fluvoxamine & sertraline OCD. heart block. venlafaxine *Atypical depression defined as: mood reactivity. cyproheptadine (Periactin) 4mg po qam antidepressant induced erectile dysfunction → sildenafil may help 26 Myoclonus ?TCA toxicity. pheochromocytoma. Less DI's 66: citalopram. ↓dose or choose alternative. Vagus nerve stimulation is a new option. SWITCH TO New agent amitriptyline. switch to alternate agent Sexual dysfunction distinguish etiology (drug vs illness).trimipramine. disulfiram. metoclopramide.

CMAJ. Hepatic adverse reactions associated with nefazodone. 2000 Apr. Catellier D. Meta-analysis of effects and side effects of low dosage tricyclic antidepressants in depression: systematic review. 2003 Nov 24. 2 1 Hemorrhages during escitalopram-venlafaxine-mirtazapine combination treatment of depression.J Clin Psychiatry. Carney SM.164(21):2367-70. 2002 Aug 14. et al. 38 AHFS (American Hospital Formulary System) Drug Information: Antidepressants. The Medical Letter: July. Premenstrual dysphoric disorder.67(2):240-6.328(7444):879-83. Coloma C. PD and Horn JR. (Medical Letter “Treatment Guidelines. Eur J clin Pharmacol 1997. Lauque D. Ashby D. Int Clin Psychophamacology 1996. The relationship between antidepressant medication use and rate of suicide. CREATE Investigators. Sertraline Antidepressant Heart Attack Randomized Trial (SADHEART) Group. American Psychiatric Press. http://www. 40 Gibbons RD. ENRICHD Investigators. Am Fam Physician. Wiley & Sons.71(3):483-90. Doecke CJ. 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Sertraline treatment of major depression in patients with acute MI or unstable angina. Epub 2005 Sep 12. Cochrane Database Syst Rev. Editors: Hales RE. et al. Diagnosis and management of depression in primary care: a clinical update and review. Paine S. New York.168(11):1439-42.114(2):79-84. WA. 69-76.288(6):701-9. al. Pharmacy Practice:National CE Program 1998. and sertraline. Antidepressant side effects.47(4):375-7. Vancouver. Lindquist M.. 1994. 3 Geddes JR.) 5 Remick RA. 31 Birrer RB.354(14):1497-506. Mansfield PR. J Affect Disord. 43 Stahl MM. Can J Psychiatry. Lancaster T. 46 Gunnell D. 2003 Jan 30. Washington. 11 Glassman AH. 36 Hughes J. (Taylor MJ. Am Psychiatric Press. Shannon M. N Engl J Med. (n=284 12weeks)Based on these results and those of previous trials. 1998 Nov 17. Fava M. Am J Psychiatry. Editors: Robertson MM. Davies C. J Pain Symptom Manage 1994. 2003 May 27.51(1):21-26 26 Nurnberg HG.69(10):2375-82. Honig A. Haby MM.) 12 Grady-Weliky TA. placebo-controlled trial. 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Available data do not indicate a significant increase in risk of suicide or serious suicide attempt after starting treatment with newer antidepressant drugs. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment.292(7):807-820. The risk is highest for those discontinuing their medication (68% relapse rate).2. This type of study cannot establish Koren G. Paroxetine was not shown to be more efficacious than placebo for treating pediatric major depressive disorder.5% (0. 2006 Feb 1.pdf Final Nov/05 http://www. 95% CI 1. attempted suicide. 2006 Apr. all ages (0. Epidemiology. 2006 Nov. ) 54 55 Simon GE. The risk of suicide with selective serotonin reuptake inhibitors in the elderly. Marcus SC. Initiation of SSRI therapy is associated with an increased risk of suicide during the first month of therapy compared with other antidepressants. Drugs in Pregnancy and Lactation 7th Ed. (Cohen LS. Paroxetine Use During Pregnancy: Is it Safe? (October). 2005 May 18. Nordeng H. et al. sertraline.) (Djulus J. and overall mortality in a nationwide cohort. with a markedly decreased risk of completed suicide and death. (First trimester: Paxil any malformations 4% vs ~3% general population. treatment compliance. better quality mental health care. such as poverty and drug dependence. J Am Acad Child Adolesc Psychiatry. 2002 Dec. Arch Pediatr Adolesc Med. 2006 Jan. 8 of 11 attempts were in aged 18-30yrs) Emslie Mann JJ. 38 of 1254 (3. the current use of any antidepressant was associated with a markedly increased risk of attempted suicide and. Merlob P. et al. Lower mortality was attributable to a decrease in cardiovascular. The 1051 women with SSRI prescriptions any time during early pregnancy gave birth to 51 (4. Am J Obstet Gynecol.19 vs 0. 2006 Nov. Spigset O. 2006 May. Am J Psychiatry. (InfoPOEMs: The use of selective serotonin-reuptake inhibitors (SSRIs) during the second half of pregnancy is associated with an increased risk of persistent pulmonary hypertension of the newborn (PPHN).4%) children with congenital malformations.000. 354: Treatment With Selective Serotonin Reuptake Inhibitors During Pregnancy Obstet Gynecol 2006 108: 1601-1604. et al. Am J Psychiatry. it makes sense to individualize the risks and benefits of continuing SSRI treatment throughout pregnancy. and neonatal seizures.66(4):629-36. Neonatal signs after late in utero exposure to serotonin reuptake inhibitors: literature review and implications for clinical applications. N Engl J Med.nice. et al. the higher number of spontaneous abortions in the antidepressant groups confirms the higher rates of spontaneous abortions in pregnant women taking antidepressant medications found in previous studies. and low toxicity in the event of a suicide attempt by overdose. compared with the total registry population (approximately 2% incidence vs. was associated with increased risk of a diagnosis of fetal distress in labor and neonatal admission to special care nursery. Neonatal abstinence syndrome after in utero exposure to selective serotonin reuptake inhibitors in term infants. 365: 482-87 & ALSO Moses-Kolko EL. et al. Silva S. at the same time. Exposure to Mirtazapine During Pregnancy: A Prospective. most common cardiac malformation was ventricular septal defects) See also: Hallberg P. JAMA 1998. 2006 Dec. 2006 Sep 13. 1%. J Am Acad Child Adolesc Psychiatry. TADS Team. However. CONCLUSIONS: The risk of suicide during acute-phase antidepressant treatment is approximately one in 3. CONCLUSION: Use of antidepressant drugs in pediatric patients is associated with a modestly increased risk of suicidality. Women with histories of depression who are euthymic in the context of ongoing antidepressant therapy should be aware of the association of depressive relapse during pregnancy with antidepressant discontinuation. 2005 Feb.160(2):173-6. Suicidal behaviour in youths with depression treated with new-generation antidepressants: meta-analysis. (InfoPOEMs: The use of selective serotonin reuptake inhibitors (SSRIs) in the year before giving birth is associated with increased risk of prematurity. so the findings may not generalize to other settings.nature. Arch Gen Psychiatry. 2006 Jan. Cognitive-Behavioral Davis RL. Expert Consensus Panel for Depression in Women.17(6):701-704. 2006 Dec.354(6):579-87. Selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished data. et al. Linder (LOE = 1a-) ) (Glaxo May/06 Meta analysis: 8958 paroxetine & 5953 placebo pts. The aggregate nature of these observational data precludes a direct causal interpretation of the results. Am J Psychiatry. 2006 Aug. (LOE = 2a-)) (Levinson-Castiel (Juurlink DN.) 49 Treatment for Adolescents with Depression Study (TADS). Double-Blind. J Clin Psychiatry. It is uncertain what overall effect antidepressant medications have on the morbidity and mortality of treated children. et al. et These findings support careful clinical monitoring during antidepressant drug treatment of severely depressed young people. Sarkissian L. Sirota L. these observational data are weakened by the need to make difficult adjustments for other important factors thought to be causally related to the outcomes studied.63(12):1358-67. (Loughhead AM. (LOE = 1b) ) 58 Emilio J Sanz. et al.(InfoPOEMs: Late third trimester exposure to maternal use of SSRIs increases the risk of neonatal behavioral abnormalities. (LOE = 2b) } 56 57 Altshuler LL.) (Dubicka B. Neonatal outcomes after prenatal exposure to selective serotonin reuptake inhibitor antidepressants and maternal depression using population-based linked health data. Ann Pharmacother.hc-sc. Treatment of depression in children and adolescents.hc-sc. Sjoblom V.123 women). Lancet. Am Fam Physician. Cohen LS. 2006 Jun. & Health Canada warning Oct/05 http://www. et al. 2006 Feb. P=0. Klinger G.163(6):1026-32. and risk of serious suicide attempt is approximately one in 1.8.13-2. (LOE = 1b)) ) {Wen SW. Postgrad Med. [Epub ahead of print] ) (Wogelius P. InfoPOEMs: The use of antidepressant medications in children is associated with an increased risk of suicidal ideation and suicide-related behaviors. 2005. et al.193(6) Internalizing behaviors in 4-year-old children exposed in utero to psychotropic medications. More SSRI prescriptions are associated with lower suicide rates in children and may reflect antidepressant efficacy. Kendall T. CMAJ. 2006 Aug. 2005 Sep 10-16. et. Multicenter. Shuhaiber S.6) respectively. Treatment with selective serotonin reuptake inhibitors in the third trimester of pregnancy: effects on the infant.54. (Simon GE. The absolute risk is low. Benefits and risks of psychiatric medications during pregnancy. Zamorski MA. Am J Obstet Gynecol. The use of selective serotonin reuptake inhibitors during pregnancy and breast-feeding: a review and clinical aspects. Drug Saf. JAMA.hc-sc. 2006 Aug. untreated depression is a serious condition. The use of antidepressants to treat depression in children and adolescents.70.01). et Hadley S. even when maternal illness severity was accounted for. (Misri S.8%) of depressed youths treated with antidepressants v. Suicidality in pediatric patients treated with antidepressant drugs. Savarino J.000 treatment episodes. & their Combination for Adolescents with Depression. prenatal SE-D exposure was associated with an increased risk of low birth weight and respiratory distress.05%). JAMA.163(5):81321. et al. 2006 Jun. The combination of FLX and CBT was superior to both monotherapy and PBO in terms of remission rates. Cognitive-behavior therapy.0%) of those given placebo (fixed effects odds ratio 1. Media.279:609-610.163(1):41-7. 2006 Mar. The Expert Consensus Guideline Series. (LOE = 3b)) Health Canada Mar/06 warning http://www. ) (Use of SSRI’s During Pregnancy Pharmacist’s Letter April 2006) (ACOG Publications: Committee Opinion No. (Sivojelezova A. Close monitoring of patients using these medications regarding the risk of suicidality is recommended.45(12):1404-11. Ryan ND. Moline ML. Am J Psychiatry.45(6):709-719. Operskalski B.163(11):1898-904. It is likely that this study sample consists of patients with a higher severity of illness than those found in a routine community practice. Williams & Wilkins. et al. Dec/05 Health Canada update http://www. Arch Gen Psychiatry. Transfer of the antidepressant mirtazapine into breast milk.pdf . 2006 Feb 9. Roberts C. respectively). Maternal Use of Selective Serotonin Reuptake Inhibitors and Risk of Congenital Malformations.189:393-8. et al. so the potential benefits and harms of continuing SSRIs in these patients should be carefully weighed. Sage SR. The relationship between antidepressant prescription rates and rate of early adolescent suicide. et al. Selective serotonin reuptake inhibitors and adverse pregnancy outcomes.gc. Yaffe SJ.2) and 0.295(5):499-507. Selective serotonin reuptake inhibitors in pregnant women and neonatal withdrawal syndrome: a database analysis Lancet 2005.63(8):865-72. Lancet. [Epub ahead of print] Results Mean (95% confidence interval) relative infant doses for mirtazapine and desmethylmirtazapine (n = 8) were 1. ) (Oberlander TF. Fluoxetine. Vitiello B. Paroxetine Treatment in Children and Adolescents With Major Depressive Disorder: A Randomized.25(1):59-73. J Clin Psychopharmacol. Exposure near the time of birth.) 52 50 Kulin AK. et al. Self-harm or suicide-related events occurred in 71 of 1487 (4. Pregnancy outcome following maternal use of the new selective serotonin reuptake inhibitors: a prospective controlled multicenter study. 2004 Aug 18.9%) children with congenital malformations.174(2):193-200. With linked population health data and propensity score matching. Citalopram use in pregnancy: prospective comparative evaluation of pregnancy and fetal outcome.(Spec No):1-107. 48 The American Academy of Child and Adolescent Psychiatry: http://www. Am J Psychiatry. Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. 2006 Aug 22. Treatment of depression in women.pdf Sept/05 Nice:Depression in children & young people http://www.)( Cheung AH.pdf .292(16):1969-76. 53 Briggs GG. fetal death. JAMA.) (Thormahlen GM.) 59 Chambers CD. Cottrell D. Antidepressants and the risk of suicide. Fonagy P. antidepressant drug treatment does not seem to be related to suicide attempts and death in adults but might be related in children and adolescents. Freeman RK.47 Whittington CJ.28(7):565-81. Hur K. Placebo-Controlled Trial.gc. 2006 Nov. Remission and residual symptoms after short-term treatment in the Treatment of Adolescents with Depression Study (TADS). 51 Paxil (Paroxetine) and Birth Defects Pharmacist's Letter October 2005. Mirtazapine does not appear to increase the baseline rate of major malformations of 1% to 3%. suicidal behavior aged 18-24yrs (2.163(1):145-147.293(19):2372-83. Shaffer D. Wang PS. Perel J. Ward RK. 2002 Aug 15. Cunningham ML. Arch Gen Psychiatry. et al.4% (0. Br J Clin Pharmacol. However.32 vs 0. 2004 Apr 24. Carlos et al. Comparative Study of Birth Outcomes.) & (Hammad TA.63(8):898-906.63(3):332-9.780 women with no SSRI prescriptions gave birth to 5112 (3. Arch Gen Psychiatry. Am J Psychiatry.581 pregnant women).92%).and cerebrovascular-related deaths during selective serotonin reuptake inhibitor use.pdf ( Preliminay report of retrospective epidemiological study of 3. cardiac 2% vs ~1% general population . Suicide risk during antidepressant treatment. 2005 Dec. and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial. Outcomes of prenatal antidepressant exposure. Since the symptoms and signs were relatively benign and short lived.) Pediatric OCD Treatment Study (POTS) Team. JAMA. et al. Antidepressant drug therapy and suicide in severely depressed children and adults: A case-control study. CONCLUSIONS: Pregnancy is not "protective" with respect to risk of relapse of major depression.html (An independent epidemiological study of delivery outcome following maternal use of SSRI antidepressants in early pregnancy has been conducted utilizing the Swedish national registry data (n=5. The 150. Br J Psychiatry. and 99% of women would give birth to infants unaffected by PPHN.363(9418):1341-5. (Kennard B.366(9489):933-40. Bhaumik DK. Pastuszak A. 2001 Mar. InfoPOEMs: Citalopram (Celexa) does not appear to be teratogenic.159(12):2055-61. In these high-risk patients. American College of Neuropsychopharmacology: SSRIs & Suicidal Behavior in youth Jan/04: http://www.) (Tiihonen J. all were nonfatal suicide attempts.) (Gibbons RD. 2006 Jan 17. Pennsilvania. The findings show an approximate 2-fold increased risk of cardiac malformations in infants exposed to paroxetine. 2005.html . but overall rates of remission remain low and residual symptoms are common at the end of 12 weeks of treatment. suggesting that an idiosyncratic response to these agents may provoke suicide in a vulnerable subgroup of patients.) (Kristensen JH. 2004 Oct 27. 0.194(4):961-6.aacap. (InfoPOEMs: Nearly 50% of women currently receiving antidepressant medication will experience a relapse of major depression during pregnancy. Among suicidal subjects who had ever used antidepressants.) (Olfson M. Antidepressants in Amniotic Fluid: Another Route of Fetal Exposure. 2. Bogen D. however.

Bambauer KZ. From a clinical point of view the analysis of antidepressants' safety profile (adverse effect and suicide risk) remains of crucial importance and more reliable data about these outcomes are needed. Pregnancy outcome of women exposed to bupropion during pregnancy: A prospective comparative study. 68 Bezchlibnyk-Butler K. et al.295(5):499-507. JAMA. so the findings may not generalize to other settings.294(5):563-70. Stimmel GL. Arch Gen Psychiatry. Practice guidelines and recommendations to adopt this strategy.163(7):1161-72. (InfoPOEMs: The available published research literature provides very weak evidence that light therapy is effective for seasonal affective disorder (SAD) or nonseasonal depression. Treatment of depression in women. Medications in the breast-feeding mother. 2005 Oct 19.3% and 8. [Epub ahead of print] Chun-Fai-Chan B.67(2):240-6. et al. Kahn Light therapy has a moderate effect on patients with nonseasonal depression when studied for only 7 days. Fluoxetine Treatment in Poststroke Depression. Brown GK. Han SW. Boulenger JP. PTSD. Eating Disorder Treatment. Utilization was higher for women and with increasing age. Toronto: Hogrefe & Huber. placebo-controlled trial. et al. Light boxes are expensive and may not provide the results desired by patients with SAD. controlled trials. Appelhof BC. J Clin Psychiatry. Stroke. Serotonergic antidepressants: Drug response and drug-drug interactions. Hollander JE. CNS Drugs. Use of selective serotonin reuptake inhibitors and sleep disturbances in community-dwelling older women. Treatment of Posttraumatic Stress Disorder With Venlafaxine Extended Release: A 6-Month Randomized Controlled Trial.2%. 95% CI. et al. Am J Psychiatry. Use of selective serotonin reuptake inhibitors and the risk of breast cancer.162(9):835-8.60 61 Misri S. in order to improve the quality of healthcare should be resisted. Williams JV. management or outcome of depression by clinicians.64(1):119-26. 2006 Oct. n=329 Dhillon S. Postpartum depression. Freemantle N. Nevertheless. and Anger Proneness. but this needs to be evaluated in a large scale cluster randomised trial. Efficacy and safety of sildenafil in men with serotonergic antidepressant-associated erectile dysfunction: results from a randomized. N Engl J Med. 2006 Mar 13. Strom BL. Fletcher J. Curr Med Res Opin. Wang JL. et al. Selective serotonin reuptake inhibitors (SSRIs) were the most commonly used antidepressants for those with a past-year major depressive episode (17. n=95 24week Times to response and remission also did not differ. Moyle W. 32:11-19. Cochrane Database Syst Rev. drug toxicity. Pharmacist’s Letter. AUTHORS' CONCLUSIONS: There is substantial evidence that routinely administered case finding/screening questionnaires for depression have minimal impact on the detection. adult outpatients (N=235) with nonpsychotic major depressive disorder were randomly assigned to 14 weeks of treatment with mirtazapine (up to 60 mg/day) (N=114) or nortriptyline (up to 200 mg/day) (N=121). enrolling heterogeneous populations of patients with depression to generate clinically relevant information on the benefits and harms of competitive pharmacological options. Barbui C. et al. Geddes JR.(Spec No):1-107. A Double-Blind. with a prospective economic evaluation. Pharmacy Practice:National CE Program 1998. 2006 Jul.20(9):763-90. Hankey GJ. whereas without such disorders. Gaynes BN. Creedy D. The risk is highest for those discontinuing their medication (68% relapse rate).89(12):6271-6. Sedative-hypnotics were used by 3. J Clin Endocrinol Metab. The Expert Consensus Guideline Series. House A. 2006 Nov 27. Cohen LS.50(10):605-13. Palmer JR. Antidepressants and the risk of seizures. Wisniewski SR. OCD & specific phobias) http://www. 2004 Dec. et al. 13th ed. Triiodothyronine (T3) addition to paroxetine in the treatment of major depressive disorder. et al. Breast-fed infant serum levels were near or below the level of quantifiability for both agents. Am J Obstet Gynecol 2005. Richards D. Drugs Aging 2002. A comparative study of the efficacy of long-term treatment with escitalopram and paroxetine in severely depressed patients. Among people aged 15 to 19 years.4%). patient acceptability. Spencer JP. JAMA. Am J Epidemiol. 2002 Jul 18. Cohen LS. et al.67(7):1104-9. Ekstrom RD. Clinical handbook of psychotropic drugs. available clinical data indicate that escitalopram is an effective first-line treatment option for the management of GAD. Sheldon T. A two stage procedure for screening/case finding may be effective. Birth 2005. Brambilla P. Rosenberg L. Spina E. Cochrane Database Syst Rev. Can J Psychiatry. Dickson P. Scordo MG. Koren G. Am J Psychiatry. 69 Bezchlibnyk-Butler K. (InfoPOEMs: Women with trauma symptoms who receive face-to-face counseling during their hospital stay and phone counseling at 4 to 6 weeks postpartum are less likely to have persistent trauma symptoms or postpartum depression at 3 months.19(4):299-320. Sutton AJ. Arch Gen Psychiatry.347(3):194-9. It may be associated with an increase in spontaneous abortions. 2000 Mar. SAD. Ensrud KE. Waterreus A.22(7):1331-41. Fayez Antidepressants for bipolar depression: a systematic review of randomized.162(4):656-62. Pharmacotherapy 1992. Eskild A.8% overall and 11. 2004 Sep. Henriques GR. Screening and case finding instruments for depression. et al.2. Am Fam Physician. Jeffries JJ. SSRIs made up the majority of use. 2006 Jul.4). Gilbody S. eds. Beck CA. 2003. in isolation. Psychotropic medication use in Canada. Preventing depression after stroke: Results from a randomized (sertaline NS) placebo-controlled trial. respectively FDA: Oct/06 Letter regarding venlafaxine overdose concern . 67 Product monographs 2004 & Pharmacists Letter: How to Switch Antidepressants June 2006. 2005 Oct 19. 2006 Jul.166(21):2314-21. et al. Kostaras D.1%. Canadian Anxiety Guideline July 2006 (Panic. Use of Psychotropic Medications in Treating Mood Disorders during Lactation : Practical Recommendations. Arch Intern Med. placebo-controlled clinical trial.166(5):498-504. treatment decisions should be based on considerations of clinical history. For mirtazapine. Bower P. Postpartum depression: a randomized trial of sertraline versus nortriptyline. For nortriptyline.0% per the Hamilton and QIDS-SR(16) scores. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment.Aug:1-8. 2006 Feb 1.2006Feb. Beck AT.12(1):18-22. Cochrane Database Syst Rev. J Clin Psychopharmacol.(4):CD002791. 62 Wisner KL. Epub 2005 Sep 21. (LOE = 1a-) ) . remission rates were 12.4%. A Comparison of Mirtazapine and Nortriptyline Following Two Consecutive Failed Medication Treatments for Depressed Outpatients: A STAR*D Report. utilization was 19. et al. Light therapy does not produce an additional effect when combined with pharmacologic therapy.pdf ) 66 Clinically significant drug interactions with antidepressants in the elderly. With any lifetime CIDI-diagnosed disorder assessed in the CCHS 1. Antidepressant efficacy of the antimuscarinic drug scopolamine: a randomized. Effectiveness of a counseling intervention after traumatic childbirth: A randomized trial. increasing with age to 11. (LOE = 1b-)) Gilbody S. We need for large. number needed to treat (NNT)= 2. Additional references: Almeida OP. Moline ML. 2000. Following lack of remission or an inability to tolerate an initial trial of citalopram for up to 12 weeks (first step) and a second trial with either monotherapy involving another antidepressant or augmentation of citalopram with bupropion or buspirone (second step). 64 Skowron DM. panic disorder and (Wisner KL.1% over 75 years. Gonzalez LS 3rd.54(10):1508-15. but the clinical meaning of these differences is uncertain. 65 Clinical Guidelines for the Treatment of Depressive Disorders. and no definitive implications for clinical practice can be drawn. Ten Have T. Golden RN. et al. 192:932-36. There seems to be a large acute effect of light therapy on symptoms of SAD in the first week of treatment but this effect disappears quickly thereafter. Scott LJ.63(10):1121-9. Waiting for more robust evidence. 2005 Apr. (LOE = 1b). pragmatic trials.7% among those with past-year depression. 2005 Nov 23. et al. Xie SX. Burgmann A. Postgrad Med. Expert Consensus Panel for Depression in Women. 2005 Aug 3. et al. 2005 Sep. The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence. it was 4. (InfoPOEMs: Bupropion is not associated with increased rates of major malformations. GAD. AUTHORS' CONCLUSIONS: There are statistically significant differences in terms of efficacy and tolerability between fluoxetine and certain ADs. Escitalopram: a review of its use in the management of anxiety disorders. 1. remission rates were 19. CNS Drugs. Barnhart DJ.) 63 Altshuler LL.26(4):353-60. McAllister M. 2001 Jul 1. Physician alerts to increase antidepressant adherence: fax or fiction? Arch Intern Med. A meta-analysis of individual patient data from the randomised trials is clearly necessary. Plosker GL. respectively.(4):CD002792.fda. Parry BL. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. Collaborative Care for Depression: A Cumulative Meta-analysis and Review of Longer-term Outcomes. Drevets WC. Furukawa T.1% overall. Fava M. Women maintaining their medication during pregnancy relapsed significantly less often than those who discontinued medication (26% vs 68%. The longer term benefits and costs of routine screening/case finding for depression have not been evaluated. Fava M. Gilbody S. ( Prescribing Antidepressants for Depression in 2005: Recent Concerns & Recommendations http://www. double-blind. RESULTS: Overall psychotropic drug utilization was 7. Clinical practice. and cost. Emotional Incontinence. Webster J. antidepressant use was 1.46:626-8. for Study of Osteoporotic Fractures Research Gp. et al. Are SSRIs safe for pregnant and breastfeeding women? Can Fam Physician. SAD.8% and 12. Opjordsmoen S. Placebo-Controlled 2006 Oct. Eberhard-Gran M.J Clin Psychiatry.4:CD004185.{InfoPOEMs Mar 2006: Nearly 50% of women currently receiving antidepressant medication will experience a relapse of major depression during pregnancy. The Canadian Journal of Psychiatry June 2001.Fluoxetine versus other types of pharmacotherapy for depression. It is likely that this study sample consists of patients with a higher severity of illness than those found in a routine community practice. (LOE = 1b) ) Cipriani A. 2001 Mar.} Coogan PF. Aug 2006. Piontek CM. 2005 Nov 1. Gijsman HJ. 2006 Aug. Selective serotonin reuptake inhibitors versus tricyclic and heterocyclic antidepressants: comparison of drug adherence. Gamble J. 2006. Women with histories of depression who are euthymic in the context of ongoing antidepressant therapy should be aware of the association of depressive relapse during pregnancy with antidepressant discontinuation. Kwon SU.pdf Furey ML.pdf Choi-Kwon S.3%. Davidson J. 631-3. followed by venlafaxine (7. J Am Geriatr Soc 2006 Oct. Rush AJ. Hotopf M. 2006. CONCLUSIONS: Pregnancy is not "protective" with respect to risk of relapse of major depression. et al.8%). Rendell JM. Am J Psychiatry.20(3):187-98.63(10):1158-1165.161(9):1537-47.

2006 Mar. and this study lacked a placebo control group.21(9):898-901. N Engl J Med.353(17):1819-34. Can J Psychiatry. Kim H. Lawrence D. crossover trial in a general population. 2006 Jul. Mortality and poststroke depression: a placebo-controlled trial of antidepressants. O'reardon JP. n=727 N Engl J Med. Am J Geriatr Psychiatry. J Psychiatry Neurosci. 2006 Jul. Efficacy and tolerability of vardenafil in men with mild depression and erectile dysfunction: the depression-related improvement with vardenafil for erectile response study. 2006 Feb. CONCLUSIONS: Over 2 months of treatment. 2005 Jul 20. CONCLUSIONS: Patients elderly 70 years of age or older with major depression who had a response to initial treatment with paroxetine and psychotherapy were less likely to have recurrent depression if they received two years of maintenance therapy with paroxetine. double-blind.31(4):228. 2006 Oct 7. In comparison with SSRIs. Mulsant BH. Canadian Task Force on Preventive Health Care. Finasteride-induced depression : A prospective study. 2005 Sep. Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report. 2006 Sep. Serotonin and noradrenaline reuptake inhibitors (SNRI) for stress urinary incontinence in adults. 2006 Jul-Aug. Arch Gen Psyc. Robinson RG. Mann JJ. Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy: a randomized controlled trial. et al. Br J Psychiatry. Am J Psychiatry. 2006 Sep.163(9):1519-30. CONCLUSIONS: After unsuccessful treatment with an SSRI. et al. BMJ.163(11):1905-17.63(5):521-9. 2006 Sep. third. (InfoPOEMs: Bupropion SR (~283mg/d). 2006 May. Kisely S. Am J Psychiatry. The lower side effect burden and ease of use of T(3) augmentation suggest that it has slight advantages over lithium augmentation for depressed patients who have experienced several failed medication trials. Suicide prevention strategies: a systematic review. The lower side effect burden. In patients with chronic TTH. nontricyclic antidepressants. Cochrane Database Syst Rev. 2006 May. Epub 2006 Apr 21.51:1087-93.65(16):2379-404.66(9):1097-1104. Placebo-Controlled Trial. 30.97(12):1749-51. 2006 Sep. 2005 Oct 27.. and ease of use of venlafaxine and mirtazapine suggest that this combination may be preferred over tranylcypromine for patients with highly treatment-resistant depression who have not benefited adequately from several prior treatments. Arch Intern Med. N'dow J. Choosing the agent that is most appropriate for a given patient is difficult.2005. Marangell LB. Linehan MM. Remission rates were modest for both the tranylcypromine group and the extended-release venlafaxine plus mirtazapine group. 2006 Mar. Ann Intern Med. et al. et al. Cardiovascular changes associated with venlafaxine in the treatment of late-life depression. (InfoPOEMs: When it comes to the new. Sackeim HA. BMC Clin Pharmacol. Epub 2005 Jul 29. Tranylcypromine Versus Venlafaxine Plus Mirtazapine Following Three Failed Antidepressant Medication Trials for Depression: A STAR*D Report. Perkins S. (InfoPOEMs: Light therapy and fluoxetine (Prozac) are equally effective treatment options for patients with seasonal affective disorder (SAD).6(1):7 [Epub ahead of print] Reynolds CF 3rd.163(5):805-12. Other research has shown these new drugs to be no more effective or better tolerated than tricyclic antidepressants. Bupropion-SR. the medical literature does not give us any clear guidance as to which one is more effective. Cochrane Database Syst Rev. Int J Geriatr Psychiatry. Parashar S. (LOE = 1b) ) Rush AJ.8%. 2005. McGrath PJ. et al. Hansen RA.Gordon PR.Drugs for Psychiatric Disorders Vol 4 (Issue 46) June 2006. et al. Duloxetine for Diabetic Neuropathic pain. Murdoch D. McGrath PJ.187:552-558. N Engl J Med. and 13.160(10):1823-9. Marcus SC. Johnson EM. Am J Psychiatry. Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care.3:CD004191. Wisniewski SR. Risk of switch in mood polarity to hypomania or mania in patients with bipolar depression during acute and continuation trials of venlafaxine. 2005 Aug. lack of dietary restrictions. 2005 Jul 20.163(1):79-87. Am J Psychiatry. 2006 May. et al. Relationship between antidepressant medication treatment and suicide in adolescents. et al. Patient preference and an individual assessment of risks and benefits should guide treatment selection. (InfoPOEMs: Prolonged treatment with paroxetine (Paxil) reduces the risk of recurrence of major depression in elderly patients. 2006 Jun 15. Kennedy SH. approximately one in four patients had a remission of symptoms after switching to another antidepressant. Selective serotonin re-uptake inhibitors (SSRIs) for preventing migraine and tension-type headaches. et al. second-generation antidepressants probably do not differ substantially for treatment of major depressive disorder. et al. the burden of adverse events in patients receiving tricyclics was greater. 2005 Dec. Other interventions need more evidence of efficacy.166(18):2035-43. 2006 Jul 19. Time course of depression and outcome of myocardial infarction. et al. Am J Psychiatry. Greenberg T.354(11):1130-8.285(10):1299-307. (LOE = 1b) ) Rosen R. The overall cumulative remission rate was 67%. Mariappan P.13(4):568-75. Andersen HF. 2003 Oct. Hunkeler EM. The Can-SAD study: a randomized controlled trial of the effectiveness of light therapy and fluoxetine in patients with winter seasonal affective disorder. Any one of the medications in the study provided a reasonable second-step choice for patients with depression.(3):CD004742. et al. Lam RW. placebo-controlled trial of sertraline in the treatment of night eating syndrome. Kennedy SH. Husain MM. For now. (LOE = 1b) ) Leverich GS.ohsu. Lewis S. Milis L. et al. Canepari C. start your patient on your favorite antidepressant. A comparison of lithium and T(3) augmentation following two failed medication treatments for depression: a STAR*D report. . JAMA. Starkstein S. Epub 2006 Jan 20. and bupropion as adjuncts to mood stabilizers. Jorge RE. Can Fam Physician. Sertraline to treat hot flashes: a randomized controlled. safer.354(12):1231-42. Arch Gen Psychiatry. sertraline. The QIDSSR(16) remission rates were 36. et al. 13. The medical management of depression.143(6):415-26. et al. Self-help and Guided Self-help for Eating Disorders. Am J Psychiatry. and fourth acute treatment steps. 2006 Oct 9. 2006 Mar 16. Thorax. Keam SJ. Am J Psychiatry. Depression during pregnancy. of faster onset. Can J Psychiatry. Rush AJ. Sterzi R. Monoamine transporter gene polymorphisms and antidepressant response in Koreans with late-life depression.pdf Shirayama T.51(3):178-84. quiz 1665. Trivedi MH. Efficacy and safety of second-generation antidepressants in the treatment of major depressive disorder. Nelson JC. Trivedi MH. 2006 Feb 4. Vardenafil Study Site Investigators. Lam RW. 2006 Oct 4.67-68.14(9):796-802. Pharmacist’s Letter May 2006: Pharmacotherapy of Treatment-Resistant Depression Rahimi-Ardabili B. et al. A randomized. SSRIs are less efficacious than tricyclic antidepressants.0% for the first. with the realization that most patients will need to switch to another drug at least once. Ma J. (LOE = 1a) ) Hubbard R. Bertolote J. Ryan D. Usefulness of paroxetine in depressed men with paroxysmal atrial fibrillation. Ballantyne Z.7%. JAMA. et al. Vol 47 (Issue 1215/1216) Aug 15/29. Most patients will not go into remission. Drugs. STAR*D Study. 2006 Mar 23.294(16):2064-74. Association between antidepressant use and prescribing of gastric acid suppressants. CONCLUSIONS: Overall.63(7):757-66. and the rates were not statistically different between groups.CMAJ. et al. Efficacy of escitalopram in the treatment of major depressive disorder compared with conventional selective serotonin reuptake inhibitors and venlafaxine XR: a meta-analysis. Erratum in: J Psychiatry Neurosci. second. Medical Letter. 2005 Oct 26. Second generation Antidepressants: Drug Class Review Sept 2006 Oregon Health & Science University http://www.(3):CD002919. Nierenberg AA.163(5) Remission rates with lithium (up to 900mg/d) and T(3) augmentation (up to 50ug/d) for participants who experienced unsatisfactory results with two prior medication treatments were modest and did not differ significantly. Smith M. et al.172(1):33-5.60(10):848-50. Sexual function during bupropion or paroxetine treatment of major depressive disorder. Two-Yr Randomized Controlled Trial & Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors & Borderline Personality Disorder. Screening for depression in primary care: recommendation statement from the Canadian Task Force on Preventive Health Care. or better tolerated. Lustman PJ. et al.163(9):1531-41. Am J Psychiatry. Shaffer D. Olfson M. Sexual side effects are lower with bupropion and nausea seems to occur more often with venlafaxine. Alhasso A.51(4):234-42. CONCLUSIONS: Physician education in depression recognition and treatment and restricting access to lethal methods reduce suicide rates. 2006 Nov. 2005 Oct. et al. Menopause. et al. 2006 Mar. SSRIs are no more efficacious than placebo in patients with migraine. p.163(2):232-9. 2006 Jan. Medical Letter “Treatment Guidelines. Predictors of relapse in a prospective study of fluoxetine treatment of major depression. Haskett RF. et al. et al. Fava M. Double-blind.332(7536):259-63.296(13):1609-18. Cusi C. Maintenance treatment of major depression in old age. Misri N.31(2):122-31. Moja P. sertraline. et al.6%. Mirtazapine orally disintegrating tablets in depressed nursing home residents 85 years of age and older. et al. Lohr KN. 2001 Mar 14. Arndt S.163(9):1542-8. respectively. Gartlehner G. J Clin Psychiatry. or venlafaxine-XR after failure of SSRIs (citalopram) for depression. Apter A. et al. Escitalopram: a review of its use in the management of major depressive disorder. Two-Year Outcome of Vagus Nerve Stimulation (VNS) for Treatment of Major Depressive Episodes. sertraline(~136mg/d) & venlafaxine XR (~194mg/d) are equally effective at inducing remission or response in patients with persistent symptoms of depression despite initial treatment with citalopram (Celexa ~41mg/d). Ascertaining which components of suicide prevention programs are effective in reducing rates of suicide and suicide attempt is essential in order to optimize use of limited resources. Arch Gen Psychiatry.60(10):978-82. Nahas Z. Maaten S. Am J Cardiol.2005Jan 4. MacMillan HL et al. Bupropion and the risk of sudden death: a self-controlled case-series analysis using The Health Improvement Network. Monthly maintenance psychotherapy did not prevent recurrent depression. JAMA. Cochrane Database Syst Rev. Mortality in individuals who have had psychiatric treatment: Population-based study in Nova Scotia. Sertraline for Prevention of Depression Recurrence in Diabetes Mellitus: A Randomized. 2005 Sep 20. These results are based on short-term trials and may not generalise to longer-term treatment. 2003 Oct. Am J Psychiatry. though. 2006 Sep. Mann JJ. et al.

Augmentation with sustained-release bupropion does have certain advantages. Huibers MJ. 2006 Nov. Am J Psychiatry. Am J Psychiatry. 2006 Jun. et al. 2006 Jul 1. 2006 Aug.55(8):1095-103. Xiong GL. Paroxetine is an effective treatment for hot flashes: results from a prospective randomized clinical trial. Nortriptyline treatment seems to be a useful alternative.67(8):1411-20.63(11):1217-23.163(8):1438-40. J Am Acad Child Adolesc Psychiatry. Evaluation of Outcomes With Citalopram for Depression Using Measurement-Based Care in STAR*D: Implications for Clinical Practice. 2006 Jun 14.Steiner M. (LOE = 1b) ) Vahedi H. Luteal phase dosing with paroxetine controlled release (CR) in the treatment of premenstrual dysphoric disorder. Bergeron R. Bupropion SR is somewhat better tolerated. Hsu IS. (TCAs: sodium bicarbonate treatment) Trivedi MH. Treatment with SSRIs is associated with symptomatic improvement in depression by the end of the first week of use.163(6):1001-8. Wisniewski SR. Jonas J. Escitalopram-induced uveal effusions and bilateral angle closure glaucoma. Medication augmentation after the failure of SSRIs for depression. Am J Cardiol. Tew JD Jr. This study failed to demonstrate any benefit from fluoxetine in the treatment of patients with anorexia nervosa following weight restoration. J Clin Psychiatry. J Clin Oncol. Walsh BT.26(5):482-488. et al.(4):CD004044. Sept 2006. et al.14(11):957-965.22(5):381-5. CONCLUSIONS: Bupropion SR treatment is an efficacious aid to smoking cessation in patients with COPD. Early Onset of Selective Serotonin Reuptake Inhibitor Antidepressant Action: Systematic Review and Meta-analysis. Hirschberg AL. Vignatelli L.295(24):2874-81. Whooley MA. Remission rates were 28% (HAM-D) and 33% (QIDS-SR). STAR*D-Child Team. Gut. Trivedi MH. Greep N. et al. Nomura Y.163(1):28-40. Wickramaratne P. Verdeli H. CONCLUSIONS: Augmentation of citalopram (40-60mg/d) with either sustained-release bupropion (~267mg/d) or buspirone (~41mg/d) appears to be useful in actual clinical settings. Am J Psychiatry. Findling RL.8 mg/day.295(12):1389-98.165(19):2286-92. et al.876. 2005 Oct 24. . et al. including a greater reduction in the number and severity of symptoms and fewer side effects and adverse events. Am J Obstet Gynecol. The study was limited by the lack of a placebo control group. Slack R. Cochrane Database Syst Rev. et al. Efficacy of bupropion & nortriptyline for smoking cessation among people at risk for or with chronic obstructive pulmonary disease. et al. Am J Geriatr Psychiatry. in this patient population (ie. Fluoxetine after weight restoration in anorexia nervosa: a randomized controlled trial. et al. Arch Gen Psychiatry. Wernicke JF. Arch Intern Med. In conclusion.45(3):280-8. Epub 2006 Jan 9. Pilowsky D.354(12):1243-52. Paroxetine showed a similar benefit in a previous study. 2006 Mar 22. Rush AJ. When at first you don't succeed: sequential strategies for antidepressant nonresponders. Pharmaceutical Drug Overdose. (InfoPOEMs: Treatment of unipolar depression in adults with selective serotonin reuptake inhibitors (SSRIs) significantly improves symptoms in as quickly as 1 week. Impact of Prior Treatment Exposure on Response to Antidepressant Treatment in Late Life. (LOE = 1b)) Taylor MJ. randomized. Knipschild PG. et al. et al. 2006 Oct 24. placebo-controlled trial of escitalopram in the treatment of pediatric depression. A controlled crossover study of the selective serotonin reuptake inhibitor citalopram in irritable bowel syndrome. STAR*D Study Team.23(28):6919-30. The mean exit citalopram dose was 41. Offspring of depressed parents: 20 years later. Freemantle N. A randomized controlled trial of duloxetine in diabetic peripheral neuropathic pain. Weissman MM. (InfoPOEMs: Buspirone and bupropion SR added to citalopram (Celexa) are similarly effective for patients with depression who do not initially respond to citalopram alone. 2006 Mar. JAMA. Zelefsky JR. Weissman MM. 2005 Oct 19. Bhagwagar Z. et al. 2006 Jun 28. Fine HF. 2006 Mar 23. The effect of fluoxetine in patients with pain and constipation-predominant irritable bowel syndrome: a double-blind randomized-controlled study. n=565 N Engl J Med. 2006 Jan. Aliment Pharmacol Ther. 2006 Aug. Epub 2006 May 5.(3):CD003724. Candelise L. Thase ME. (InfoPOEMs: Citalopram in a dose of 20 mg daily for 3 weeks (perhaps increasing to 40 mg at that time) modestly improves symptoms in patients with irritable bowel syndrome (IBS). bupropion XL was at least as effective as venlafaxine XR and had a significantly more favorable sexual side effect profile. Geddes JR. A double-blind. JAMA. Wagner KD. Wijkstra J. 2006 Aug. Geddes J. Ventura D. 2005 Aug. (LOE = 1a-) ) Tenback DE. Prognosis of patients taking selective serotonin reuptake inhibitors before coronary artery bypass grafting. 2005 Jul 20. Wagena EJ. 2005 Sep 1. A Double-blind Comparison Between Bupropion XL and Venlafaxine XR: Sexual Functioning. Neurology.58 Suppl 13:23-9.193(2):352-60. Antidepressant drugs for narcolepsy. Stearns V. Thase ME. Warner V. Cochrane Database Syst Rev. Finger PT. Remissions in maternal depression and child psychopathology: a STAR*D-child report. and the improvement continues at a decreasing rate for at least 6 weeks. Antidepressant Efficacy.295(22):2605-12. 2006 Nov. relatively young. Pharmacological treatment for psychotic depression. Tack J. D'Alessandro R. and Tolerability. et al. Balk F. A randomized trial of an N-methyl-D-aspartate antagonist (ketamine) in treatment-resistant major depression. 2005 Oct 1. J Clin Psychopharmacol. Treatment Guidelines from the Medical Letter. Rubinstein VJ. Lijmer J. Evidence that early extrapyramidal symptoms predict later tardive dyskinesia: a prospective analysis of 10. Rush AJ. Depression and cardiovascular disease: healing the broken-hearted. 1997. 2006 Jun. sexually active outpatients). et al. JAMA. Am J Ophthalmol. et al.98(1):42-7. Merat S. Arch Gen Psychiatry.000 patients in the European Schizophrenia Outpatient Health Outcomes (SOHO) study. The response rate was 47% (QIDS-SR) n=2. et al. so this is likely a class effect of serotonin specific reuptake inhibitors (SSRIs). Zarate CA Jr. 2006 Oct.63(8):856-64. Nolen W. Wijkstra J.141(6):1144-7.