How to choose

?Antidepressant
objectives

How to choose

Official Guidance

Case scenarios
Antidepressants
Groups
Discontinuation
Common symptoms
&
problems Refractory Depression
 SSRIs
-Fluoxetine
- -Citalopram
-Escitalopram
-Fluvoxamine
-Paroxetine
-Sertraline Others
Groups

Mirtazapine-
-Trazodone
-Bupropion
TCAs -Vortioxetine
-Amitriptyline
-Clomipramine
-Imipramine
-Nortriptyline Hospital

Seserine-
-Citalo
-Alzac
-Mirtimash
SNRIs -Tryptizol
-Trittico
-Venlafaxine
-Duloxetine
-Desvenlafaxine
Mild: CBT &
Exercise

Moderate
Severe:
Antidepressants

SSRIs
recommended
 When to
Act

What to
expect

For how
long
CASE 1
 Female, 20 year-old,
student has depression
with atypical features
.she has low BMI

Fatigue+No Concern for

weight gain

Choices
-SSRIs
?Fluoxetine
?Fluoxetine -SSRIs+Modafinil
-SNRIs
 Fluoxetine

Citalopram Fluvoxamine

Escitalopram Paroxetine

Expensive 28tabs/172 LE
 Sertraline

Modafinil:
Bravamax 200 Dose
once daily(addictive) 50-200
lustral50
Works within hours & ½ tab 1st 5days , 1 tab
clinical improvement after once daily
.several days

S/E
Residual fatigue? GIT upset: after food
Modafinil Insomnia: at morning
Headache
*Sexual dysfunction
CASE 2
 Female, 35 year-old,
Diabetic, Hypertensive,
has depression with
psychosis
with increased
BMI(obese)

SNRIs Depression with

psychosis, comorbid
Increased BP
diseases, Concern for
weight gain

TCAs
Side Effects
V.S
Comorbid diseases
 SSRIs
Fluoxetine+
Antipsychotic
Side Effects
-Initial anxiety: add
benz( Xanax xr 0,5
mg)
Dose
20-80
-Insomnia: add prozac20 cap
Trazodone

GIT upset(after food)-

*-Sexual dysfunction
 ?Antipsychotic

Aripiprazole Olanzapine
Dose: 15-30
Recommended: Quetiapine
10-15 daily
Other causes
-Disease itself
-Substance
-chronic diseases
-Nervous system

Switch
-Agomelatin
-Bupropion
-Vortioxetine

Non-pharma
-Wait
-Dose reduction
-Drug holidays

Pharma
-Sildenafil
-Bupropion
-Mirtazapine
CASE 3
Male, 65 year-old, No
chronic diseases, has
depression

Depression with
old age
 Citalopram

Citalo 20
?Hyponatraemia
?Hyponatraemia tabs&syrup
Dose 20-60
once daily

S/E
GIT bleeding -SSRIs usual side effects
-ADD PPI -postural hypotension
 Hyponatraemia
Normal range
serum sodium 136-145 mmol/L

Management
-fluid restriction
-increase sodium intake
-if persist: stop drug
CASE 4
 Female, 45 year old
with eye tumor
has depression

Depression with
somatic symptoms

Duloxetine TCAs
pain killers
 Cymbalta xr60
once daily

No insomnia Dose 60-120

No increase in
Tolerable S/E
BP
CASE 5
 Female, 30 year-old with
depression comorbid
with anxiety and panic
attacks

S/E
-No GIT upset
-insomnia, headache, GAD& panic
sexual dysfunction
-Severe attacks
discontinuation
symptoms

Paroxetine Choices:
Seroxate cr 12.5/25 -SNRIs
once daily -Paroxetine
Dose 20-50 -Nortiptyline(Motival)
 The term discontinuation
symptoms is used to describe
symptoms experienced on
stopping prescribed drugs that
are not drug of dependence (not
withdrawal)
Discontinuation symptoms may
be entirely new or similar to
some of the original symptoms
of the illness

Discontinuation
symptoms
Although any one can experience
The symptoms of discontinuation symptoms, risk is
discontinuation reaction may be increased in those prescribed
mistaken for relapse of illness or short half life drugs (paroxetine&
the emergent of new physical venlafaxine)
illness those who have developed anxiety
symptoms at start
Affective: GIT:
Irritability Nausea

Neuromotor:
Ataxia
Vasomotor:
Diaphoresis Neurosensory:
Parathesia

Rarely:
Mania Other neurologic
In
al:
creased dreaming
If Severe If Mild
Reintroduce original Reassure the patient
antidepressant and add that symptoms are
longer half life drug common after
(fluxetine) discontinuation
tapper gradually Antidepressants and
will pass in few days
Refractory Depression
 Pseudo treatment resistant depression
-Substance associated
Depression did not
-Sub therapeutic dose respond to 2 different antidepressants
?Management
?Management
-No compliance from 2 different classes
-Comorbid personality
Each one 6 weeks
-Not appropriate diagnosis
 1st Line:
-Add Lithium
-C0mbine Olanzapine and Fluxetine
-Add Quetiapine
-Add arpiprazole
-SSRIs+Bupropion
-SSRIs Or Velafaxine +Mirtzapine

2nd Line:
-Add Ketamine
-Add lamotregin
-Increased dose of SSRIs+Bupropion
-Increased dose of velafaxine
-Add risperidone

ECT