Do not routinely offer antidepressant medication as first-line treatment for less severe depression, unless that is the person’s preference. DO NOT INITIATE DOSULEPIN.
Anticholinergic load. Antidepressants, particularly tricyclics have an anticholinergic activity which accumulates with other anticholinergic drugs such as medicines for PD, psychosis, overactive bladder, COPD and N&V. In the elderly this can cause serious physical instability, delirium and cognitive decline.
SSRIs are known to increase risk of GI bleeds especially if co prescribed with NSAIDs, aspirin and in the very elderly.
Prescribers are reminded of the risk of serotonin syndrome with SSRI when combined with other antidepressants, triptans, and opioids including tramadol.
Citalopram and escitalopram prolong the QT interval in a dose-dependent fashion. To a lesser extent, the concern has also been raised for fluoxetine. Sertraline is associated with QT interval prolongation but the evidence is less well established. There is little compelling evidence that recommended doses of other SSRIs prolong the QT interval.
Fluoxetine, citalopram and sertraline are all included as first-line options for SSRI. The long half-life of fluoxetine is a benefit on withdrawal, but a drawback when switching drugs, e.g. to a TCA.
In elderly or with reduced hepatic function maximum dose of citalopam is 20mg and maximum dose of escitalopram is 10mg.
See flowchart below for options
In generalised anxiety disorder, if the patient cannot tolerate SSRIs or SNRIs, consider offering pregabalin (as Rewiska® or Alzain® brand)
Depression initial dose: Usually 75 mg daily in divided doses (or a single dose at night). This may be increased gradually if necessary to a total of 150 mg a day, with the additional doses being given in the late afternoon and/or at bedtime.
The sedative effect is usually rapidly apparent, while antidepressant activity may be seen within three or four days or may take up to 30 days to develop adequately.
Maintenance dose:The usual maintenance dosage is 50-100 mg daily. The total dosage may be given in a single dose preferably in the evening or at bedtime. When satisfactory improvement has been reached, dosage should be reduced to the lowest amount that will maintain relief of symptoms. Elderly should be restricted to 50mg daily maximum
Enuresis: Children from 6-10 years may receive 10-20 mg a day, while those aged 11-16 years may need 25 mg a day
NICE TA367 (Nov 15): Vortioxetine (Brintellix) is recommended as a possible treatment for adults having a first or recurrent major depressive episode, if the current episode has not responded to 2 antidepressants. Approved by PAMM Jan 16