1. Or What When Dr Bruce Davies
Anti-depressants
Or What When
Dr Bruce Davies

2. Range
Tricyclics
Tetracyclics
SSRI
SNRI
MAOI
Oddities
Adjuvants

3. Factors Influencing Choice
Features of illness, e.g. agitation, hypersomia
Suicide risk
Other therapy
Other illness.
Side effects
Cost
Special problems e.g. Age, driving, pregnancy

4. Drug Failure Non compliance. Inadequate dosage.
Other drugs e.g. alcohol, caffeine.
Unresolved outside problems.
Up to 25% failure even if above don’t apply.

5. Tricyclics Amitryptyline Potent sedative Weight gain ++
Anticholinergic ++
Most researched
150mg / day
(Therapeutic in 95% of adults)
Clomipramine
Similar side effects to amitryptyline.
Said to be best for obsessional symptoms.
150mg / day

6. Tricyclics Dothiepin Sedative Same side effects as amitryptyline.
By far and away the most toxic antidepressant.
150 mg / day
Imipramine
Stimulant
Anticholinergic ++
150 mg/ day

7. Tricyclics Lofepramine Least toxic TCA. Minimal sedative side effects.
Anticholinergic +
Doubts about efficacy.
210 mg / day
Protriptyline
Stimulant.
Anticholinergic +
40mg / day

8. Tetracyclics Maprotiline Similar side effect profile to amitryptyline.
Seizures severe in overdose.
150 mg /day
Mianserin
Good safety in overdose.
Few sedative or anticholinergic properties.
? Agranulocytosis risk
90 mg / day

9. ? SSRI First choice in elderly. First choice if heart disease.
First choice if suicide risk.
More expensive.
Side effects
Like TCA reduce with time.
Gut problems predominate.
Flat dose response curve – so no need to titrate dose upwards. ?

10. SSRI Citalopram Few interactions Most expensive 20 mg /day Fluoxetine
Sedation –
Skin s/e
Anxiety +
Cheapest
20-80 mg /day
Fluvoxamine
Gut s/e +
Insomnia -
200 mg /day
Paroxetine
Sedation +
Withdrawal problems ?
Sertraline
Diarrhoea
50 mg /day

11. SSNRI
Venlafaxine
Selective Serotonin and noradrenaline reuptake inhibitor – like amitryptyline.
Few other effects – unlike amitryptyline.
75-150mg / day minimum
Dry mouth, somnolence, high BP, nausea, headache and dizziness.

12. MAOI
The 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.

13. Oddities Trazodone. Unique structure.
Low cardiotoxicity, few anticholinergic side effects.
Drowsiness +.
Nausea.
150 mg /day.

14. Oddities Tryptophan Natural amino acid - Serotonin precursor.
Eosinophilia-myalgia syndrome, Hospital initiation only.
Adjuvant to others ?
Flupenthixol
Some doubts as to efficacy.
Fast action
1 mg / day

15. Adjuvants and Combinations
Realm of specialists
Lithium, carbamazepine
Mixtures i.e. SSRI and TCA
Dangerous – need expert supervision

16. Anxiety 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.

17. Anxiety ? Role of benzodiazepines. ? Beta-blockers. Buspirone.
Some efficacy, but small.
Slow onset, 2-4 weeks.

18. DSM - IV Duration > 2 weeks
Depressed mood or Marked loss of interest or pleasure in normal activities
Plus 4 of:
Significant change in weight
Significant change in sleep pattern
Agitation or retardation
Fatigue or loss of energy
Guilt / worthlessness
Can’t concentrate or make decisions
Thoughts of death or suicide

19. Incidence Of Depression : 2000 Patients
100 - major
100 - minor
200 - subclinical
Depression. In 50% of patients it may not be acknowledged.

20. ICD - 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?

21. ICD - 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.
Severe
Most of the criteria in severe form especially questions 5 & 9.

22. BUT 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.

23. Based On
BNF June 2000.
Depression in General Practice. Tylee, Priest & Roberts. Pub. Martin Dunitz
GP Psychotropic Handbook. S Bazire. Quay Books
Basic Notes in Psychiatry. Michael Levi. Kluwer Books