Which Antidepressant To Choose Among So Many?...

How to Treat Depression - a Mini-Lecture with Dr. Dines

Old Treatments

MAOI - not used anymore

TCA - have a quinidine heart effect. In the old days patients used to be admitted
to ICU commonly with TCA toxicity. You had to check EKG at baseline and with every dose increase.

ECT - new machines are very effective and much safer. They use high peak / low voltage electricity.


New Treatments

SSRI - Prozac
Knocked out the old drugs, much less anticholinergic effects.

3 groups meds:
SSRI
NE
Dual acting

We will discuss each of them separately.

Prozac - long half-life, takes weeks to wash out.

Paxil - most SE and drug interactions, "dirty" drug, i.e. not selective, as opposed to Lexapro, for example. Paxil is sedating. Paxil is now a Category D drug during pregnancy.

Lexapro - least drug-drug interactions, purest SSRI (Zoloft is close second with SE of diarrhea)

Remeron - unique, powerful, dual acting at any dose.
(Dr. Dines uses mainly Lexapro, Zoloft and Remeron)

Effexor - truly dual acting at high dose only, can increase BP -> HTN in 13%

Wellbutrin, Bupropinion - NE, Dopamine -> useful for drug addicts. If a medication is causing sexual inhibition or GI symptoms, it may be worth switching to Wellbutrin because it has the least sexual side effects and no GI side effects.


Look for typical features in your patients:

-Serotonin features - obsessive-compulsive, keep clean, anxiety -> use pure SSRI

-NE complex - low motivation, underactivity, hypersomnia -> use dual acting drugs

When you start SSRI, patient may feel worse x 2 days and then get better.


Dr. Dines uses: Lexapro 40%, Remeron 40%, 20% - all the rest

Again look for mediator symptoms -> Serotonin syndrome vs. NE syndrome and choose a drug accordingly

Resources:
Depression - ACP Special Focus 1/05 - practical and comprehensive
Psychiatry on the web. BMJ Career Focus, Jan 2006
All Antidepressants Are Equally Effective. Side Effects Determine Choice - WebMD 9/05
Efficacy and Safety of Second-Generation Antidepressants in the Treatment of Major Depressive Disorder - Ann of Int Med 9/05
FDA Toughens Paxil Pregnancy Warning - SmartMoney.com
No evidence to recommend a particular second-generation antidepressant on the basis of efficacy http://goo.gl/qG8P8