New Guidelines for Antidepressants

New guidelines say to select antidepressants based on side effects, other medical conditions, drug interactions, and cost … because they’re all similarly effective. This means the best bets for initial therapy are usually an SSRI, SNRI, bupropion, or mirtazapine … along with appropriate counseling. Here are details from the experts at Prescribers’ Letter:

Prescribing Antidepressants based upon Side effects:

  • The new guidelines recommend prescribers take advantage of side effects when possible.
  • For patients with insomnia, we prescribers should use a MORE sedating antidepressant, such as paroxetine or mirtazapine.
  • For patients with fatigue or sleepiness we should use a LESS sedating drug, such as fluoxetine, bupropion, or venlafaxine
  • For those who have sexual side effects on an antidepressant, we should try bupropion.
  • For those who want to minimize weight gain on an antidepressant, then bupropion or fluoxetine should be prescribed.

Prescribing Antidepressants based upon Chronic conditions:

  • Tricyclic antidepressants can aggravate heart disease … but might help patients who also have chronic pain.

Prescribing Antidepressants based upon Drug interactions:

  • Fluoxetine and paroxetine are strong CYP2D6 inhibitors and therefore can inhibit the metabolism of some beta-blockers, antipsychotics, atomoxetine (Strattera), etc.
  • Some antidepressants may make tamoxifen LESS effective for preventing breast cancer recurrence. Don’t combine tamoxifen with fluoxetine, paroxetine, sertraline, duloxetine, or bupropion.

Treatment duration:

  • Wait 4 to 8 weeks before changing therapy … but keep in mind it can take up to 12 weeks to see the maximal response.
  • Continue therapy for 4 to 9 months after a response to prevent relapse … and even longer for subsequent episodes.

Changing therapy:

  • If the initial antidepressant doesn’t help, try increasing the dose … or switching to another antidepressant in the same or different class.
  • If this isn’t enough, try ADDING an antidepressant from a different class … or adding buspirone, lithium, thyroid, or an atypical antipsychotic (Abilify, etc).
  • Save atypical antipsychotics for add-on therapy for resistant depression … or for patients with bipolar or psychotic symptoms. Don’t use them alone just for depression due to safety concerns.
New guidelines say to select antidepressants based on side effects, other medical conditions, drug interactions, and cost … because they’re all similarly effective. This means the best bets for initial therapy are usually an SSRI, SNRI, bupropion, or mirtazapine … along with appropriate counseling.
Here are details from the experts at Prescribers’ Letter:
Side effects.
The new guidelines recommend prescribers take advantage of side effects when possible.
For patients with insomnia, we prescribers should use a MORE sedating antidepressant, such as paroxetine or mirtazapine.
For patients with fatigue or sleepiness we should use a LESS sedating drug, such as fluoxetine, bupropion, or venlafaxine
For those who have sexual side effects on an antidepressant, we should try bupropion.
For those who want to minimize weight gain on an antidepressant, then bupropion or fluoxetine should be prescribed.
Chronic conditions.
Tricyclic antidepressants can aggravate heart disease … but might help patients who also have chronic pain.
Drug interactions.
Fluoxetine and paroxetine are strong CYP2D6 inhibitors and therefore can inhibit the metabolism of some beta-blockers, antipsychotics, atomoxetine (Strattera), etc.
Some antidepressants may make tamoxifen LESS effective for preventing breast cancer recurrence. Don’t combine tamoxifen with fluoxetine, paroxetine, sertraline, duloxetine, or bupropion.
Treatment duration.
Wait 4 to 8 weeks before changing therapy … but keep in mind it can take up to 12 weeks to see the maximal response.
Continue therapy for 4 to 9 months after a response to prevent relapse … and even longer for subsequent episodes.
Changing therapy.
If the initial antidepressant doesn’t help, try increasing the dose … or switching to another antidepressant in the same or different class.
If this isn’t enough, try ADDING an antidepressant from a different class … or adding buspirone, lithium, thyroid, or an atypical antipsychotic (Abilify, etc).
Save atypical antipsychotics for add-on therapy for resistant depression … or for patients with bipolar or psychotic symptoms. Don’t use them alone just for depression due to safety concerns.

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