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.
- 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.
- 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.