Antidepressants choice

Simon GE, VonKorff M, Heiligenstein JH, et al (1996). Initial antidepressant choice in primary care. JAMA 275, 1897-902. 

Medications that have been used as treatment for anxiety and depression in the postwithdrawal state include antidepressants, benzodia2epines and other anxiolytics, antipsychotics, and lithium. In general, the indications for use of these medications in alcoholic patients are similar to those for use in nonalcoholic patients with psychiatric illness. However, following careful differential diagnosis, the choice of medications should take into account the increased potential for adverse effects when the medications are prescribed to alcoholic patients. For example, adverse effects can result from pharmacodynamic interactions with medical disorders commonly present in alcoholic patients, as well as from pharmacokinetic interactions with medications prescribed to treat these disorders (Sullivan and O Connor 2004). 

Carbamazepine GM FE TEE 1 Improves mood. Related to tricyclic antidepressants. Drug of choice in FE (10-20)... 

Antidepressant medications appear to be useful for certain children and adolescents, particularly those who have severe or psychotic depression, fail psychotherapeutic measures, or experience chronic or recurrent depression. SSRIs generally are considered the initial antidepressants of choice, although comorbid conditions may favor alternative agents. Clinicians should be aware of the possibility of behavioral activation with the SSRIs, including such symptoms as impulsivity, silliness, daring conduct, and agitation.44 Desipramine should be used with caution in this population because of several reports of sudden death, and a baseline and follow-up electrocardiogram (ECG) may be warranted when this medication is used to treat pediatric patients.9... 

PD may be treated successfully with TCAs, SSRIs, SNRIs, or MAO Is, as well as benzodiazepines51,52 (Table 37-6). While all these agents are similarly effective, SSRIs have become the treatment of choice in PD. Benzodiazepines often are used concomitantly with antidepressants, especially early in treatment,... 

A number of non-hormonal therapies have been studied for symptomatic management of vasomotor symptoms, including antidepressants [e.g., selective serotonin reuptake inhibitors (SSRIs) and venlafaxine], herbal products (e.g., soy, black cohosh, and dong quai), and a group of miscellaneous agents (e.g., gabapentin, clonidine, and megestrol). The choice of therapy depends on the patient s concomitant disease states, such as depression and hypertension, and the risk for potential adverse effects. 

Amitriptyline appears to be the tricyclic antidepressant (TCA) of choice, but imipramine, doxepin, nortriptyline, and protriptyline have also been used. 

Antidepressants are efficacious for acute and long-term management of GAD. They are considered the treatment of choice for long-term management of chronic anxiety, especially in the presence of depressive symptoms. Antianxiety response requires 2 to 4 weeks. 

Factors that influence the choice of antidepressant include the patient s history of response, history of familial response, concurrent medical conditions, presenting symptoms, potential for drug-drug interactions, comparative side-effect profiles of various drugs, patient preference, and drug cost. 

The SSRIs are often selected as first-choice antidepressants in elderly patients. 

GG is used extensively for analysis of antidepressants (Orsulak et al, 1989), but HPLC assays and enzyme immunoassays have become more popular in recent years. However, GC has advantages such as economy and ready availability. LCD and NPD generally are the detectors of choice (Coutts and Baker, 1982). NPD is relatively efficient for the analysis of tricyclic antidepressants (TCAs) as derivatization is not necessary, although the secondary, demethylated amines are sometimes derivatized to improve resolution and peak shape (Coutts and Baker, 1982). Acetylation, under aqueous or anhydrous conditions, followed by GC-NPD, has been used extensively for analysis of TCAs and the tetracyclic antidepressant maprotiline in plasma samples (Drebit et al., 1988). O Table 1-1 summarizes GC assays for some commonly prescribed antidepressants and their metabolites. 

Antidepressants have been shown effective in the treatment of major depression with response rates at approximately 60-70%. The only treatment for depression consistently shown to be more effective is ECT with response rates of 80-90%. There is no definitive means of predicting which medication will work best for a given patient nevertheless, the choice of a medication should not be made capriciously. Several factors can guide medication selection and thereby maximize the likelihood of a successful response. 

The fourth factor influencing medication choice is the safety of the medication. This is especially important given the snicide potential of depressed patients. The newer antidepressants, inclnding the SSRls and so-called atypical antidepressants, are mnch safer in overdose than the older TCAs and MAOIs. In the case of the TCAs, ingestion of a 1-2 week snpply is lethal 50% of the time. 

Lithium remains the treatment of choice for bipolar patients who experience classic euphoric episodes of mania. Current evidence suggests that those with mixed episodes or rapid cycling episodes respond preferably to anticonvulsants or atypical antipsychotic drugs. In addition to its use as a mood stabilizer, lithium is effective in converting unipolar antidepressant nonresponders to responders. Finally, lithium may also be an effective treatment for patients with clnster headaches. 

When treating mild-to-moderate panic disorder, we recommend avoiding benzodiazepines in favor of CBT or antidepressants. Because CBT and antidepressants are both effective for panic disorder and major depression (commonly comorbid with panic disorder), the choice between the two largely rests on patient preference. Antidepressants are preferred for those who are pessimistic regarding the potential benefit of CBT, cannot afford CBT, or are unable (or unwilling) to invest the time necessary to complete a course of CBT. In our experience, some patients may accrue significant beneht from the combined treatment, particularly those with more moderate symptoms who struggle with the exposure aspects of therapy. 

SSRls and SNRIs. The SSRl antidepressants, together with venlafaxine, have replaced the benzodiazepines as treatments of choice for GAD. Paroxetine and escitalopram are FDA approved for GAD, though it is generally believed that all SSRls and SNRIs are effective for GAD. Similar to the TCAs, SSRIs/SNRIs appear to be most effective for the intrapsychic symptoms of GAD but less effective than benzodiazepines for the somatic manifestations of the disorder. 

Antidepressants and clonidine are the most commonly used augmentation strategies for ADHD. If the patient has tics or is troubled by insomnia, clonidine is a reasonable choice. After collecting a baseline EKG, clonidine should be started at 0.05 mg at bedtime for children and adolescents and 0.1 mg at bedtime for adults. The dose can be increased every 2 weeks or so while monitoring the patient s blood pressure and pulse. Although it has not been studied as well, guanfacine may work in much the same manner as clonidine. 

The serotonin-boosting antidepressants are a reasonable first choice in the treatment of impulsivity and mood lability in patients with BPD. They have proved effective in the limited studies conducted thus far and are also easy to tolerate and safe in overdose. This last factor is an important consideration when treating BPD patients prone to impulsivity and at times suicidal behavior with little advance warning. When these antidepressants are used, they should be started and titrated in a similar fashion to that used in the treatment of major depression and other mood... 

Treatment of choice - second-generation antidepressants such as a SSRI,... 

Treatment of choice - mood stabilizer with or without an antidepressant (e.g. lithium, valproate, carbamazepine, lamotrigine). Antidepressants include an SSRI, venlafaxine, mirtazepine as possibilities but few controlled trials to substantiate choice. 

Depression In general, the MAOIs appear to be indicated in patients with atypical (exogenous) depression, and in some patients unresponsive to other antidepressive therapy. They are rarely a drug of first choice. 

Donohue, Julie M., and Ernst R. Berndt. 2004. Effect of Direct-to-Consumer Advertising on Medication Choice The Case of Antidepressants. Journal of Public Policy Marketing 2- 2) n5-n7. 

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