🙂 Antidepressants

SSRIs are commonly first-line; SNRIs, mirtazapine, vortioxetine, TCAs and MAOIs have selected roles. Choice depends on diagnosis, previous response, symptom profile, comorbidity, interactions, overdose toxicity, pregnancy considerations and patient preference.

• Classes: SSRIs, serotonin modulators, SNRIs, NDRIs, NMDA antagonist, heterocyclics/TCAs, MAOIs, melatonergic agents, psychostimulants, ketamine/esketamine (1).

Confirm diagnosis/severity and screen for mania/hypomania, psychosis, substances and suicide risk. Review medications, bleeding risk, sodium risk and cardiac factors. Explain delayed benefit, early adverse effects and adherence.

Early activation or increased suicidal thinking, serotonin toxicity, severe hyponatraemia, mania, significant bleeding and arrhythmia/overdose require urgent review. TCAs are dangerous in overdose. MAOIs have major food/drug interactions.

• Citalopram: QT prolongation limits dose to 40 mg/day or less. Fluoxetine: very long half-life, least likely to cause discontinuation symptoms, and the only antidepressant proven effective in children. Fluvoxamine can raise theophylline, warfarin and clozapine levels (1).

SSRIs/SNRIs: GI upset, headache, anxiety/activation, sleep change and sexual dysfunction; SNRIs may raise BP. Mirtazapine may sedate and increase appetite/weight. Discontinuation symptoms follow abrupt reduction, especially with shorter half-life agents.

Review early after initiation and after dose changes, sooner when suicide risk is elevated. Continue after remission according to recurrence risk and guideline. Taper gradually and individualise; do not abruptly stop during pregnancy or acute illness without review.

• SSRIs cause discontinuation symptoms if stopped abruptly (less with fluoxetine) (1).