Pharmacological treatments in MH:
Antidepressants- for depression/anxiety:
Antidepressants usually need to be taken for 1 or 2 weeks (without missing a dose)
before the benefit starts to be felt. It's important not to stop taking them if you get
some mild side effects early on, as these effects usually wear off quickly.
If you take an antidepressant for 4 weeks without feeling any benefit, speak to your
GP or mental health specialist. They may recommend increasing your dose or trying
a different medicine.
A course of treatment usually lasts at least 6 months. Some people with recurrent
depression may be advised to take them indefinitely.
Different Classes:
1. Selective serotonin reuptake inhibitors (SSRIs)
Common mode of action and effects/side-effects: serotonin reuptake inhibition (leads to i5-HT in
synaptic cleft; see Table 7.6):
– 5-HT1A agonism—antidepressant, anxiolytic, anti-obsessive, anti- bulimic effects.
– 5-HT2 agonism—agitation, akathisia, anxiety/panic, insomnia, sexual dysfunction.
– 5-HT3 agonism—nausea, GI upset, diarrhoea, headache.
Advantages: ease of dosing; may be better tolerated than TCAs—fewer anticholinergic side-
effects; low toxicity in overdose.
Disadvantages: may be less effective for severe depressive episodes; problems on
discontinuation (see b p. 964).
The most common symptoms of SSRI discontinuationsyndrome are described as either
being flu-like, or feeling like a sudden return of anxiety or depression.
...
1 They include:
Dizziness.
Vertigo.
Lightheadedness.
Difficulty walking.
Nausea/vomiting.
Fatigue.
Irritability.
Headaches.
, Common examples: Citalopram; Fluoxetine, Sertraline
Citalopram:
Indication: depressive illness (moderate- severe), panic disorder
Side effects: risk of suicide as it increases suicidal thoughts
Interactions:
Monitoring:
Education:
2. Serotonin/noradrenaline reuptake inhibitors (SNRIs):
Mode of action: 5-HT and NE reuptake inhibition.
Common adverse effects: nausea, GI upset, constipation, loss of appetite, dry mouth, dizziness,
agitation, insomnia, sexual dysfunction, headache, nervousness, sweating, weakness.
Commonly prescribed: Venlafaxine, Duloxetine
Interactions
NSAIDs: NICE guidelines advise 'do not normally offer SSRIs', but if
given co-prescribe a proton pump inhibitor
warfarin / heparin: NICE guidelines recommend avoiding SSRIs and
considering mirtazapine
aspirin: see above
triptans - increased risk of serotonin syndrome
monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin
syndrome
SSRIs and pregnancy
BNF says to weigh up benefits and risk when deciding whether to
use in pregnancy.
Use during the first trimester gives a small increased risk of
congenital heart defects
Use during the third trimester can result in persistent pulmonary
hypertension of the newborn
Paroxetine has an increased risk of congenital malformations,
particularly in the first trimester
Antidepressants- for depression/anxiety:
Antidepressants usually need to be taken for 1 or 2 weeks (without missing a dose)
before the benefit starts to be felt. It's important not to stop taking them if you get
some mild side effects early on, as these effects usually wear off quickly.
If you take an antidepressant for 4 weeks without feeling any benefit, speak to your
GP or mental health specialist. They may recommend increasing your dose or trying
a different medicine.
A course of treatment usually lasts at least 6 months. Some people with recurrent
depression may be advised to take them indefinitely.
Different Classes:
1. Selective serotonin reuptake inhibitors (SSRIs)
Common mode of action and effects/side-effects: serotonin reuptake inhibition (leads to i5-HT in
synaptic cleft; see Table 7.6):
– 5-HT1A agonism—antidepressant, anxiolytic, anti-obsessive, anti- bulimic effects.
– 5-HT2 agonism—agitation, akathisia, anxiety/panic, insomnia, sexual dysfunction.
– 5-HT3 agonism—nausea, GI upset, diarrhoea, headache.
Advantages: ease of dosing; may be better tolerated than TCAs—fewer anticholinergic side-
effects; low toxicity in overdose.
Disadvantages: may be less effective for severe depressive episodes; problems on
discontinuation (see b p. 964).
The most common symptoms of SSRI discontinuationsyndrome are described as either
being flu-like, or feeling like a sudden return of anxiety or depression.
...
1 They include:
Dizziness.
Vertigo.
Lightheadedness.
Difficulty walking.
Nausea/vomiting.
Fatigue.
Irritability.
Headaches.
, Common examples: Citalopram; Fluoxetine, Sertraline
Citalopram:
Indication: depressive illness (moderate- severe), panic disorder
Side effects: risk of suicide as it increases suicidal thoughts
Interactions:
Monitoring:
Education:
2. Serotonin/noradrenaline reuptake inhibitors (SNRIs):
Mode of action: 5-HT and NE reuptake inhibition.
Common adverse effects: nausea, GI upset, constipation, loss of appetite, dry mouth, dizziness,
agitation, insomnia, sexual dysfunction, headache, nervousness, sweating, weakness.
Commonly prescribed: Venlafaxine, Duloxetine
Interactions
NSAIDs: NICE guidelines advise 'do not normally offer SSRIs', but if
given co-prescribe a proton pump inhibitor
warfarin / heparin: NICE guidelines recommend avoiding SSRIs and
considering mirtazapine
aspirin: see above
triptans - increased risk of serotonin syndrome
monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin
syndrome
SSRIs and pregnancy
BNF says to weigh up benefits and risk when deciding whether to
use in pregnancy.
Use during the first trimester gives a small increased risk of
congenital heart defects
Use during the third trimester can result in persistent pulmonary
hypertension of the newborn
Paroxetine has an increased risk of congenital malformations,
particularly in the first trimester
