Review regularly once diagnosis has been made and treatment initiated.
Initially within 1-2 weeks. Consider phone review after a week if needed. This can be made by any member of a primary health team, i.e. practice nurse.
Continue to monitor risk and ask about suicide. In the first few days of treatment with an SSRI an increase in anxiety, restlessness or agitation may occur. This can be distressing and may be associated with increased suicidality.
Review again after 4 weeks and then ideally every 3 months until decision made to cease treatment.
Consider using Kessler Score or PhQ-9 to monitor progress
If antidepressants have been prescribed then ask about side effects particularly:
- symptoms of hyponatraemia – dizziness, lethargy, nausea, confusion, cramps, seizures
- hypertension/ hypotension – if taking venlafaxine
- mania
- anti-cholinergic symptoms
- sedation, insomnia, activation, changes in weight, sexual dysfunction.
Some side effects can be managed and will decrease with time, i.e. mild nausea and headaches. This information can be given to a patient to help manage their expectations.
Sexual dysfunction is a common problem with many medications particularly SSRIs.
The following guide provides a framework for managing antidepressant-induced sexual dysfunction:
- rule out other causes
- wait: some patients will improve within six months
- reduce dose: risk of relapse
- switch to antidepressant with lower risk of sexual dysfunction (e.g. mirtazapine, moclobemide, bupropion) -NZF switch table
- add low dose of bupropion or mirtazapine (more evidence for bupropion than mirtazapine). Women are more likely to respond to bupropion than sildenafil or tadalafil.
- add sildenafil or tadalafil (more effective for men than women)
- exercise: high drop-out rate.
The following table details the comparative rates of common side effects amongst the commonly prescribed antidepressants
Medicine |
Anticholinergic |
Agitation/ insomnia |
GI* |
Sedation |
Weight gain |
Sexual dysfunction |
QT prolongation |
SSRIs
|
|
|
|
|
|
|
|
Citalopram
|
0
|
+
|
+
|
0
|
+
|
+++
|
+
|
Escitalopram
|
0
|
+
|
+
|
0
|
+
|
+++
|
+
|
Fluoxetine
|
0
|
++
|
+
|
0
|
+
|
+++
|
+
|
Paroxetine
|
+
|
+
|
+
|
+
|
++
|
++++
|
0/+
|
Sertraline
|
0
|
++
|
++
|
0
|
+
|
+++
|
0/+
|
|
|
|
|
|
|
|
|
SNRI/NaSSA
|
|
|
|
|
|
|
|
Venlafaxine
|
0
|
+
|
++
|
0/+
|
+
|
+++
|
+
|
Mirtazapine
|
+
|
0
|
0
|
++++
|
++++
|
+
|
+
|
|
|
|
|
|
|
|
|
TCAs
|
|
|
|
|
|
|
|
Amitriptyline
|
++++
|
0
|
+
|
++++
|
++++
|
++
|
+++
|
Clomipramine
|
++++
|
+
|
+
|
++++
|
++++
|
++
|
++
|
Dosulepin (dothiepin)
|
+++
|
0
|
+
|
++++
|
++++
|
++
|
+++
|
Doxepin
|
+++
|
0
|
0
|
+++
|
++++
|
++
|
+++
|
Imipramine
|
+++
|
+
|
+
|
+++
|
++++
|
++
|
+++
|
Nortriptyline
|
++
|
0
|
0
|
++
|
+
|
++
|
+++
|
|
|
|
|
|
|
|
|
MAOIs
|
|
|
|
|
|
|
|
Moclobemide (RIMA)
|
+
|
0
|
+
|
0/+
|
0/+
|
0/+
|
0/+
|
Phenelzine
|
+
|
+
|
+
|
++
|
++
|
+++
|
0
|
|
|
|
|
|
|
|
|
Atypical
|
|
|
|
|
|
|
|
Bupropion
|
0
|
+
|
+
|
0
|
0
|
0
|
+
|
It is also important to identify any possibility of serotonin syndrome which is a severe form of serotonin toxicity. The can be mild with tremor and low grade restlessness or present with more severe symptoms as below. This may require supportive management and cessation of the causative agents. If severe the patient may require referral to an emergency department as it can be fatal.
Features of Serotonin Toxicity (BPAC - 2009)
Clinical Features |
Contributing factors |
Abdominal cramps, agitation, diarrhoea, myoclonus, tremulousness, coma, tachycardia, hypotension, disorientation, profuse sweating, hyperpyrexia.
|
- Overdosage
- Drug interaction, especially SSRI + MAOI or SSRI + serotonergic TCA (e.g. clomipramine, amitriptyline, imipramine)
- Inadequate drug-free interval in changing medications
- Idiosyncratic reaction
|
There are several drugs and herbal products that have serotonergic activity and therefore can cause serotonin syndrome when combined or given alone at high doses.
Drugs that may cause serotonin toxicity (BPAC -2009)
Class |
Drugs |
antidepressants
|
TCAs (especially clomipramine), MAOIs (including moclobemide), SSRIs, mirtazapine, venlafaxine, St John’s Wort
|
opioids
|
Tramadol, pethidine, dextromethorphan
|
stimulants
|
Amphetamines, sibutramine
|
5HT1 agonists
|
Sumatriptan, naratriptan, zolmitriptan
|
others
|
Ecstasy, LSD, cocaine. Selegiline, tryptophan, buspirone, lithium, linezolid
|
For more information on Serotonin syndrome/toxicity – Medsafe Prescriber Update