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Antidepressant Drug Selection Treatment App


Antidepressant medication classes


Background

  • People are most likely to develop their first depressive episode between the ages of 30 and 40.
  • Females are affected about twice as often as males.
  • Major depressive disorder affects over 160 million people (~2% of the world's population).
  • Response rates to the first antidepressant administered range from 50 to 75%.
  • It can take at least six to eight weeks from the start of medication to improvement.
A major depressive episode implies a prominent and relatively persistent (nearly every day for at least two weeks) depressed or dysphoric mood that usually interferes with daily functioning, and includes at least five of the following nine symptoms:
  • Depressed mood
  • Loss of interest in usual activities
  • Significant change in weight and/or appetite
  • Insomnia or hypersomnia
  • Psychomotor agitation or retardation
  • Increased fatigue
  • Feelings of guilt or worthlessness
  • Slowed thinking or impaired concentration
  • Suicide attempt or suicidal ideation
  • Note:  In DSM-5,  major depressive disorder is classified as a mood disorder. The diagnosis hinges on the presence of single or recurrent major depressive episodes. Additionally, qualifiers are used to classify both the episode itself and the course of the disorder.


Selections


 

Goal:  Find the most effective antidepressant medication or combination of medications with minimal side-effects.

Serotonin Reuptake Inhibitors - SSRIs


Select this option for any of the following:

  • Need general info or dosing guidelines for available agents?
  • Switching a patient from a current SSRI to an alternative SSRI.

See link above for additional information on discontinuing an antidepressant or performing a cross-taper.


  • Citalopram (Celexa)
  • Escitalopram (Lexapro)
  • Fluoxetine (Prozac)
  • Fluvoxamine (Luvox)
  • Paroxetine (Paxil)
  • Sertraline (Zoloft)

 

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)


Select this option for any of the following:

  • Need general info or dosing guidelines for available agents?
  • Switching from another agent to an SNRI or using dual therapy.

  • Desvenlafaxine (Pristiq)
  • Duloxetine (Cymbalta)
  • Venlafaxine (Effexor)
  • Levomilnacipran (Fetzima)

 

 

Tricyclic antidepressants (TCAs)


Select this option for any of the following:

  • Need general info or dosing guidelines for available agents?
  • Switching from another drug  to a TCA or using it as an add on.
 
  • Amitriptyline (Elavil)
  • Desipramine (Norpramin)
  • Doxepin (Sinequan)
  • Imipramine (Tofranil)
  • Nortriptyline (Pamelor)


 

Norepinephrine and Dopamine Reuptake Inhibitor (NDRI)


Select this option for any of the following:

  • Need general info or dosing guidelines for available agents?
  • Switching from another drug to bupropion or adding this agent.

  • Bupropion (Wellbutrin)



 

Mixed Serotonergic Effects (Mixed 5-HT)


Select this option for any of the following:

  • Need general info or dosing guidelines for available agents?
  • Switching from another drug  to a mixed serotonergic drug or adding this drug to the current regimen.

  • Nefazodone (Serzone)
  • Trazodone (Desyrel; Oleptro)
  • Vilazodone (Viibryd)
  • Vortioxetine (Brintellix)


 

Serotonin and α2-Adrenergic Antagonist


Select this option for any of the following:

  • Need general info or dosing guidelines for available agents?
  • Switching from another drug to mirtazapine or adding it.
 
  • Mirtazapine (Remeron)



 

Monoamine Oxidase Inhibitors (MAOIs)

Key info for this group omitted for the initial release of this program.

  • Phenelzine (Nardil)
  • Selegiline (transdermal) (Emsam)
  • Tranylcypromine (Parnate)
  • Isocarboxazid (Marplan)


 
 





Clincial Pearls


Treatment failures or inadequate response top of page

Clinical result -  Action taken

  • Most patients are started on an SSRI --> if inadequate response consider maximizing the dose after confirming compliance with therapy.  If the patient had an adverse effect specific to that drug, consider changing to an alternative SSRI or move to one of the other classes such as a dual reuptake inhibitor.
  • If the patient has an inadequate response after maximizing the dose, consider the addition of a second agent or switching to a non-SSRI antidepressant.
  • If the patient responds to therapy, maintain current regimen and reevaluate the patient at each visit.
  • If the patient fails to respond to single or dual therapy at maximal doses while attempting changes within some of the classes, consider adding an atypical antipsychotic (2nd generation) drug such as aripiprasole, brexipiprazole, olanzepine or quetiapine for refractory patients.



References top of page

 

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association;2013.

  2. Bousman CA, Dunlop BW. Genotype, phenotype, and medication recommendation agreement among commercial pharmacogenetic-baseddecision support tools. Pharmacogenomics J. 2018;18(5):613-
    622. [PubMed: 29795409]

  3. Cleare A, Pariante CM, Young AH et al. Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2015;29(5):459-525. [PubMed: 25969470]

  4. Cipriani A, Forukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. Lancet. 2018;391:1357-1366. [PubMed: 29477251]

  5. Gaynes BN, Rush AJ, Trivedi MH, et al. The STAR*D study: Treating depression in the real world. Cleve Clin J Med. 2008;75(1):57-66. [PubMed:18236731]

  6. Hasin DS, Sarvet AL, Meyers JL et al. Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the united states. JAMA
    Psychiatry. 2018;75(4):336-346. [PubMed: 29450462]

  7. Kok RM, Reynolds CF. Management of depression in older adults: A review. JAMA. 2017;317(20):2114-2122. [PubMed: 28535241]

  8. La Torre A, Giupponi G, Duffy D, Conca A. Sexual dysfunction related to psychotropic drugs: A critical review—part I: Antidepressants.
    Pharmacopsychiatry. 2013;46(5):191-199. [PubMed: 23737245]

  9. Lesch KP, Gutknecht L. Pharmacogenetics of the serotonin transporter. Prog Neuropsychopharmacol Biol Psychiatry . 2005;29(6):1062-1073. [PubMed: 15951088]

  10. Maletic V, Robinson M, Oakes T, et al. Neurobiology of depression: an integrated view of key findings. Int J Clin Pract . 2007;61(12):2030-2040. [PubMed: 17944926]

  11. Mann JJ. The medical management of depression. N Engl J Med. 2005;353(17):1819-1834. [PubMed: 16251538]

  12. McIntyre RS. The role of new antidepressants in clinical practice in Canada: A brief review of vortioxetine, levomilnacipran ER, and vilazodone. Neuropsychiatr Dis Treat. 2017;13:2913-2919. [PubMed: 29238196]

  13. Mohamed S, Johnson GR, Chen P et al. Effect of antidepressant switching vs augmentation on remission among patients with major depressive disorder unresponsive to antidepressant treatment. The VAST-D randomized clinical trial. JAMA. 2018;318:132-145.

  14. Rosenblat JD, Lee Y, McIntyre RS. Does pharmacogenomics testing improve clinical outcomes for major depressive disorder. A systematic review of clinical trials and cost-effectiveness studies. J Clin Psychiatry. 2017;78(6):720-729. [PubMed: 28068459]

  15. Sullivan PF, Neale MC, Kendler KS. Genetic epidemiology of major depression: Review and meta-analysis. Am J Psychiatry. 2000;157(10):1552-1562.  https://pubmed.ncbi.nlm.nih.gov/11007705/.

  16. Stone EA, Lin Y, Quartermain D. A final common pathway for depression? Progress toward a general conceptual framework. Neurosci Biobehav Rev . 2008;32(3):508-524. [PubMed: 18023876]

  17. Taylor C, Fricker AD, Devi L, et al. Mechanisms of action of antidepressants: From neurotransmitter systems to signaling pathways. Cell Signal. 2005;17(5):549-557. PubMed: 15683730]].

 

Antidepressant Drug Selection Treatment App