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ramandeepdargan

Choice of Antidepressant

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What do people think is the best antidepressant in an over 65 with low Na and postural hypotension?

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Why not treat the hyponatraemia and postural hypotension, and then put them on mirtazapine?

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cause symptoms are severe enough now.....agree that with these physical problems u cant get a good MSE...but symptoms seem out of proportion

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Depends on how bad the hyponatraemia is, and it's cause. Should only take a couple of days to fix though. If it can't wait that long, then put them on one that is more sodium friendly, or ECT if they're very severe.

How low is the sodium?

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128 ... i have put on trazodone....i know it can cause postural hypoension but thought out of postural hypotension and lo Na postural hypotension is less serious.

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Mirtazepine for me- works, and doesn't interact cos of being processed by different cytochromes- v important in elderly with multiple meds...

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Trazodone to work as an antidepressant probably you need to get up to atleast 150 mg. To get up to that dose in elderly that too in a lady with postural hypotension is going to take some time. If you rush trazodone is notorious for causing falls. Mirtazapine is a good choice with concomittant search for the cause and treatment of hyponatremia. Other alternatives that I would give careful consideration are Lofepramine and Venlafaxine.

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yes i was thinking of lofeprmine but wasnt confident of limited experience with it

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I have been using it for a while now ( Lofepramine). It has proved to be useful especially in patients with Lewy body dementia/Parkinson's disease. It comes in liquid form as well. So you can start in extremely tiny doses and slowly build it up and is usually well tolerated. The one problem I have noted is constipation but as you know it is lesser of the evils and can be treated well if we are aware of it.

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All antidepressants have been reported to present with hyponatremia, including Trazodone and Lofepramine... although SSRIs as a class are most prone.

Reboxetine, nortryptilline and mirtaz have been the least reported ones... but thats probably because they are less used compared to SSRIs, but even if %s are taken, Mirtaz, rebox and nortryp are less prone to cause hyponat...

But I would go along with Chris... correct the hyponatremia... sometimes the depressive symptoms improve... (but it usually takes time) and then try Mirtaz... (although I am not sure if Mirtaz works at all)...

My personal treatment of choice for any depression for any age would be Venlafaxine...

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If the patient is in safe environment and under supervision to minimise risks such as suicide its no harm in waiting to start antidepressants till the hyponatremea is treated(128 doesnot sound too low and it might not take that long to correct with proper fluid balance) antidepressant itself might take more time to act and risks of further hyponatremia increases.

talking therapies, might be worth trying if the depression is not severe(as suggested ECT is available for severe depression)

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My personal treatment of choice for any depression for any age would be Venlafaxine...

Exactly my thoughts as well dorian

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I think Venlafaxine should be reserved as second and third line.

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I think Venlafaxine should be reserved as second and third line.

Why is that? is it just on the basis of nice guidelines? or is there some evidence to say that depression become resistant if treated with Venlafaxine before an SSRI?

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On the contrary I think the question should be framed why Venlafaxine as a first choice? when weve got other 'soft' ones. or u belive in 'Hit them hard in the first go'

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On the contrary I think the question should be framed why Venlafaxine as a first choice? when weve got other 'soft' ones. or u belive in 'Hit them hard in the first go'

Oh yes... I believe in that... whats wrong in hitting them hard in the first go... In fact that has got a lot of advantages... patient satisfaction to say the least... moreover I dont understand the concept of a soft antidepressant... Venla is an SSRI at lower doses but an SNRI at higher dose... that said, I guess a dose of 150 and above will be a standard dose (upto 300)...

It has the same side effect profile as SSRI... including the caution in epilepsy and cardiac disease...

The only extra thing is its hypertensive effect at >225mg, in known hypertensives, which can be controlled by tweaking the antihypertensives...

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Wat do ppl think about Reboxetine, Moclobemide for depression. I know Moclobemide is also licensed for social phobia but we all know about these licenses as they dont mean a great deal.

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On the contrary I think the question should be framed why Venlafaxine as a first choice? when weve got other 'soft' ones. or u belive in 'Hit them hard in the first go'

[highlight]Oh yes... I believe in that.[/highlight]. whats wrong in hitting them hard in the first go... In fact that has got a lot of advantages... patient satisfaction to say the least... moreover I dont understand the concept of a soft antidepressant... Venla is an SSRI at lower doses but an SNRI at higher dose... that said, I guess a dose of 150 and above will be a standard dose (upto 300)...

It has the same side effect profile as SSRI... including the caution in epilepsy and cardiac disease...

The only extra thing is its hypertensive effect at >225mg, in known hypertensives, which can be controlled by tweaking the antihypertensives...

Well then theres no argument if thats ur 'clinical decision' but i disagree

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On the contrary I think the question should be framed why Venlafaxine as a first choice? when weve got other 'soft' ones. or u belive in 'Hit them hard in the first go'

[highlight]Oh yes... I believe in that.[/highlight]. whats wrong in hitting them hard in the first go... In fact that has got a lot of advantages... patient satisfaction to say the least... moreover I dont understand the concept of a soft antidepressant... Venla is an SSRI at lower doses but an SNRI at higher dose... that said, I guess a dose of 150 and above will be a standard dose (upto 300)...

It has the same side effect profile as SSRI... including the caution in epilepsy and cardiac disease...

The only extra thing is its hypertensive effect at >225mg, in known hypertensives, which can be controlled by tweaking the antihypertensives...

Well then theres no argument if thats ur 'clinical decision' but i disagree

but, let's add in....

1) there's no convicing evidence that venlafaxine is more effective than any other antidepressant.

2) 'same side effect profile' as ssri's is debateable. most of the drugs have the same side effects listed on their spc in a different order and in different proportions. that may or may not mean they have the same side effect profile depending on your viewpoint.

3) it may be more toxic in overdose than alternatives.

4) it appears that it is more likely to cause withdrawal symptoms than alternatives.

5) contrary to your assertion i don't think there is any evidence relating to venlafaxine and patient satisfaction.

so, to summarise.

it appears that the evidence in favour of prescribing venlafaxine first line is that reps imply that it is a stronger antidepressant by virtue of it's effects on two neurotransmitters despite the fact that rcts do not show a convincing difference.

the evidence against is that it is clearly no more effective than alternative drugs, patients are more likely to discontinue it due to side effects than alternatives, it is more likely to cause withdrawal symptoms than alternative drugs,

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J, I'll have to disagree

Venlafaxine is a great antidepressant and way better than the others

Clinical experience should not be dismissed with disdain

and we all know how much evidence based evidence based medicine is

having said that, one has to decide the treatment based on individual case and their presenting symptom profile and one can argue that venlafaxine should be reserved as a second line

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j

1. I agree there is no 'solid evidence'.... but thats the case for treatment of any psychiatric disorder.

I think there is some data (atleast 3 meta analysis) to show that Venlafaxine slightly edges over SSRIs

Thase ME, Entsuah AR, Rudolph RL. Remission rates during treatment with venlafaxine or selective serotonin reuptake inhibitors. Br J Psychiatry. 2001;178:234-241.

Smith D, Dempster C, Glanville J, Freemantle N, Anderson I. Efficacy and tolerability of venlafaxine compared with selective serotonin reuptake inhibitors and other antidepressants: a meta-analysis. Br J Psychiatry. 2002;180:396-404

Nemeroff C, Entsuah R, Willard L, Demitrack M, Thase M. Comprehensive Pooled Analysis of Remission (COMPARE) data: venlafaxine vs SSRIs. World J Biol Psychiatry. 2004;5(suppl 1):92.

Although there is equal number of data to show that Venlafaine is not superior to SSRI...

I think we are being caught in the middle of war between industries.

In such a case, there is not going to be enough evidence for anything....

2. Side effect profile again is very subjective, each person may experience  different side effects; I went through the BNF to look at the listed side effects, and they were similar except for the caution for the hypertension.

3. Toxicity in overdose probably true ( I dont know if there is 'solid evidence' to say SSRIs are less toxic in an overdose; again individual variations)

4. Withdrawal symptoms again are similar to SSRIs (only exception being fluoxetine probably). I have seen a withdrawal reaction for all antidepressants especially Paroxetine and Fluvoxamine, which could be as bad as any other withdrawals.... But this is hoping that our clinical skills will help them be compliant with the medications...

5. Well... as far as patient satisfaction goes, the evidence is strictly personal, when people get better, they are satisfied, and I have seen more people getting better with Venlafaxine than SSRIs (in my limited clinical experience, and I expect to see the gap widening)...

That said, its not all about the dual acting effect, because I dont find duloxetine to be as effective... (again limited experience)

But...

I dont think there is enough evidence to quote anything with confidence as far as mental illness is concerned...

There is a recent editorial by Leucht and Davis in Schiz bulletin, which says that there is no evidence for anything we do in Schizophrenia, nevertheless, we do treat people with antipsychotics (which is just one of the treatments for just one of the domains of the complex illness)...

As far as evidence based medicine in psychiatry is concerned, we are still groping in the dark... We are not even sure what the etiology of common mental illness are... and to date, most of the treatement we use were serendipitous discoveries....

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That doesnt give us a licence to do whatever we like.and every medical speciality has gone through this stage....Psychiatry i think is in early 'exploratory and understanding phase' and i dont thik whatever has been achieved till now should be trivialised........even discovery of gravitation was serendipity.....

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I have worked under 1 or 2 consultants who had a very concrete view of medication that they preferred. At times, i felt as if my personal judgement was taken away. They had all the studies in their brain to prove their point but ultimately, I have learnt after working with a few other consultants that we should choose for the individual patient. I agree that one drug may be the best but some of our patients can respond even to the unpopular ones. NICE guidelines- I will refrain from commenting on it bcos there is a lot of cost effectiveness etc and lets not venture into that area.

Lets leave it to the patient. Many depressives might have known family members or even friends who might have got better with fluoxetine, mirtazapine or whatever . One of my consultants used to ask the pt if he knew of these medication and what he thought worked for his friends. He would prescribe him that medication provided it is indicated. He often told me that this is a psychological boost for the patients as you are listening to them and giving them the choice and that autonomy itself can give them the courage to beat their blues.

You may agree or diagree with this but I admired this man as he got his patients better with practical strategies.

Patients choice in some situations can be helpful.

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