Antidepressants SSRI group

SSRIs (selective serotonin reuptake inhibitors) (Box 23.3) have been available on the UK market since 1989, and have been widely prescribed.

Their prescription to child patients; however, has become very controversial, because of lack of evidence of effectiveness in this patient group, and also concern over increased suicide risk. Recent NICE guidance is that 'antidepressant medication should not be used for the initial treatment of children and young people with mild depression'; even in moderate to severe depression; the place of medication is given as 'brief psychological therapy +/- fluoxetine' (http://www.nice. org.uk/page.aspx?o=cg028niceguidelineword).

On the face of it, there seems to be some discrepancy between this and the NICE guidance for adults: 'When an antidepressant is to be prescribed in routine care, it should be a selective serotonin reuptake inhibitor (SSRI)' (http://www. nice.org.uk/page.aspx?o=cg023niceguidelineword). However, NICE is really preaching to the choir on this. SSRIs have been vigorously promoted, and have been commercially successful. Many GPs use them as first-line treatment for depressive illness, on the basis of claimed therapeutic advantages that have not always stood up to critical examination.

In specialist care, there is seldom much point in initiating SSRI prescription, as most patients referred with depression will already have been tried on them in primary care. If they have had a good trial of an SSRI, there would be no point in trying a different SSRI, as the similarities far outweigh the differences.

If there has been no response, a different drug class (TCA or MAOI) should be tried. If there has been a partial response, a second drug (for example, trimip-ramine at night, especially if sleep remains a problem) can be added; this is a safe manoeuvre in specialist hands.

Occasionally, an SSRI may be added to the treatment regimen of a patient who has made a partial response to tricyclic antidepressant (TCA) medication; for example, adding fluoxetine 20 mg mane to the treatment of a patient taking trimipramine 150 mg nocte may have a modest effect in improving mood, and the alerting effects may also be useful.

Box 23.3 SSRI Antidepressants Generic name

Proprietary name

Citalopram

Cipramil

Escitalopram

Cipralex

Fluoxetine

Prozac

Fluvoxamine

F averin

Paroxetine

Seroxat

Sertraline

Lustral

Points of comparison between TCAs and SSRIs include:

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