Other antidepressant drugs

When the last edition of this book was coming out, antidepressants new to the market included Venlafaxine (see below) and Nefazadone. However, Nefazodone had to be withdrawn after a few years, because of liver toxicity. This should stand as a further warning, as if any were needed, against hasty prescription of new medications. (The wise psychiatrist will wait a few years while other doctors try out new drugs on their patients.) Nevertheless, the field of antidepressant prescribing seems to continue to be a 'dedicated follower of fashion'; the latest SSRI or other compound being likely to be widely adopted if it is innocuous and skillfully marketed.

Flupenthixol, which has somewhat confusingly been renamed flupentixol, is mainly used as an antipsychotic drug - most frequently as the long-acting depot injection Modecate. However, low doses (1-3 mg daily) are given by mouth as an antidepressant medication. It can be a useful adjunct when there has been a partial response to other forms of antidepressant treatment.

Tryptophan is a precursor of the amines and is thought to be low in depression. It was a popular adjuvant treatment in depression some years ago, but had to be withdrawn because of eosinophilia-myalgia syndrome. This was probably due to contamination of supplies with yeast. It is now available again; it should be initiated under specialist supervision.

Venlafaxine has been successfully marketed as 'a serotonin noradrenaline reuptake inhibitor or SNRI', although, of course, it shares this characteristic with other existing drugs. However, it has fewer sedative and antimuscarinic effects than the TCAs. The Committee on Safety of Medicine (CSM) recommends that venlafaxine be initiated and maintained by specialists only, and avoided in patients with heart disease, electrolyte imbalance, and hypertension.

Mirtazepine, a presynaptic a2-antagonist, increases brain noradrenaline and serotonin functionality. It is markedly sedative; it is useful in anxiety for that reason, but it also seems to be an effective antidepressant. Other drugs include reboxetine and duloxetine.

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