Cipramil, Cipralex, Cymbalta, Trevilor. To whom will I give what antidpressant and when?

Nachdem das Buch Psychopharmakotherapie griffbereit ja nun schon ins Tschechische übersetzt wird, expandiert das Psychiatrie to go-Universum nun auch in den Rest der Welt. Einer der am häufigsten gelesenen Artikel auf diesem blog ist der Artikel über meine Strategie, welches Antidepressivum ich wem verschreibe.

Renate FitzRoy, die in Schottland lebt und als Übersetzerin arbeitet (ihre webseite findet ihr hier), war so freundlich, diesen post ins Englische zu übersetzen. Vielen Dank! Und hier findet ihr den Text in der englischen Übersetzung:

Cipramil, Cipralex, Cymbalta, Trevilor. To whom will I give what antidpressant and when?

Once I have made up my mind to prescribe an antidepressant, I follow a certain algorithm in my head to decide which medication I will use.

Question 1: Has the patient been given an antidepressant in the past and has it been effective?

If the answer is yes, I will use the same medication again. Full stop. End of algorithm.

Question 2: Do I prescribe the antidepressant for a generalised anxiety disorder?

Then I’ll prescribe Duloxetine (Cymbalta) or Venlafaxin (Trevilor), the latter has been licensed especiallly for genrealised anxiety disorder. Both are very effective for this indication and both should be given at high doses.

Question 3: Do I prescribe the antidepressant for a compulsive-obsessive disorder?

Then I use first Citalopram (Cipramil). I will go for a higher dose, at first 40 mg per day and then decide individually whether a higher dose is appropriate in spite of known risks. The QTc interval must be monitored and the patient made aware of the warning. At doses higher than 40 mg, Citalopram may prolong the QTc interval and cause dangerous arrhythmia (for more details click here).

Then there are unipolar and bipolar depressions left.

Question 4: Is it a depression with low activity, normal activity or hyperactivity (agitated depression)?

  • In patients with very low activity, I begin with Duloxetine (Cymbalta), target dose 60-90 mg.
  • With somewhat low to normal activity, I prescribe Citalopram as a first step, target dose 40 mg per day. This usually achieves good results.
  • If not satisfied with the success in a low-activity depression, I will quickly (two weeks) change over to Duloxetine (Cymbalta) because not only does it inhibit the reuptake of serotonin (as does Citalopram), but it also inhibits the reuptake of noradrenaline, which will lead to more activity.
  • In patients with normal activity, I will only switch to Duloxetine if no progress has been made after 3-4 weeks.
  • With heightened activity levels and disturbed sleep patterns in particular, I prefer Mirtazapine at night. However, I only recommend it if weight is not a problem and I discussed the possibility of weight gain with the patient (and they are happy to go ahead). I start with 15 mg at night. Depending on the severity of the sleeping disorder and agitation, I may go up to 45mg per day. If this sorts out the sleeping problem and normalises activity, I stick with 15mg Mirtazapine at night and add 20-40 mg Citalopram in the morning.

This algorithm works for 95 % of cases. If the medication is not effective or side effects occur, I use the following medication instead:

  • Citalopram (Cipramil) is not tolerated: -> try Escitalopram (Cipralex). Both are just serotonin reuptake inhibitors and are usually well tolerated and very effective.
  • Duloxetine is not effective enough: -> try Venlafaxine. Both inhibit the reuptake of serotonin as well as noradrenaline. Given at high doses, Venlafaxine has the unwanted side effect of also inhibiting the reuptake of dopamine, which can trigger or reinforce delusion/hallucination-like symptoms. It often makes the patient more restless than Duloxetine, but may be more effective in individual cases.

What about old antidepressants ?

  • Clomipramine is what I sometimes use as augmentation in compulsive-obsessive disorders.
  • Amitriptylin is what I sometimes use in chronic pain disorders.
  • Fluoxetine, Fluvoxamine, Mianserine, Paroxetine and the other older antidepressants are only used according to Rule 1: it has been effective before and may help again. I do not use them otherwise.

And if all that is not effective?

  • Augmentation with Lithium. Often helpful.
  • Augmentation with thyroid hormone. Rarely helps. I only use it occasionally.

Other things to bear in mind:

  • Severe psychotic depression: ECT.
  • If there is a psychotic component or delusion-like brooding, a low dose of an antipsychotic should be added.
  • In patients with great anxiety and no history of addiction, think of a benzodiazepine.
  • In suicidal patients, add a benzodiazepine.
  • Bear in mind the normal timescale of improvement: Approx. two weeks after taking antidepressants, activity often increases, while the mood will often lift after four weeks. Anxiety disorders improve after four to six seeks, compulsive-obsessive disorders often after six to twelve weeks only.