Depression and Suicide _ ______________________________________________________________________
Medication Interactions Most antidepressant drugs have clinically significant drug interactions and it is beyond the scope of this course to discuss all possible interactions. Practitioners are encouraged to con- sult references such as the Physician’s Desk Reference or the American Hospital Formulary Service for information about adverse drug-drug interactions. Strategies to Manage Side Effects Research has found that prescribing clinicians consistently underestimate both the frequency of side effects and patient discomfort caused by them, with distress caused by blurred vision and constipation being the most underestimated [202]. The suggested management of many side effects consists of either reducing the dose or discontinuing the medication. However, several focused interventions for specific side effects can be implemented when patients are reluctant to discontinue or switch to another medication, when the side effect is mild- to-moderate in severity, or when there is evidence of treatment response ( Table 3 ) [22].
ADDITIONAL CONSIDERATIONS WITH INITIAL THERAPY Duration of Initial Treatment Response trajectories are highly variable following antide- pressant initiation for MDD. Some patients show robust improvements within one to three weeks, while others have a slower velocity of symptom change. A sizeable subgroup lacks response, and an underidentified subgroup worsens [150; 203]. In predicting substantive response or remission six to eight weeks after treatment initiation, symptomatic improvement by two to three weeks is a modest predictor, but minimal symptomatic improvement by two to three weeks is a far more robust negative predictor of poor or non-response that signals the need to optimize treatment intensity [150; 203; 204; 205].
TREATMENT OF SIDE EFFECTS ASSOCIATED WITH ANTIDEPRESSANT USE
Side Effect
Treatment
Orthostatic hypotension
Fludrocortisone Add salt to diet
Dry mouth
Pilocarpine oral rinse Gum and/or hard candy
Constipation
Hydration Bulk laxatives Bethanechol
Urinary hesitancy
Visual changes
Pilocarpine eye drops
Sedation
Bedtime dosing Modafinil, armodafinil, methylphenidate Morning dosing Trazodone or melatonin at bedtime
Insomnia
Myoclonus
Clonazepam
Seizures
Antiepileptic medication
Impaired sexual arousal, erectile dysfunction, orgasm dysfunction
Sildenafil Tadalafil
Buspirone Bupropion Flibanserin
Hyperlipidemia
Statin medication Beta-blocker Benzodiazepines
Akathisia
Diaphoresis
Terazosin Clonidine Benztropine
Weight gain
Exercise Other antidepressant with less weight promotion, if necessary
Source: [22]
Table 3
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