Common mental health medicines
Chris Johnson,
Antidepressant Specialist Pharmacist NHSGGC – Dec 2013
Outline
Non-medicalised
• Non-pharmacological
Drugs (Pharmacological)
• Antidepressants
• Anxiolytics and hypnotics
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Non-medicalised
• Addressing causes of stress
– Money worries, relationship issues, etc
• Exercise – 20-30min walks
• Good sleep hygiene
– Bedtime routine
– ↓/avoid caffeine
• Irn-Bru, coke, Red Bull, tea, coffee
– ↓/avoid alcohol
– Make time to unwind
• Meditation, prayer, quiet time
• Make time for yourself
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Antidepressants - Uses
• Depression (Moderate to severe)
• Anxiety disorders
– General anxiety disorder (GAD)
– Panic disorder
– Post Traumatic Stress Disorder (PTSD)
• Nerve pain
– Neuropathic pain – Diabetes, slipped discs
• Insomnia
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Different antidepressants
• Selective serotoinin re-uptake inhibitors (SSRIs)
– Citalopram, fluoxetine, sertraline, etc
• Tricyclic antidepressants
– Amitriptyline, lofepramine, clomipramine, etc
• Others
– Mirtazapine, venlafaxine, trazodone
• Monoamine oxidase inhibitors
– Phenelzine, etc
• General theory on how antidepressants work
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Time to effect – Therapeutic doses
SSRIs
• Depression (initial doses)
– 20’s plenty – citalopram, fluoxetine, paroxetine
– 50’s enough – sertraline
• Anxiety disorders
– Start lower and increase according to response
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Time to effect – Therapeutic doses
• TCAs
– Depression – 100-150mg
– Anxiety – depends on the drug
• Mirtazapine – Depression 30-45mg
• Venlafaxine
– Depression 75mg to 150mg
– Anxiety – start 75mg
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SSRIs - 20’s Plenty & 50’s Enough!
Adli M, et al. Is dose escalation of antidepressants a rational strategy after a mediumdose treatment has failed? A systematic review. Eur Arch Psychiatry Clin Neurosci
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2005;255:287-400.
As an example all antidepressants demonstrate a similar profile
Benkert O, M. Muller M, Szegedi A, Hum Psychopharmacol Clin Exp 2002; 17: S23–S26.
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Time to effect
• Depression (Moderate to severe)
– 2-4 weeks some effect
• Response
– 1/3 full response
– 1/3 partial response
– 1/3 no response
• Anxiety (Moderate to severe)
– Up to 6 weeks
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Papakostas GI J Clin Psychiatry 2007;68(supp 10):11
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Side effects
When starting
• SSRIs
– Nausea 82% reducing to 32%
– Restlessness, agitation – settles within 10 days
• Rare suicidal thoughts
• Venlafaxine
– 45% nausea
• TCAs and mirtazapine
– Drowsiness
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Side effects – sexual dysfunction
Antidepressant
• 3-8% report this SE
• 34-75% report on direct
questioning
Venlafaxine
SSRIs
Approximate
prevalence of
sexual
dysfunction
70%
60-70%
Tolerance to side effect
Duloxetine
• 10% disappears
TCAs
• 11% partially disappears Mirtazapine
Placebo
Trazodone
46%
30%
25%
14%
Unknown
Adapted from Maudsley 2012 and
Serretti & Chiesa 2009.
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Side effects
• Insomnia/sedation (hypersomnia)
– SSRIs
• 22% insomnia
• 38% hypersomnia
– TCAs,
– Mirtazapine (low dose 15mg)
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Side effects
• Falls
– Especially elderly
– Bigger doses more risk
TCAs – Mirtazapine - SSRIs
• Cognitive dysfunction – TCAs
– Affects thought processes
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Weight changes
Antidepressant
Depression
• ↓/↑ weight
• ↓ appetite
• ↓ motivation
Amitriptyline
On treatment
• Reduced symptoms
– ↑motivation
Imipramine
13.3%
Mirtazapine
12.7%
Fluoxetine
4.8-6.8%
Sertraline
4.2%
Citalopram
3.9%
Placebo
Venlafaxine
• Drug effects
– ↑ carbohydrate craving
% Patient with
Weight gain
22%
2.6-6.3%
Weight loss.
Weight gain can vary from 0.5-1kg with
SSRIs8 to 2.5-3.3kg with mirtazapine7
Summarised from review articles: Papakostas 2007 and
Fava 2000
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How long’s a course
Depression
• 1st episode – 6 months
• 2nd episode – 12 months
• 3rd or more – 2 years (or longer)
Anxiety
• 1st episode – 9-12 months
• Other episodes – individual basis
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Anxiolytics and hypnotics - Use
• Muscle spasms (short term)
• Epilepsy
• Anxiety (short term 2-4 weeks max)
• Insomnia (short term 2-4 weeks max)
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Anxiolytics and hypnotics
• Benzodiazepines
– Hypnotics – nitrazepam, temazepam, diazepam
– Anxiety – diazepam, lorazepam, chlordiazepoxide
• Z-hypnotics
– Zopiclone, zolpadem
• How they work
• Others
– Promethazine – sedating antihistamine
– Propranolol – beta-blocker
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But for insomnia!!
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Side effects B&Zs
Benzos and z-hypnotics – same problems
• Day time sedation
• Falls – hip fractures
• Cognitive dysfunction (affects thoughts processes)
• Confusion
– ?Dementia
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Side effects – B&Zs
• Disinhibition (like alcohol)
– Risk if thoughts of suicide
• Paradoxical effects
– Increase anxiety and insomnia
• Increase depressive symptoms
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Side effects others
• Propranolol
– Slow heart rate
– Fatigue
– Cold hand and/or feet
– Avoid in asthma
• Promethazine
– Next day sedation
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Other drugs
• St Johns Wort (Hypericum) - Depression
– Interacts with lots of medicines
– Similar effect to paroxetine BMJ 2005;330:503.
– Not necessarily better tolerated!!
• Omega-3 fatty acids
– Treatment resistant depression add-in?????
• Valerian – insomnia
– Similar to oxazepam (n=70)
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Stopping Antidepressants/Benzos
Speed of reduction depends on
• Which drug?
– Some more withdrawals than others
• How long you have been taking them?
Generally
• Slow and managed (minimises withdrawals)
• With follow up
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Support Services
• Libraries – Health reading section
• Glasgow SPCMH http://glasgowspcmh.org.uk/home.php
• Glasgow Help. http://glasgowhelp.com/home.php
• Moodgym (CBT) http://moodgym.anu.edu.au/welcome
• NHS Choices http://www.nhs.uk/Pages/HomePage.aspx
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