Least sedating ssri
In 2009, researchers based in Europe and Japan created substantial controversy when their data suggested that escitalopram and sertraline were superior in efficacy and acceptability among commonly prescribed antidepressants.
Reflecting this continuing uncertainty, the latest practice guideline by the Agency for Health care Research and Quality does not recommend one agent over another and suggests only that differences in side effect profiles should be considered when choosing an antidepressant.
To date, no specialty organization has offered recommendations on how to choose antidepressants in a rational, evidence-based manner, leaving primary care doctors on the front lines with little guidance.
So how should primary care doctors select which antidepressants to use?
In this article we present the theory and evidence for an individualized, patient-centered treatment model for major depression designed around a targeted symptom cluster-based approach to antidepressant selection.
When using this model for healthy adults with major depressive disorder, the choice of antidepressants should be guided by the presence of 1 of 4 common symptom clusters: anxiety, fatigue, insomnia, and pain.
Individuals with this symptom cluster may benefit most from an SSRI (Table 2).
This suggests that certain “side effects” of antidepressants—for example, sedation or activation—may be capitalized on to treat specific symptoms of depression.Any primary care model for a symptom cluster-based approach to antidepressant selection must be centered on a set of commonly occurring symptoms, each of which may effectively be treated by a pharmacologically appropriate class or classes of antidepressants.Based on available evidence and expert consensus, the most common and clinically relevant symptoms accompanying depression are anxiety, fatigue, insomnia, and pain.Since deficiencies of norepinephrine and dopamine are thought to be the cause of atypical depression, recommending an SNRI (to increase norepinephrine) or NDRI (to boost both norepinephrine and dopamine) is the logical choice.
Fluoxetine, an unusual SSRI with some norepinephrine reuptake inhibition, Under the current proposal, the best antidepressants for treating the symptom cluster of fatigue, weight gain, and anhedonia should be bupropion (NDRI), venlafaxine or desvenlafaxine (SNRIs), and fluoxetine (SSRI) (Table 3).It is important to note that the same neurons arising from the brainstem that mediate anxiety also project to the frontal cortex to control mood and to the basal ganglia to influence obsessions and compulsions.