Pharmacological Interventions



Medication Advantages Disadvantages






Reduced risk of toxicity in overdose

Better tolerated than other ADs; better compliance

Fewer interactions; due to shorter half lives; better in those on multiple medications

Effective in the treatment of depression with anxiety

Increased risk of bleeding; consider a PPI in older people and in patients on NSAIDs or aspirin

SSRIs can exacerbate hyponatraemia; especially in the elderly

Citalopram and escitalopram increase the QT interval - avoid with these drugs

Sertraline may result in higher rates of diarrhea


Fluoxetine Paroxetine


Fluoxetine is more commonly used in younger adults; start with 10mg daily for several days

Fluoxetine; lower rates of withdrawal symptoms and suicidal thoughts or behavior 

Paroxetine can be used for pain treatment in patients with depression

High propensity for interactions

Increased likelihood of the person stopping treatment because of side effects

Monitor the elderly more closely for side-effects and start on low dose

Paroxetine; higher rate of withdrawal symptoms such as suicide, higher risk of weight gain an sexual symptoms

Fluoxetine; longer half life and more potential interactions

Avoid in women on tamoxifen



Used in chronic pain (fibromyalgia, chronic musculoskeletal pain, peripheral neuropathy) as well as depression

Increased likelihood of stopping treatment because of side effects; need to increase the dose more gradually

May increase blood pressure


Licensed for anxiety with symptoms such as palpitation, sweating and tremor



Side effects

Drug Anticho-linergic Cardiac Postural Hypo-tension Nausea Sedation Insomnia Procon- vulsant Sexual Dysfunction Weight Gain Withdrawal Symptoms Inhibition of Hepatic QT Interval Prolon-gation  Toxicity in Over-dose Specific Problems
Sertraline * * ** *** * *** * ***  ** *** ** * * All SSRIs Can: a. Increase nervouseness in first three days of treatment  b. Possibly increase risk of suicide attempts in depressed chldren and adolescents c. increased risk of gastrointestinal bleeding.
Citalopram * * ** **** * *** * ***  ** *** ** **  *
Fluoxetine * * ** ***  * ***  * ***  ** U **** * *
Escitalopram * * ** ***  * ***  * ***  ** ***  ** ** *
Paroxetine * * ** ***  * ***  * **** ***  **** **** * *
Duloxetine * * ** **** ** ***  U ***  ** U ** * U  
Propranolol  *    ***                      



Antianxiety medication

Start dose Adults <65y

Max dose Adults <65y

Start dose Adults >65y

Max dose Adults >65y

Hepatic impairment

Renal Impairment







No information available for eGFR less than 20 mL/min; start at reduced dose and titrate slowly







Caution if eGFR less than 30 mL/ min: Start at reduced dose and titrate slowly






Reduce dose or increase dose interval in mild to moderate impairment.

Use with caution
Fluoxetine  20mg 60mg 20mg 40mg Caution  due to prolonged half-life No adjustment needed
Paroxetine  20mg 50mg 20mg 40mg Caution due to prolonged half-life  In severe impairment: initial dose 10mg max dose 40mg 
Duloxetine  60mg 120mg 60mg 120mg Avoid Avoid if eGFR less than 30 mL/minute/1.73 m2
Propranolol 40 mg od  40 mg  tds        


 check all this 

  • The DTB reports a study that tried to work out how many people who had not responded to an antidepressant at 4 weeks would get a benefit if the same one was continued until 8 weeks.
  • Always ask about alcohol history, and take this into account when considering treatment options, particularly drug options
  • The importance of continuing once remission achieved.
  • The risk and nature of discontinuation symptoms (especially with paroxetine and venlafaxine).
  • Review the patient after 2w, and then 2–4 weekly for the first 3m. See review section
  • If <30y or risk of suicide, see more often (e.g. after 1w).
  • If significant side-effects early in treatment:
  • Continue with close monitoring if acceptable to patient.
  • Stop/change antidepressant.
  • Offer short-term (2w) benzodiazepine to help anxiety/agitation, but not in those with chronic anxiety ( or previous drug dependence or alcohol dependence issues) as they are more likely to develop dependence
  • Expect initial improvement after 2–4w. If no/minimal response after 3–4w, increase support and consider:
  • If inadequate response after 6–8w, consider switching to an alternative antidepressant 
  • Remember that a single antidepressant usually gives fewer side-effects than combinations of antidepressants.
  • When switching antidepressants:
  • If one SSRI has been ineffective, try an alternative SSRI.
  • If that is ineffective, try an alternative class of antidepressants (venlafaxine, tricyclic, MAOI). 





benzo = Do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises.

antipsychotic - Do not offer an antipsychotic for the treatment of GAD in primary care


gastroprotective drug



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