Intended for healthcare professionals

Clinical Review

ABC of mental health: Psychotropic drug treatment

BMJ 1997; 315 doi: (Published 13 September 1997) Cite this as: BMJ 1997;315:661
  1. Soumitra R Pathare,
  2. Carol Paton


    This article takes a broad view of the factors affecting the choice and effectiveness of common drugs in psychiatric use. Specific treatment issues are dealt with in earlier articles in this series.

    Antidepressant drugs

    Decision tree for drug treatment of depression

    All antidepressants are equally effective in treating depression, and no single drug has been shown to have a more rapid onset of action than another. The choice of antidepressant is dictated by a combination of factors including the clinical presentation, the patient's physical health, the anticipated side effect profile, and the prescriber's preferences.

    Types of depression—Certain types of depression respond better to particular classes of drugs, such as atypical depressive illness to monoamine oxidase inhibitors or mixed anxiety and depression to selective serotonin reuptake inhibitors. Patients with agitated depression respond well to a sedating tricyclic drug such as amitriptyline. If social withdrawal is prominent, a “stimulating” antidepressant such as imipramine or a selective serotonin reuptake inhibitor such as fluoxetine may help.

    Suicide risk—Overall, selective serotonin reuptake inhibitors are safer than tricyclics in overdose, with dothiepin having been found to be the most toxic. Since suicide risk in any given patient is extremely difficult to predict, it has been argued that selective serotonin reuptake inhibitors should be the first choice of treatment in all cases of depressive illness. The financial implications of completely abandoning tricyclics in favour of selective serotonin reuptake inhibitors are enormous. However, the cost of drug related morbidity and treatment failure due to poor compliance must also be considered. For the moment, the most effective and economical way to prevent suicide is to

    • Identify those at greatest risk of suicide

    • Give small supplies to patients at risk—a week's prescription at a time

    • Use a therapeutic dose of any antidepressant, not a small dose of a “safe” one. …

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