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Prescribing Newer Antidepressants

The Carlat Psychiatry Blog, Volume , Number ,

Michael Gitlin, MD, director of the Outpatient Mood Disorder Program at UCLA gave The Carlat Psychiatry Report his view on newer antidepressants. He emphasized that these newer medications are no more effective than our standard antidepressants, but that it’s always good to have more options available for patients who may not have responded to—or who can’t tolerate—other medication trials. Here are some of Dr. Gitlin’s impressions about the newer antidepressants.

Vilazodone (Viibryd)
“It has serotonin transporter blocking properties like an SSRI, and it seems to affect the serotonin A1 receptor like buspirone. But while it has been shown to help for comorbid anxiety and for generalized anxiety disorder when compared to placebo, there isn’t any data to show it’s any better than SSRIs for these conditions.

Be aware that vilazodone can be overly stimulating, which might not be something you want for a patient with comorbid anxiety. To minimize that kind of side effect, have the patient take it in the morning. Also let patients know that the rate of stimulation diminishes over a period of weeks.

Use the dosing that the manufacturers recommend: Start at 10 mg, then 20 mg, and then up to 40. Be aware, though, that dosing at 40 can cause nausea or added stimulation. The vilazodone package insert says that absorption is improved if you take vilazodone with food.”

Vortioxetine (Trintellix)
“Like vilazodone, vortioxetine has clear SSRI-like properties: It blocks the presynaptic serotonin transporter, but unlike vilazodone, it also prominently affects many of the serotonin subreceptors. Let patients know that GI side effects can include nausea, vomiting, diarrhea, and constipation.
As for dosing, start at 5 mg, go up to 10, and don’t exceed a full dose of 20 mg. At 20 mg, side effects can become an issue.”

Levomilnacipran (Fetzima)
“Levomilnacipran is an isomer of milnacipran, which is marketed as Savella, a drug FDA indicated for fibromyalgia. But milnacipran has close to a dozen controlled studies showing that it’s an effective antidepressant. It is an SNRI, a dual action agent, so you can compare it with other SNRIs, including venlafaxine, desvenlafaxine, and duloxetine. As for implications of levomilnacipran’s noradrenergic prominence? It doesn’t affect its efficacy, but rather its side effect profile. Tell patients that side effects include constipation and sweating.”

Registered users and subscribers can read the full interview with Dr. Gitlin, including his take on the role of antipsychotics for treating depression. Become a subscriber today, or register for free here.