Complications
Treatment options include: switching to a drug with a different mechanism of action (e.g., bupropion or mirtazapine or trazodone) or, in the absence of contraindications, considering augmentation with sildenafil.[470][471]
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Note that there is growing recognition of a more persistent negative impact on libido of these medications in some patients persisting after drug discontinuation; however, it remains poorly understood and characterised.[472]
Children, adolescents, and young adults may experience a transient increase in risk for self-injury, most severe with rapid escalation in dosing.[210] Close monitoring and risk management is recommended when prescribing an antidepressant to a person under the age of 25 years, or to anybody thought to be at increased risk for suicide.[165]
Weight gain is most common with mirtazapine but can also be seen with SSRIs, venlafaxine, and tricyclic antidepressants. Patient may be switched to bupropion.
Patient may be switched to another SSRI or a low-dose tricyclic antidepressant or mirtazapine may be added. Clinicians may consider offering a short course of benzodiazepines, starting at the lowest possible effective dose, to counter short-term agitation associated with SSRI initiation.
As many as 1 in 5 patients diagnosed with depression may later go on to experience mania, hence convert to a bipolar disorder diagnosis; the best predictor is a family history of bipolar disorder.[473] Depressed patients with undiagnosed bipolar affective disorder may convert to frank mania if they receive antidepressants. Ask patients about a prior history of manic episodes (e.g., periods of days to weeks marked by unusually high energy, euphoria, insomnia, hyperactivity, or impaired judgement) before starting antidepressant therapy.
Patients who develop manic or hypomanic symptoms after starting an antidepressant should be evaluated by a psychiatrist. Frank mania suggests bipolar illness and should prompt discontinuation of the antidepressant and initiation of a mood stabiliser, preferably under psychiatric supervision. Early initiation of mood-stabiliser drug therapy in bipolar disorder is important.[474]
Antidepressant-withdrawal mania or hypomania is an unusual event but may occur with almost any drug after sudden withdrawal, tapered discontinuation, or a decrease in dose.[475]
The syndrome may be self-limiting, may abate with the re-institution of the antidepressant, or may require anti-manic treatment. Mood stabilisers do not necessarily protect against the syndrome.[476]
It occurs after discontinuation of an antidepressant that was taken for at least 6 weeks. Typical symptoms include influenza-like symptoms, hyperarousal, insomnia, vertigo, and sensory disturbances (e.g., 'brain zaps'). Patients will often know how vulnerable they are to these symptoms, if they have ever skipped a dose or run out of their medication. Clinicians should slowly decrease the dose to reduce the risk of unpleasant discontinuation symptoms; this can usually be done over several weeks, but in some cases may take several months or longer in particularly susceptible patients.[324][328]
The use of SSRIs may be associated with an increased risk of suicidal behaviour in patients under 25 years old and reduced risk in adults over 25 years old.[213][477][478] Close monitoring and risk management is recommended when prescribing an antidepressant to a person under the age of 25 years, or to anybody thought to be at increased risk for suicide.[165]
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