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Other factors to consider include: Some people experience withdrawal effects after missing 1 or 2 doses, especially when using a drug with a short half-life (e.g. At the end of a treatment course, taper antidepressant over several weeks and monitor for withdrawal symptoms. SSRIs are relatively activating and usually best given as a single daily dose each morning.
Routine use of doses above those recommended rarely increases antidepressant effect.
Continuation of the same antidepressant can also be considered in patients who show a partial response at 6 weeks.
Treatment resistance This is defined as a lack of satisfactory response after a trial of two antidepressants given sequentially at an adequate dose for an adequate time, with or without psychological therapy.
When withdrawing treatment on completion or otherwise, reduce the dose gradually over at least 4 weeks to avoid discontinuation symptoms.
Some improvement is usually seen within two weeks of starting antidepressant treatment at a therapeutic dose.
For most indications the SSRIs are considered first-line as they are better tolerated and have a wider safety margin than the tricyclic antidepressants (TCAs) and irreversible nonselective monoamine oxidase inhibitors (MAOIs).
MAOIs (phenelzine, tranylcypromine) are now rarely used because of their severe, and potentially fatal, interactions with some foods and medications.
SSRIs are metabolised by different isoenzymes, hence their potential for interaction varies which may influence drug choice.Citalopram is a relatively weak inhibitor of CYP2D6 compared with the other SSRIs, and thus it interacts with a more limited range of drugs than fluoxetine and paroxetine.The most important interactions are those with other drugs that affect serotonergic neurotransmission as these can lead to serotonin toxicity and, in severe cases, serotonin syndrome Features of serotonin toxicity (see Table 4) may be relatively mild, such as tremor and low grade restlessness. Serotonin syndrome is the most severe form of serotonin toxicity characterised by a recognised cluster of prominent and severe clinical features that usually require supportive management and stopping the causative agent(s).start with 25–50 mg of nortriptyline and increase by 25 mg every third night to 100 mg.It is usual to take SSRIs in the morning due to the risk of insomnia and TCAs at night because they may be sedative.