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Table 3 Experts' ratings: Choice of antidepressant

From: Expert opinion on detecting and treating depression in palliative care: A Delphi study

Drug
0 = not useful, 10 = very useful
Experts comments
Mirtazapine
Round 1: Median 9.0 (7-10); n = 11
Round 2: Median 9.0 (7-10); n = 11
-Some data, good profile regarding side effects, at this time most used
-Seems well tolerated
-When side effects on sleep and appetite are handy
-Too soft
-Has useful sedative properties and well tolerated
-My first-line - evidence is that it is more effective than SSRIs and appetite stimulant and sedative qualities are useful side effects
Citalopram
Round 1: Median 9.0 (5-10); n = 11
Round 2: Median 9.0 (5-10); n = 13
-Side effects due to its antIHJJistaminic action
Venlafaxine
Round 1: Median 7.5 (0-10); n = 8
Round 2: Median 8.0 (0-9); n = 13
-Less side effects than tricyclics
-Useful if patient needs help for sedation
-If depression is associated with chronic high level of anxiety
-Not straightforward - discontinuation symptoms common. Cardiac toxicity
Sertraline
Round 1: Median 7.0 (2-10); n = 11
Round 2: Median 7.5 (0-10); n = 12
-Favourable side effect profile
-Interaction with dopamine system could give different and more side effects than other SSRIs
-Least adverse effects, presently best available
Escitalopram
Round 1: Median 8.0 (0-10); n = 10
Round 2: Median 7.0 (0-10); n = 13
-Not cost effective alternative to citalopram
-Better tolerated than R-citalopram and less interaction with cytocrome 450 2D6
Amitriptyline
Round 1: Median 5.0 (1-9); n = 10
Round 2: Median 4.0 (0-8); n = 12
-Side-effects
-Too sedative, effect too delayed, frequent compliance obstacle due to side effects
-If indicated for neuropathic pain
-For individual TCAs I don't think there is sufficient evidence to differentially rate, although clinically I would favour those drugs that are used most often in palliative care anyway e.g. amitriptyline
-An excellent antidepressant
Paroxetine
Round 1: Median 5.5 (0-9); n = 10
Round 2: Median 3.0 (0-7); n = 13
-Too many pharmacological interactions
-Interactions and withdrawal problems
-No place - withdrawal syndrome
Fluoxetine
Round 1: Median 3.0 (0-6); n = 10
Round 2: Median 3.0 (0-6); n = 13
-Too long half time, not useful for physically ill people
-Long t1/2 and interactions
-Too disinhibitory, but not better antidepressant than other SSRIs
Imipramine
Round 1: Median 5.0 (0-6); n = 7
Round 2: Median 2.0 (0-8); n = 11
-Just in patients with depressive history who have already utilized before
Nortriptyline
Round 1: Median 2.0 (0-9); n = 9
Round 2: Median 2.0 (0-7); n = 11
-If indicated for neuropathic pain
-Less than amitriptyline
Mianserin
Round 1: Median 5.0 (0-9); n = 7
Round 2: Median 0.0 (0-7); n = 11
-Little used in practice compared with other drugs and little evidence available
-No point really - it is pharmacologically similar to mirtazapine, which doesn't hit the white cells