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Clinician’s Corner: Older Miscellaneous Anti Depressants

This column is a “catch all” of the older miscellaneous drugs. All are available generically, and the newest one is 25 years old.  What I love about this column all these drugs were introduced after I graduated pharmacy school in 1981.  We dispensed a lot of Desyrel® until the late 1980’s when Prozac and the other SSRI’s and later Effexor® and the SNRI’s took over the depression market. Today trazodone is dosed mostly at bedtime for insomnia

Wellbutrin® was another one of those drugs with a peculiar mechanism, in that it did not cause drowsiness, like all the others. I remember when the insurance companies refused to pay for Zyban, because it was for smoking cessation.  Practitioners then wrote for “Wellbutrin-SR”, then the insurance companies required a prior auth for all bupropion!  Those insurance companies have been saying “NO” for a very long time! Your Thompson Pharmacist is always a great resource for you when the insurance companies say NO! Let your Thompson Pharmacist work with your doctor to provide you alternatives.

Next week will cover the “newer” miscellaneous antidepressants.

Trazodone (Desyrel®) 50, 100 and 150mg tablets {FDA approved Dec-1981}

Side effects: dizziness, lightheadedness, confusion, drowsiness, fatigue, headache, dry mouth, priapism (even at lower doses)

Other Uses

  • Decrease alcohol cravings
  • Reduce depression and anxiety in patients with alcoholism
  • Panic disorder and agoraphobia with panic attacks (300mg)
  • Insomnia due to antidepressant therapy.

Distinguishing Features: causes low blood pressure and dizziness. (caution in elderly, especially when dosed at bedtime), more commonly used for insomnia than major depressive disorder

  • Doses for insomnia are less than for depression treatment

Bupropion (Wellbutrin, Zyban) {FDA approved Dec-1985}

Mechanism of Action: norepinephrine and dopamine reuptake inhibitor (NDRI)

Dosage

  • Starting dose: must be started low and increased to minimize the risk of seizures. Don’t exceed 450mg per day.

Other Uses

  • Weight loss
  • Attention deficit disorder
  • Neuropathic pain
  • Smoking cessation
  • Adjunct to other anti-depressant therapy.
  • Bupropion plus an SSRI (like Prozac and Zoloft) is the most common antidepressant combination

Side Effects

  • Less nausea, diarrhea, and sleepiness than SSRIs
  • Seizures: be sure to titrate slowly!
  • Blurred vision
  • Agitation
  • GI disturbances
  • Tremor
  • Excessive sweating
  • Weight loss
  • High blood pressure
  • Dry mouth
  • Insomnia
  • Constipation
  • Does NOT cause sexual dysfunction + is minimally sedating
    • Often the choice antidepressant for patients complaining of sexual side effects & decreased energy levels.

ABUSE POTENTIAL: Bupropion is called “poor man’s cocaine” because users say it gives them a cocaine-like high for about $2.50/pill

Distinguishing Features

  • May be beneficial in patients with fatigue, poor concentration, and interested in smoking cessation.
  • Appetite-suppressing effects (weight neutral)
  • No sexual dysfunction
  • Caution in patients with psychotic features. Doesn’t help with anxiety.
  • Contraindicated in patients with bulimia, anorexia, and seizure disorder

Mirtazapine (Remeron®)  {FDA approved: June 1996}

Side effects: dizziness, drowsiness and weight gain.

Unlabeled uses: sleep apnea, weight gain, antipsychotic induced akathisia. Some prescribers will use in the elderly to stimulate the appetite and cause weight gain.