What is the best choice
of antidepressant for Madam KS?

         The first-line pharmacotherapies for
depression are the selective serotonin reuptake inhibitor (SSRI), the serotonin
and norepinephrine reuptake inhibitor (SNRI), and the norepinephrine-dopamine
reuptake inhibitors (NDRI) bupropion. SSRI is replacing tricyclic
antidepressant (TCA) as the standard for first-line therapy due to several
reasons. SSRI is easier to prescribe because it can be started at a therapeutic
dose, requiring less titration. Furthermore, SSRI causes less intolerable
adverse effects in comparison with TCA, hence results in better compliance.
Besides, the efficacy of SSRI is as good as the TCA. Most importantly, SSRI is
safer in case of overdose compared to TCA especially in suicidal patients. The
Fatal Toxicity Index of the SSRI is between 1/10 and 1/30 of the TCA.

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         In the case of Madam KS, SSRI is the
appropriate choice of drug. Among the SSRIs, she was prescribed with
fluvoxamine initially. Fluvoxamine has been shown to have the highest affinity
at the ?1-receptor thus is more superior to be used in psychotic depression.
Apart from that, in contrast to paroxetine, sertraline, and fluoxetine,
fluvoxamine has no effect on psychomotor speed, cognitive processing or arousal
hence the patient would be able to carry out daily activities. Moreover, it has
been observed that fluvoxamine has inhibitory effect on melatonin degradation
which has not been noticed in other SSRIs hence it benefits sleep quality.
There is study suggests that fluvoxamine improves sleep quality more rapidly
than fluoxetine. There is also evidence shows that fluvoxamine causes less
disruption in sleeping pattern as compared with paroxetine which would result
in drug induced sleep disruption till the withdrawal phase 1.
Therefore, fluvoxamine is the suitable drug of choice unless my patient develops
adverse effects.


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