Medication

SSRIs are better tolerated and are safer in overdose than other classes of antidepressant and so are often considered first line. Notes about specific SSRIs are given below.

• Sertraline: This may be a useful SSRI if there has been a recent cardiac event.
• QTCitalopram/escitalopram: Tablet and oral suspension available. It is useful for agitated depression/anxiety and relatively safe if the patient is at risk of seizures. There is a risk of QT prolongation and drug interactions. Review concurrent medications, refer to British National Formulary (BNF).
• Fluoxetine: It is long acting and offers low risk of withdrawal effects. It has many drug interactions so it may not be suitable in palliative care patients.

Side effects include:

• nausea, vomiting, anorexia, dyspepsia, diarrhoea
• risk of gastrointestinal (GI) bleeding - avoid or use with caution if history of GI bleeding, patient over 80 years or taking non-steroidal anti-inflammatory drugs (NSAIDs)/aspirin
• insomnia, sweating, impaired sexual function
• vivid dreams, agitation, hyponatraemia
• risk of serotonin syndrome in combination with other serotonergic medicines, for example tricyclics and some opioids.

• Tablet and oro-dispersible tablet.
• Appetite stimulant and sedative, particularly at lower doses.
• Well tolerated in the elderly and patients with heart failure.

• Amitriptyline: also treats nerve pain.

Side effects include:

• dry mouth, hypotension and confusion limit dose
• avoid if cardiac disease or risk of seizures
• sedative/anxiolytic action may be helpful.