Non-Pharmacologic

·        CBT-Cognitive behavioral therapy

·        IPT-Interpersonal therapy

·        Motivational interviewing

·        Psycho-education:

Pharmacologic

·      SSRI: Fluoxetine 20-40 mg PO daily SE : NVD, abdominal cramps, restlessness, H/A, Insomnia, sexual dysfunction, wt gain, increase risk of GI bleeding

 NB: Discontinuation syndrome: N\V, restlessness, sexual impotence, anorgasmia

·      SNRI: Venlafaxine 37.5 -75 mg PO OD SE: dry mouth, anxiety, avoid in HTN, dizziness

·      SARI: Trazadone SE: Priapism

·      NDRI: Bupropion 150-300 mg PO OD SE: Wt loss, seizures, insomnia. CI: eating disorders, seizures

·      T_eCA: Mirtazapine 30-45 mg day SE: weight gain, sedation

·      TCAs: Amitriptyline 25-200mg/day SE: anticholinergic effects, antihistaminergic effects (sedation, weight gain, orthostatic hypotension), sexual dysfunction

·      MOI: Phenelzine, Isocarboxazid, Tranylcypromine, Selegiline

·      RIMA (Reversible inhibitor of Monoamine oxidase A): Moclobemide

** F/U after 4 weeks

Approach to management

• Begin with a trial of antidepressant for 4-6weeks.
• If there is a full response to therapy, continue as maintenance for at least one year
• If partial response augment or combine with CBT, IPT, lithium or any of the 2^nd generation antipsychotics (aripiprazole, olanzapine, quetiapine or risperidone) and follow up in another 4 -8 weeks
• If no response to this augmentation or if there was no response at all in the initial 4-6 weeks of trial of antidepressant, consider switching to another anti-depressant class. If no response, switch again or combine with another antidepressant class (e.g. SSRI or SNRI plus bupropion or mirtazapine)

 Causes of tiredness

MAD SHRIMP

• M- Meications
• A - Anaemia
• D- Depression
• S - Sleep problems
• H- Hypothyroid
• R- Rheumatoid arthritis
• I – Idiopathic/infections eg HIV, TB
• M- Multiple sclerosis
• P - Polymyalgia, Fibromyalgia