Indications: treatment of major depressive disorder

Cautions: elderly; predisposition to seizures (prescribe only if benefit clearly outweighs risk) including concomitant use of drugs that lower seizure threshold, alcohol abuse, history of head trauma, and diabetes; measure blood pressure before and during treatment.

Contra-indications: acute alcohol or benzodiazepine withdrawal; severe hepatic cirrhosis; CNS tumour; history of seizures, eating disorders, or bipolar disorder.

Hepatic impairment: reduce dose to 150 mg daily; avoid in severe hepatic cirrhosis.

Renal impairment: reduce dose to 150 mg daily

Pregnancy: avoid—no information available

Breast-feeding: present in milk—avoid

Side Effects: dry mouth, gastro-intestinal disturbances, taste disturbance; agitation, anxiety, dizziness, depression, headache, impaired concentration, insomnia (reduced by avoiding dose at bedtime), tremor; fever; pruritus, rash, sweating; less commonly chest pain, flushing, hypertension, tachycardia, anorexia, asthenia, confusion, tinnitus, and visual disturbances; rarely hepatitis, jaundice, palpitation, postural hypotension, vasodilatation, abnormal dreams, ataxia, dystonia, depersonalisation, hallucinations, hostility, incoordination, irritability, impaired memory, paraesthesia, seizures, twitching, blood-glucose changes, urinary frequency, urinary retention, exacerbation of psoriasis, and Stevens-Johnson syndrome; very rarely aggression, delusions, paranoid ideation, and restlessness; also reported suicidal ideation.

Dose: ADULT over 18 years, start 1–2 weeks before target stop date, initially 150 mg daily for 6 days then 150 mg twice daily (max. single dose 150 mg, max. daily dose 300 mg; minimum 8 hours between doses); period of treatment 7–9 weeks; discontinue if abstinence not achieved at 7 weeks; consider max. 150 mg daily in patients with risk factors for seizures; ELDERLY max. 150 mg daily.