Indications: major depressive disorder; generalised anxiety disorder; diabetic neuropathy stress urinary incontinence)

Cautions: elderly; cardiac disease; hypertension (avoid if uncontrolled); history of mania; history of seizures; raised intra-ocular pressure, susceptibility to angle-closure glaucoma; bleeding disorders or concomitant use of drugs that increase risk of bleeding.

Contra-indications: hepatic impairment renal impairment avoid if eGFR less than 30 ml/minute/1.73 m2, pregnancy toxicity in animal studies—avoid in patients with stress urinary incontinence; risk of neonatal withdrawal symptoms if used near term, breast-feeding: present in milk—manufacturer advises avoid

Side Effects: nausea, vomiting, dyspepsia, constipation, diarrhoea, abdominal pain, weight changes, decreased appetite, flatulence, dry mouth; palpitation, hot flush; insomnia, abnormal dreams, paraesthesia, drowsiness, anxiety, headache, dizziness, fatigue, weakness, tremor, nervousness, anorexia; sexual dysfunction; visual disturbances; sweating, pruritus; less commonly gastritis, halitosis, hepatitis, bruxism, dysphagia, tachycardia, hypertension, postural hypotension, syncope, raised cholesterol, vertigo, taste disturbance, cold extremities, impaired temperature regulation, impaired attention, movement disorders, muscle twitching, musculoskeletal pain, thirst, stomatitis, hypothyroidism, urinary disorders, and photosensitivity; rarely mania; very rarely angle- closure glaucoma; also reported supraventricular arrhythmia, chest pain, hallucinations, suicidal behaviour), seizures, hypersensitivity reactions including urticaria, angioedema, rash (including Stevens-Johnson syndrome) and anaphylaxis, hyponatraemia.

Dose: Major depression, ADULT over 18 years, 60 mg once daily.

Generalised anxiety disorder, ADULT over 18 years, initially 30 mg daily, increased if necessary to 60 mg once daily; max. 120 mg daily.

Diabetic neuropathy, ADULT over 18 years, 60 mg once daily; max. 120 mg daily in divided doses.

Note : In diabetic neuropathy, discontinue if inadequate response after 2 months; review treatment at least every 3 months.