The question concerns a 66-year-old female with depression. In 1982-83 she was treated with Tryptiz

Fråga: The question concerns a 66-year-old female with depression. In 1982-83 she was treated with Tryptizol (amitriptyline) 100 mg daily. In September 1983 she had a severe seizure type grand mal while on amitriptyline, after which the treatment was stopped. Now the patient has become depressed again. Which antidepressant should be used?

Sammanfattning: Seizures are a rare side-effect of antidepressants treatment, but have been reported for all groups of antidepressants. The literature is contradictory, but apparently no antidepressants are superior in causing fewer seizures. Seizures are associated with overdose of all antidepressants, and it must be recommended that an antidepressant suitable for therapeutic drug monitoring be used, for instance nortriptyline, for which therapeutic drug monitoring is well established.

Svar: Seizures are a rare side-effect of antidepressant treatment. An American study reported only 16 patients with a convulsive disorder as a result of antidepressant treatment out of 42000 patients treated with antidepressants (1).

Concerning the tricyclic antidepressants, seizures have been reported to the Swedish Adverse Drug Reactions Advisory Committee (SADRAC) (2) for clomipramine, lofepramine, amitriptyline, nortriptyline and protriptyline. Seizures are stated as a side-effect in FASS (3) for all of the tricyclic antidepressants except lofepramine and nortriptyline. For maprotiline and mianserine seizures have been reported and are also mentioned in FASS (3). Of the new antidepressants seizures are only mentioned as a side-effect for fluvoxamine (3), but have been reported to SWEDIS for fluvoxamine, citaloprame, paroxetine and moclobemide.

Rosenstein et al (4) found it difficult to evaluate the relative risk for seizures among the different antidepressants because available data are not comparable. Nevertheless, they state that the selective serotonin reuptake inhibitor fluvoxamine (and fluoxetine, not registered in Sweden) appears to have a lower incidence of seizures than the other antidepressant drugs. On the other hand Rudorfer et al state that the relatively low seizure rate with tricyclic antidepressants is favourable compared with the newer compounds (5).

Seizure risk increases with all antidepressants following overdose (4). Preskorn et al found a correlation between elevated plasma concentrations of tricyclic antidepressants and tricyclic antidepressant-induced seizures and suggested that the incidence of seizures can be reduced by therapeutic drug monitoring (6).