Abuse and misuse of antidepressants

Figures & data

Table 1 Abused and misused antidepressants: effects and adverse effects

Drug/drug class	Route of administration	Reported drug effect	Potential adverse effects
Bupropion	Intranasal > oral > intravenous	Stimulant-like effects including euphoria and enhanced motivation; “high”	Seizure, psychotic symptoms, cardiotoxicity; withdrawal/discontinuation phenomena
Monoamine oxidase inhibitors	Oral	Stimulant-like effects	Hypertensive crisis, delirium, thrombocytopenia; withdrawal/discontinuation phenomena
Tricyclic antidepressants	Oral	Euphoria, “high”, more sociable; dissociative effects including: distorted sense of time and “numbness”	Confusion, delirium, seizure, orthostatic hypotension, cardiac conduction disorder, cardiac arrhythmia; withdrawal/discontinuation phenomena
Serotonin and norepinephrine reuptake inhibitors	Oral (one case involved crushing pills and ingesting oral)	Stimulant-like effects, more empathic and sociable, euphoria	Hypertensive crisis, weight loss, tremor; withdrawal/discontinuation phenomena
Selective serotonin reuptake inhibitors	Oral (one case involved opening tablets and ingesting contents oral) >> intravenous	Stimulant-like effects	Appetite suppression, serotonin syndrome, seizure; withdrawal/discontinuation phenomena
Tianeptine	Oral >> intra-arterial	Stimulant-like effects	Appetite suppression; withdrawal/discontinuation phenomena
Amineptine	Oral	Stimulant-like effects	Tachycardia, decreased appetite and weight loss, irritability, insomnia, hepatotoxicity

Note: No published cases of abuse/misuse were found of serotonin 2 (5-HT2) receptor antagonists (eg, trazodone, nefazodone) or alpha-2 adrenergic receptor antagonists (eg, mirtazapine).

Table 2 Clinical tools and principles for minimizing risk of antidepressant misuse

Method of ascertainment	Example	Principle
Clinical interviews	Obtain history of illicit substance and alcohol abuse Obtain history of antidepressant and other prescription medication misuse Ask about family history of substance abuse Consider motivation for misuse	Universal precautions reduce stigma and improve care
Objective instruments	Screening tools (eg, Screening, Brief Intervention, and Referral to Treatment	Uniform approach to baseline risk assessment using objective measures
Ongoing monitoring	Urine toxicology, serum drug levels, frequent appointments, monitor for aberrant behaviors (eg, early refill requests, erratic appointment attendance, indifference to side effects)	Combining objective data with clinical observation is more effective at minimizing risk