From the Guidelines
For patients with a history of seizures, selective serotonin reuptake inhibitors (SSRIs) like sertraline (50-200 mg daily), citalopram (20-40 mg daily), and escitalopram (10-20 mg daily) are generally recommended as first-line antidepressant medications. These medications have a lower seizure risk compared to other antidepressant classes, as supported by the most recent evidence 1.
Key Considerations
- Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine (75-225 mg daily) and duloxetine (30-60 mg daily) are also relatively safe options.
- It's essential to start with lower doses and gradually increase to minimize seizure risk.
- Medications to avoid include bupropion, which may lower the seizure threshold, as noted in the context of naltrexone-bupropion ER for obesity treatment 1.
Treatment Approach
- Treatment should be continued for at least 6-12 months after symptom resolution to prevent relapse.
- SSRIs and SNRIs are preferred because they don't significantly lower the seizure threshold compared to tricyclic antidepressants and some other antidepressants.
- Close monitoring is essential, especially during dose adjustments, and coordination between the psychiatrist and neurologist is recommended to manage both depression and seizure disorders effectively.
Safety Precautions
- Patients should be observed for neuropsychiatric adverse effects, including suicidal thoughts and behaviors, especially in individuals younger than 24 years, as cautioned with the use of bupropion and other antidepressants 1.
From the Research
Recommended Antidepressant Medications
The following antidepressant medications are recommended for patients with a history of seizures:
- Selective serotonin reuptake inhibitors (SSRIs) such as sertraline, citalopram, fluoxetine, escitalopram, fluvoxamine 2, 3
- Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine, duloxetine 2, 3
- Mirtazapine, reboxetine, paroxetine 2, 3
Antidepressant Medications to Avoid
The following antidepressant medications are not recommended for patients with a history of seizures:
- Amoxapine, bupropion, clomipramine, maprotiline 2
Considerations for Prescribing Antidepressants
When prescribing antidepressants to patients with a history of seizures, the following considerations should be taken into account:
- The risk of seizures associated with antidepressant use, particularly with tricyclic antidepressants (TCAs) 4, 5
- The potential for antidepressants to lower the risk of triggering seizures 2
- The need to screen patients for predisposition to seizures before initiating antidepressant treatment 4
- The importance of selecting antidepressants based on the patient's individual needs and medical history 2, 6
Key Findings
- The risk of seizures associated with antidepressant use is generally considered to be low, particularly with newer antidepressants such as SSRIs and SNRIs 4, 2
- The use of TCAs is associated with a higher risk of seizures compared to newer antidepressants 4, 5
- Antidepressants may have a positive effect on epilepsy severity, particularly newer antidepressants such as SSRIs and SNRIs 3