“Serotonergic vortex”—Vortioxetine (Trintellix) is a “serotonin modulator and stimulator” (SMS) approved in 2013 for treatment of depression. The original trade name was BRINTELLIX, suggestive of “Bring Intelligence”. In 2016 the trade name was changed to Trintellix to avoid confusion with antiplatelet drug BRILINTA (ticagrelor).
Although expensive, Trintellix is a reasonable first-line option for depression if cognitive deficits are prominent. Cognitive dysfunction characteristic of profound depression can be referred to as pseudodementia. Trintellix’s marketing slogan is “fight the fog of depression”, which refers to its ability to improve pseudodementia. This is useful because, on average, depression impairs cognition similarly to 24 hours of sleep deprivation (Mahableshwarkar et al, 2016). Vortioxetine improves cognition, although the effect is modest, roughly equivalent to 50 mg of caffeine (Jaeger et al, 2018).
Side effects: Vortioxetine is relatively well-tolerated. At the suggested maintenance dose of 20 mg, incidence of sexual dysfunction is 44%. At 10 mg vortioxetine has fewer sexual side effects than SSRIs. Vortioxetine is more likely to cause constipation than diarrhea. Headache and dizziness have been reported. It does not cause weight gain or prolong QT interval. Vortioxetine appears to be among the safest psychotropic medications in overdose, with no known deaths, although sample size is small. Due to long half-life of 3 days, it does not cause discontinuation symptoms with missed doses.
About 30% of patients experience nausea, as could be expected from a “vortex” of serotonergic mechanisms. Nausea due to antidepressants (including vortioxetine) typically resolves after a couple of weeks. Nausea with vortioxetine is tempered by 5-HT3 antagonism. Other drugs that block 5-HT3 include the antiemetic ondansetron (Zofran) and the NaSSA antidepressant mirtazapine (Remeron). Ginger also relieves nausea via the same mechanism.
Dosing: The starting dose is 10 mg. The suggested maintenance dose for MDD is 20 mg, but staying at 10 mg may be adequate, with fewer side effects.