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Question 1

A 30-year-old woman presents to her GP surgery for review. For the past two months she has been feeling generally low in mood. This has been associated with poor sleep, reduced appetite and a loss of interest in her usual hobbies. There are no significant ongoing causes of stress in her life and no alcohol or drug problems. She works full-time in a supermarket and is single with no children.

You discuss possible treatment options including referral to the Primary Care Mental Health Team but she elects for a trial of medication.

Write a prescription for ONE drug that will help to treat the patients’ symptoms.

Answer 1

This lady has some of the more common features of depression - sleep disturbance, appetite disturbance and anhedonia. NICE recommend the use of psychological interventions (such as counselling) and selective serotonin reuptake inhibitors (SSRI) in patients who require treatment.

Drug:

Fluoxetine/Citalopram/sertraline/paroxetine - 4 points

Escitalopram - 3 points

Clomipramine - 2 points

Amitriptyline -1 points

Fluoxetine 20mg PO OD - 4 points

Fluoxetine 40mg - 60mg PO OD - 2 points

Citalopram 20mg PO OD - 4 points

Citalopram 10mg PO OD - 3 points

Citalopram 40mg PO OD - 2 points

Sertraline 50mg PO OD - 4 points

Sertraline 100-200mg PO OD - 2 points

Paroxetine 20mg PO OD - 4 points

Answer 2

Selective serotonin reuptake inhibitors

Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for the majority of patients with depression.

citalopram (although see below re: QT interval) and fluoxetine are currently the preferred SSRIs

sertraline is useful post myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants

SSRIs should be used with caution in children and adolescents. Fluoxetine is the drug of choice when an antidepressant is indicated

Adverse effects

gastrointestinal symptoms are the most common side-effect

there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID

patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI

fluoxetine and paroxetine have a higher propensity for drug interactions

Citalopram and the QT interval

the Medicines and Healthcare products Regulatory Agency (MHRA) released a warning on the use of citalopram in 2011

it advised that citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval

the maximum daily dose is now 40 mg for adults; 20 mg for patients older than 65 years; and 20 mg for those with hepatic impairment

Interactions

NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor

warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine

aspirin: see above

triptans - increased risk of serotonin syndrome

monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome

Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks. For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week. If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.

When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.

Discontinuation symptoms

increased mood change

restlessness

difficulty sleeping

unsteadiness

sweating

gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting

paraesthesia

SSRIs and pregnancy

• BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
• Use during the first trimester gives a small increased risk of congenital heart defects
• Use during the third trimester can result in persistent pulmonary hypertension of the newborn
• Paroxetine has an increased risk of congenital malformations, particularly in the first trimester