SSRI's

Question 1

Give 4 examples of SSRIs

Answer 1

• Citalopram
• Fluoxetine
• Paroxetine
• Sertraline

Question 2

How do SSRIs work?

Answer 2

Selectively inhibit serotonin re-uptake in the synaptic cleft to increase its action

Question 3

Why is serotonin action increase helpful in depression?

Answer 3

It is strongly involved in mood regulation and low levels have been seen in depression

Question 4

How are SSRIs administered?

Answer 4

PO

Question 5

What are SSRI’s first line treatment for?

Answer 5

Depression

Question 6

What is another indication of SSRIs?

Answer 6

GAD

Question 7

What are the specific indications for fluoxetine?

Answer 7

• Childhood depression

- Bulimia nervosa

Question 8

What is a specific indication for citalopram?

Answer 8

Panic disorder

Question 9

What is a specific indication for sertraline?

Answer 9

Obsessive-compulsive disorder

Question 10

What specific risk is fluoxetine associated with?

Answer 10

Increased risk of self-harm and suicidal ideation

Question 11

When are SSRIs contraindicated?

Answer 11

• Pregnancy
• Poorly controlled epilepsy
• During mania

Question 12

When should caution be used with SSRIs?

Answer 12

• Epilepsy
• Cardiac disease
• Diabetes
• ECT
• Acute angle-closure glaucoma
• History of bleeding disorders

Question 13

What can SSRIs interact with?

Answer 13

• Alcohol
• NSAIDs
• Aspirin
• Anti-epileptics
• Theophylline
• Monoamine oxidase inhibitors
• Tramadol
• St Johns Wort
• Grapefruit (sertraline)

Question 14

How can SSRIs interact with alcohol?

Answer 14

Increase sedation

Question 15

How can SSRIs interact with NSAIDs and aspirin?

Answer 15

Increased risk of bleeding

Question 16

How can SSRIs interact with anti-epileptics?

Answer 16

Reduce the seizure threshold

Question 17

When should MAOIs be started after stopping SSRI?

Answer 17

A week after (5 for fluoxetine)

Question 18

When should SSRIs be started after stopping a MAOI?

Answer 18

2 weeks after

Question 19

How can SSRIs interact with tramadol and St John’s Wort?

Answer 19

Increased risk of serotonin discontinuation syndrome

Question 20

What monitoring should patients on SSRIs receive?

Answer 20

• Improvement of symptoms check every 1-2 weeks for first 6 weeks
• Ask about suicide and self-harm

Question 21

After how long of no results should SSRI be switched?

Answer 21

1 month (6 weeks in elderly)

Question 22

How long should patients be left at the same dose following remission?

Answer 22

6-12 months

Question 23

What should be given to patients after cessation of treatment with anti-depressants?

Answer 23

Follow-up appointment

Question 24

What are the common side-effects of SSRIs?

Answer 24

• GI upset
• Nausea
• Hyponatraemia
• Dry mouth
• Sexual dysfunction
• Anorexia and weight loss

Question 25

What are the rarer side-effects of SSRIs?

Answer 25

- Increased bleeding risk - Suicidal ideation - Convulsions - QT interval prolongation - Serotonin syndrome - SSRI discontinuation syndrome

Question 26

What causes serotonin syndrome?

Answer 26

Increased serotonin activity

Question 27

Which SSRI most commonly causes SSRI discontinuation syndrome?

Answer 27

Paroxetine

Question 28

What mnemonic can help to remember the side-effects of SSRIs?

Answer 28

SSRIS

Question 29

What does SSRIS mnemonic stand for?

Answer 29

- Sore tummy - Sexual dysfunction - Reduced weight/salivation - Increased bleeding risk - Serotonin toxicity

Question 30

What counselling should a patient starting SSRIs receive?

Answer 30

- Mode of action - Side-effects - Lifestyle measures - Onset and compliance - Duration - Withdrawal - Switching - Serotonin syndrome - Signs of SSRI discontinuation syndrome

Question 31

What is it important to say about side-effects of SSRIs?

Answer 31

They are mostly mild and often transient

Question 32

What lifestyle measures may help to improve the action of SSRIs?

Answer 32

- Healthy diet - Regular exercise - Adequate sleep

Question 33

What is important to tell patients about the onset and compliance with SSRIs?

Answer 33

Onset may take several weeks so is important to persist with the treatment

Question 34

What should patients on SSRIs be told about the duration?

Answer 34

They may need to take for some time after episode has resolved

Question 35

What should patients be told about withdrawal from SSRIs?

Answer 35

Withdrawal must be done slowly to avoid side-effects

Question 36

What information should be given to patients wishing to switch from an SSRI to another anti-depressant?

Answer 36

May need time in between

Question 37

What signs of serotonin syndrome should the patient starting an SSRI be told about?

Answer 37

- Agitation - Confusion - Nystagmus - Myoclonus - Tremor - Seizures - Autonomic instability

Question 38

What advice should patients be given if they experience symptoms of serotonin syndrome?

Answer 38

Seek urgent medical help

Question 39

What are the symptoms of SSRI discontinuation syndrome?

Answer 39

- Headache - Paraesthesia - Shock sensations - GI upset - Lethargy - Insomnia - Mood changes