ssri_flashcards
What are SSRIs considered for the treatment of depression?
First-line treatment for the majority of patients with depression.
Which SSRIs are currently preferred?
Citalopram and fluoxetine are currently the preferred SSRIs.
Which SSRI is useful post myocardial infarction?
Sertraline is useful post myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants.
Should SSRIs be used with caution in children and adolescents?
Yes, SSRIs should be used with caution in children and adolescents. Fluoxetine is the drug of choice when an antidepressant is indicated.
What are the most common side effects of SSRIs?
Gastrointestinal symptoms are the most common side-effect.
What should be prescribed if a patient taking SSRIs is also taking an NSAID?
A proton pump inhibitor should be prescribed if a patient is also taking an NSAID.
What should patients be counseled about after starting an SSRI?
Patients should be counseled to be vigilant for increased anxiety and agitation after starting an SSRI.
Which SSRIs have a higher propensity for drug interactions?
Fluoxetine and paroxetine have a higher propensity for drug interactions.
What warning did the MHRA release about citalopram in 2011?
The MHRA released a warning 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.
What are the maximum daily doses of citalopram for adults, patients older than 65 years, and those with hepatic impairment?
40 mg for adults; 20 mg for patients older than 65 years; and 20 mg for those with hepatic impairment.
What are the interactions of SSRIs with NSAIDs, warfarin/heparin, aspirin, triptans, and MAOIs?
NSAIDs: Co-prescribe a proton pump inhibitor. Warfarin / heparin: Avoid SSRIs and consider mirtazapine. Aspirin: Increased risk of gastrointestinal bleeding. Triptans: Increased risk of serotonin syndrome. MAOIs: Increased risk of serotonin syndrome.
When should patients be reviewed after the initiation of antidepressant therapy?
Patients should normally be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at increased risk of suicide should be reviewed after 1 week.
How long should patients continue on treatment if they make 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.
How should the dose be adjusted when stopping an SSRI?
The dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine).
Which SSRI has a higher incidence of discontinuation symptoms?
Paroxetine has a higher incidence of discontinuation symptoms.
What are the discontinuation symptoms of SSRIs?
Increased mood change, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting, paraesthesia.
What are the considerations for 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.
summarise SSRIs
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
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 25 years or at increased risk of suicide 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
A 54-year-old man attends his GP. He was started on fluoxetine eight weeks ago for depression and is now requesting to stop his medication as he feels so well. What should be recommended regarding his treatment?
It should be stopped straight away
It should be continued for at least 6 weeks
It should be continued for at least 3 months
It should be continued for at least 6 months
It should be continued for at least 12 months
It should be continued for at least 6 months
This greatly reduces the risk of relapse. Patients should be reassured that antidepressants are not addictive.
A 19-year-old man presents to his GP with symptoms of low mood, anhedonia and reduced appetite which have been present for 3 months. He has had episodes of suicidal ideation in the past, but not recently.
He is reluctant to try cognitive behavioural therapy. The GP recommends starting sertraline, and the patient agrees.
After how long should this patient be reviewed?
1 month
1 week
2 weeks
3 months
6 months
1 week
Patients ≤ 25 years who have been started on an SSRI should be reviewed after 1 week
The patient should be reviewed after 1 week. All patients who start a selective serotonin reuptake inhibitor (SSRI) are initially at an increased risk of suicidal ideation, however, this side effect is most prevalent in younger patients. For this reason, patients under 25, or patients who are at an increased risk of suicide, should be reviewed after 1 week.
1 month is an incorrect answer because this patient’s age means that he is at higher risk of suicidal ideation and attempting suicide after starting an SSRI. A one-month period is appropriate when tapering off SSRIs (gradually reducing the dose) to reduce the risk of withdrawal and increased side effects, however, it is too long to wait for an initial review.
2 weeks is an incorrect answer because this patient is under 25. However, patients over 25 should be reviewed after 2 weeks after starting an SSRI, unless the doctor deems them at higher risk of suicide, in which case 1 week is more appropriate. It is worth noting that SSRIs will not reach full efficacy after 1 or 2 weeks, so symptoms are unlikely to have improved and the purpose of this review is mostly to assess for the presence of suicidal ideation. SSRIs can take 4+ weeks for beneficial effects to be seen. If no improvement is seen after 4 weeks of SSRI therapy, an alternative dose or drug is considered.
3 months is an incorrect answer because it is too long to wait before a review for the reasons above. Patients should be counselled to be vigilant for an increase in suicidal thoughts, agitation and anxiety when starting SSRIs. These side effects, if present, should be addressed sooner than 3 months, and patients will commonly try more than one SSRI (or other class of antidepressant) before finding one which has an acceptable balance of side effects and benefits for them. Other common side effects of SSRIs include gastrointestinal disturbances, sexual dysfunction and hyponatraemia.
6 months is an incorrect answer because it is too long to wait before an initial review for the reasons above. Once a patient is stable on an SSRI and has achieved remission, patients should be advised to continue on the drug for at least 6 months to reduce the risk of relapse.
A 64-year-old man is brought to the emergency department after being found at home in a state of self-neglect. It is suspected that he has a neurological event causing him to lose motor function. On examination, he is hypothermic and has a right-sided weakness.
On questioning, the patient states that he has not been able to take any of his regular medications, and since stopping them has begun to feel dizzy, restless, and has been experiencing electric shock sensations across his whole body.
Stopping which medication is most likely responsible for these symptoms?
Atorvastatin
Bisoprolol
Gabapentin
Paroxetine
Sitagliptin
Paroxetine
Dizziness, electric shock sensations and anxiety are symptoms of SSRI discontinuation syndrome
This scenario describes a patient who has immediately stopped their medication due to a suspected neurological event. The patient describes dizziness, electric shock sensations, and restlessness, which are associated with a discontinuation syndrome. Discontinuation syndrome occurs with the non-gradual stopping of selective serotonin reuptake inhibitors (SSRIs), such as paroxetine. Discontinuation syndrome is why many SSRIs should be stopped gradually.
Atorvastatin is an incorrect answer. Whilst there can be adverse effects on cholesterol control when stopping atorvastatin, the described withdrawal symptoms are not typically seen.
Bisoprolol is an incorrect answer. Abruptly stopping beta-blockers can cause tachycardia and hypertension, however, the described electric shock sensations would not be typically seen.
Gabapentin is an incorrect answer. Abruptly stopping gabapentin may result in some withdrawal symptoms (such as anxiety and dizziness), however, the electric shock sensations are not commonly described and are more typical of SSRI discontinuation syndrome.
Sitagliptin is an incorrect answer. Abruptly stopping sitagliptin can result in poor glycaemic control and return of diabetes symptoms, however, the described symptoms in this scenario would not be typical.
A 29-year-old woman is reviewed by her psychiatrist. She has been on citalopram for 4 years for depression.
The patient reports a significant improvement in her symptoms recently having started a new job and regular participation in cognitive behaviour therapy. As a result, she wishes to stop taking her medications. You advise her that to discontinue her medication she should slowly reduce the dose over a period of time.
When should the patient be advised to start reducing the dose of citalopram?
2 weeks following remission of symptoms
3 months following remission of symptoms
4 weeks following remission of symptoms
6 months following remission of symptoms
Immediately
6 months following remission of symptoms
Antidepressants should be continued for at least 6 months after remission of symptoms to decrease risk of relapse
Selective serotonin reuptake inhibitors (SSRIs) such as citalopram are considered first-line treatment for depression. If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission before slowly reducing and then discontinuing the medication. This is to prevent the risk of relapse of symptoms.
A significant number of patients experience a relapse of their depressive symptoms following the discontinuation of antidepressants. Discontinuing antidepressants sooner than the recommended 6 months following symptom remission has been associated with an increased risk of relapse and is therefore not advised.
A 40-year-old with known rheumatoid arthritis, established on sulfasalazine and regular paracetamol and ibuprofen, is seen by her GP with ongoing low mood. Non-pharmaceutical interventions have been trialled with limited improvement and now the patient reports they feel their depressive symptoms are worsening.
As such the GP decided to commence the patient on an antidepressant.
What agent would increase this patient’s risk of a GI bleed the most, therefore, warranting a protein pump inhibitor as cover?
Amitriptyline
Citalopram
Haloperidol
Selegiline
St John’s Wort
Citalopram
SSRI + NSAID = GI bleeding risk - give a PPI
Citalopram is a common selective serotonin reuptake inhibitor (SSRIs), which are now considered the first-line treatment for most patients with depression. As the name suggests SSRIs increase the extracellular level of serotonin by limiting its reabsorption at the pre-synapses. Gastrointestinal (GI) disruption is common with SSRI use, and they are associated with a significant risk of GI bleeding. It is thought SSRI potential deplete platelet serotonin, resulting in a reduction in clot formation, therefore, increasing the risk of bleeding. As this patient is already established on an NSAID the addition of an SSRI will increase her risk of GI bleeding further and therefore a protein pump inhibitor (PPI) should also be prescribed.
Amitriptyline is a tricyclic antidepressant (TCA) that can be used in the management of major depressive disorders as well as several different pain syndromes. Amitriptyline inhibits serotonin transporter (SERT) and norepinephrine transporter (NET) both increasing neurotransmitter availability. The main adverse effects of TCAs are related to their anticholinergic effects resulting in symptoms such as blurred vision, dry mouth, and constipation etc. GI bleeds are not commonly associated with TCAs.
Haloperidol is a typical antipsychotic, rarely used for patients with severe depression and psychotic symptoms. It blocks receptors in the brain’s dopamine pathways and therefore the main adverse effects include, extrapyramidal side effects (akathisia, dystonia etc), hypotension and anticholinergic effects. Again GI bleeds are rare.
Selegiline is a selective and irreversible inhibitor of monoamine oxidase B (MAO-B), and therefore in the class of monoamine oxidase inhibitors (MAOIs). MAOIs are used as antidepressants and work by preventing the breakdown of monoamine neurotransmitters, increasing their availability. MAOIs have been associated with an increased risk of serotonin syndrome and hypertensive crises but GI bleeds are rare.
Hypericum perforatum, commonly known as St John’s Wort is a plant frequently used in alternative medicine, particularly for the management of depression. Although its use remains controversial multiple studies have indicated it may have superiority over placebo on treating mild to moderate depression, with the active ingredients thought to be hypericin and hyperforin. St John’s wort can interfere with other medications, and its use with other antidepressants is associated with an increased risk of serotonin syndrome, however, it has not been associated with an increased risk of GI bleeding.
You see a 21-year-old patient in your morning clinic. She has been struggling with university and has been given a diagnosis of depression and anxiety for which you have decided to start her on medication. You are talking her through this and explaining there are certain things which are important to note when taking antidepressant medication. You have started fluoxetine 20mg once a day.
What is the most important piece of advice to give her at the end of the consultation?
She should avoid cranberry juice when on this medication
She will need an ECG after she has been taking the medication for one month
She will need to continue this medication for at least 3 months to prevent relapse
She will need to have a follow-up appointment with you in one week
She will need to have a follow-up appointment with you in two weeks
Patients ≤ 25 years who have been started on an SSRI should be reviewed after 1 week
Important for meLess important
She will need to have a follow-up appointment with you in one week is correct, she should have a review to monitor the increased risk of suicide and self-harm.
She should avoid cranberry juice when on this medication is incorrect. Cranberry juice does not affect SSRIs. Grapefruit juice is a CYP inhibitor and can increase serum levels of SSRIs.
She will need an ECG after she has been taking the medication for one month is incorrect. Some SSRIs are associated with dose-dependent QT interval prolongation and should be avoided. There is no requirement for patients to have routine monitoring of ECGs.
She will need to continue this medication for at least 3 months to prevent relapse is incorrect. She should continue on the medication for at least 6 months to prevent relapse.
She will need to have a follow-up appointment with you in two weeksis incorrect, as she is under 25 she should be reviewed after 1 week.
A 24-year-old woman presents to the emergency department complaining of feeling sweaty and confused. These symptoms began around 12 hours ago. On examination, the patient is disorientated and rigid. Her temperature is 38.6ºC. On further questioning, she tells you she had consumed recreational drugs.
The patient’s past medical history includes depression and she has been on sertraline long-term. She has been started on selegiline after her depression symptoms worsened. She also has asthma and uses a salbutamol reliever regularly.
What may have led to the patient’s presentation?
Cannabis
Cocaine
Heroin
Salbutamol
Selegiline
Selegiline
SSRIs and MAOIs should never be combined as there is a risk of serotonin syndrome
Important for meLess important
Selegiline is the correct answer. This patient is presenting with signs and symptoms of serotonin syndrome. Serotonin syndrome is a life-threatening condition associated with increased serotoninergic activity in the central nervous system. Features include mental status changes, autonomic hyperactivity (hyperthermia, sweating) and neuromuscular abnormalities (hyperreflexia and rigidity). Patients should never be given both SSRIs and monoamine oxidase inhibitors such as selegiline as both can increase serotonin levels excessively.
Cannabis is incorrect. This drug is not an identifiable cause of serotonin syndrome as it does not interact with the serotonin system. Serotonin accumulation is the culprit of the development of serotonin syndrome, making this option incorrect.
Cocaine is incorrect. This drug is similarly not an identifiable cause of serotonin syndrome given the fact it does not interact with the serotonin system. Cocaine primarily affects the dopamine and norepinephrine systems in the brain, leading to its stimulating effects.
Heroin is incorrect. This drug is also not an identifiable cause of serotonin syndrome. Heroin primarily affects the opioid receptors in the brain, leading to its pain-relieving and sedative effects.
Salbutamol is not correct. Salbutamol does not elevate serotonin levels leading to toxicity. Other medications or substances that can lead to serotonin syndrome include St. John’s wort, tramadol and amphetamines.
A patient reports feeling unwell after suddenly stopping paroxetine. Which one of the following symptoms is most consistent with selective serotonin reuptake inhibitor discontinuation syndrome?
Postural hypotension
Diarrhoea
Myoclonic jerks
Hallucinations
Seizures
Diarrhoea
Gastrointestinal side-effects such as diarrhoea are seen in SSRI discontinuation syndrome
Selective serotonin reuptake inhibitor discontinuation syndrome can present with a wide variety of symptoms including diarrhoea, vomiting and abdominal pain.
A 25-year-old woman presents to the ED accompanied by her family due to a sudden change in her behaviour. She is notably agitated, restless, disoriented, and confused. Her recent commencement of an unspecified medication has been mentioned.
Physical examination reveals profuse sweating, marked muscle rigidity, hyperreflexia, mydriasis, and flushed skin. Her medical history includes generalized anxiety disorder for which she has been taking escitalopram with minimal symptom relief.
What is the most likely medication that has been newly prescribed to this patient?
Aripiprazole
Diclofenac
Paracetamol
Risperidone
Sumatriptan
Sumatriptan
Triptans should be avoided in patients taking a SSRI
The correct answer is sumatriptan. The patient presents with symptoms indicative of serotonin syndrome, such as agitation, restlessness, confusion, muscle rigidity, hyperreflexia, dilated pupils and flushed skin. Serotonin syndrome is a consequence of excessive serotonergic accumulation in the central nervous system and can range from mild to life-threatening. It often results from the concurrent use of multiple serotonergic agents.
Given that the patient was already on an SSRI (escitalopram), it is likely that sumatriptan has precipitated these symptoms. Sumatriptan is a triptan used in migraine management; it acts as a serotonin receptor agonist. When combined with escitalopram’s selective inhibition of serotonin reuptake, the risk for serotonin syndrome increases, making sumatriptan the most probable cause. It is worth noting that escitalopram is also notorious for QTc prolongation and, while not directly relevant to this presentation, it should be kept in mind for any unwell patient taking this medication as it most likely warrants an ECG as part of investigations.
Aripiprazole is an antipsychotic drug which does not notably increase the risk of inducing serotonin syndrome when co-prescribed with escitalopram. The British National Formulary lists its association with this condition as ‘frequency not known’. However, there is an increased risk of hyponatraemia when used together with SSRIs.
Diclofenac, a non-steroidal anti-inflammatory drug (NSAID), should be prescribed cautiously in patients on escitalopram due to an elevated bleeding risk. However, it has not been implicated in increasing the likelihood of developing serotonin syndrome.
Paracetamol is not associated with an increased risk of serotonin syndrome. It is a widely used analgesic and antipyretic agent without known serotonergic properties.
Risperidone, another antipsychotic medication, similarly has no significant evidence suggesting it causes serotonin syndrome when co-administered with escitalopram. Nonetheless, there exists a potential for heightened hyponatraemia risk under such combination therapy.
A 22-year-old man with ankylosing spondylitis, managed with regular ibuprofen, presents with symptoms consistent with depression. He scores 12 on the PHQ-9, indicating moderate depression, but denies any thoughts of self-harm or suicidal ideation. After discussing management options, he expresses a desire to commence antidepressant therapy.
What is the most appropriate management?
Advise him to self refer to local NHS talking therapies
Fluoxetine + amitriptyline
Fluoxetine + omeprazole
Mirtazapine + omeprazole
Sertraline monotherapy
Fluoxetine + omeprazole
SSRI + NSAID = GI bleeding risk - give a PPI
Selective serotonin reuptake inhibitors (SSRIs) are considered the first-line pharmacological treatment for patients presenting with moderate depression.
This patient is currently taking a nonsteroidal anti-inflammatory drug (NSAID) on a regular basis to manage his ankylosing spondylitis, which increases the risk of gastrointestinal (GI) bleeding. Consequently, when initiating an SSRI in this scenario, it is prudent to co-prescribe a proton pump inhibitor (PPI) to mitigate this risk. Thus, fluoxetine + omeprazole represents the most appropriate management strategy.
While sertraline is another effective SSRI for treating depression, prescribing it without concomitant PPI protection would elevate the patient’s risk of GI bleeding. As such, it is not considered a suitable option in this context.
Initiating two antidepressant medications simultaneously is generally discouraged; therefore, commencing treatment with fluoxetine + amitriptyline would be inappropriate. Moreover, this combination does not address the potential increase in GI bleed risk associated with NSAID use.
Mirtazapine, an atypical antidepressant, is not typically recommended as a first-line agent for moderate depression and hence is not the preferred choice here.
Although a self referral to local NHS talking therapies might be advisable for individuals with mild depression, it would not be fitting for this patient given his PHQ-9 score indicative of moderate depression and his inclination towards pharmacotherapy. In such instances, counselling or other forms of psychotherapy should ideally complement rather than replace antidepressant therapy
A 27-year-old woman telephones her GP, asking for advice. She is very keen on stopping all of her medications and wishes to stop them all abruptly. She has a past medical history of asthma, depression and intermittent tennis elbow pain, for which she takes a salbutamol inhaler, citalopram and paracetamol respectively.
Which of the following is most likely to occur with regards to abrupt cessation of her medications?
Blunted affect
Cyanopsia
Diarrhoea
Hypertension
Weight gain
Diarrhoea
Gastrointestinal side-effects such as diarrhoea are seen in SSRI discontinuation syndrome
Important for meLess important
The salient point here is to note the use of citalopram. Stopping a salbutamol inhaler and paracetamol suddenly are not likely to lead to any side effects. Stopping a selective serotonin reuptake inhibitor (SSRI), such as citalopram, abruptly will lead to discontinuation symptoms. From those listed, by far, the most likely is diarrhoea, as gastrointestinal side-effects are generally common with SSRI discontinuation syndrome. To avoid this, SSRIs should gradually be tapered.
A blunted affect is unlikely to occur as a result of sudden discontinuation. This is often a side effect of antidepressants themselves. Discontinuation sometimes leads to the opposite - emotional lability and visible mood swings.
Cyanopsia, or blue-tinted vision, is not known to occur with SSRI discontinuation. It is a recognised side effect of some drugs, including sildenafil.
Hypertension has been reported in a few cases upon discontinuation of SSRIs, but diarrhoea and gastrointestinal symptoms are far more likely. It is more common with sudden discontinuation of beta-blockers.
Weight loss, rather than weight gain, is often reported upon sudden discontinuation of SSRIs.
You review a 17-year-old man with a history of anxiety and depression. He is under the care of the Child and Adolescent Mental Health Service who have recommended the prescription of a SSRI. What is the most appropriate drug to prescribe?
Citalopram
Fluoxetine
Paroxetine
Sertraline
Escitalopram
Fluoxetine
Fluoxetine is the SSRI of choice in children and adolescents
The correct answer is Fluoxetine. According to the UK National Institute for Health and Care Excellence (NICE) guidelines, Fluoxetine is the first-line selective serotonin reuptake inhibitor (SSRI) for children and adolescents under 18 years with moderate to severe depression. This recommendation is due to its proven efficacy and safety profile in this age group.
On the other hand, Citalopram is not recommended as a first-line treatment in children or adolescents with depression. In fact, it carries a warning of potential dose-dependent QT interval prolongation which can lead to serious cardiac arrhythmias. Moreover, there is less evidence supporting its use in this age group compared to Fluoxetine.
Paroxetine also has less supportive evidence for use in children and adolescents with depression. It has been associated with an increased risk of suicidal behaviours in young people compared to other SSRIs. Therefore, it should be used cautiously and isn’t the most appropriate choice here.
Sertraline, although considered safe and effective for adults with depression, lacks robust evidence for its efficacy in treating depressive symptoms in children and adolescents. Furthermore, it may have more gastrointestinal side effects compared to Fluoxetine.
Lastly, Escitalopram is not typically recommended as a first-line treatment for children or adolescents either due to a lack of sufficient evidence supporting its effectiveness in this population.
A 19-year-old female has presented to the emergency department due to a week-long history of diarrhoea. She reports no blood in her stool or infective contacts. The patient feels she is sleeping more and feels generally weak.
She has a past medical history of depression for which she was started on sertraline. Two weeks ago she stopped taking this drug as she said she had a much brighter outlook on life. Her mental state is reported as currently stable and you assess her as euthymic.
Her general examination reveals bilaterally dilated pupils which are noted on previous attendances as a child.
What feature in this patient is most likely due to cessation of her medication?
Diarrhoea
Euthymia
Generalised weakness
Hypersomnia
Mydriasis
Diarrhoea
Gastrointestinal side-effects such as diarrhoea are seen in SSRI discontinuation syndrome
Diarrhoea is the correct option as this young woman has stopped taking her sertraline two weeks prior to her presentation of protracted diarrhoea, which along with abdominal cramping and vomiting, are common symptoms seen in SSRI discontinuation syndrome. Furthermore, using Occam’s razor, given the timeline and the normal blood results and lack of infective contacts, it is more likely to be this syndrome compared to inflammatory bowel disease or gastroenteritis.
Euthymia is incorrect as the SSRI discontinuation syndrome more commonly results in increased mood change.
Hypersomnia is an incorrect option because insomnia changes to the sleep pattern are more commonly seen in SSRI discontinuation.
Generalised weakness is an incorrect option as this is more than likely due to diarrhoea and there is no focal neurology in the limbs to suggest anything different. Moreover, SSRI discontinuation syndrome can result in paraesthesias rather than a general feeling of fatigue and weakness.
Mydriasis is an incorrect option as SSRI discontinuation syndrome is not related to these pupillary changes; in fact, the serotonin syndrome caused by taking too much SSRI can result in this. The stem also clearly states these pupils have been dilated since a young age making congenital mydriasis the most likely diagnosis in this case.
