SSRIs

Question 1

SSRIs are metabolized by

Answer 1

the liver

Question 2

the half life of SSRIs is ____ in children than adults

Answer 2

shorter

Question 3

SSRI with longest half life and thus fewest symptoms of withdrawal or discontinuaiton syndrome

Answer 3

Fluoxetine

Question 4

circumstances in which lab is required when starting SSRIs

Answer 4

rule out hypothyroidism

if patient is on VPA

Question 5

Order in length of half life of SSRIs

Answer 5

1. fluoxetine (96 hours)
2. citalopram (35)
3. escitalopram( 30)
   sertraline (26)
4. Paxil (21)
5. Fluvoxamine (15)

Question 6

have SSRIs been approved by health canada for treatment of depression ?

Answer 6

NO!

in US fluoxetine is approved for children and escitalopram for adolescents

Question 7

In RCTs the SSRI most effective for treating pediatric depression in younger than 12 years is

Answer 7

Fluoextine (only one in clinical trials to actually work to treat depression under 12 years)

Question 8

caveat of current evidence for SSRIs

Answer 8

there was a very high placebo response rate very similar to that of SSRIs (30-60 % compared to 40-70% response with medication)

Question 9

largest RCT looking at depression in adolescents showed

Answer 9

CBT + fluoxetine more effective than either CBT alone or placebo

Question 10

List common short term side effects of SSRIs

Answer 10

GI symptoms
sleep changes
restlessness
headaches
appetite change
sexual dysfunction
behavioural activation

Question 11

List some rare side effects of SSRIs

Answer 11

increased bleeding risk
SIADH
serotonin syndrome
QT prolongation (with citalopram > 40 mg)

Question 12

previous FDA analysis regarding suicide and SSRIs found

Answer 12

increased RR of 1.66 of suicide adverse events

Question 13

further study incluidng non published RCT data on SSRIs and suicide found

Answer 13

NNH of 112 and NNT of 10, meaning that no increased risk of suicide in control vs SSRI group
also noted a concomittent decrease epidemiologically of suicide in adolescents that coincides with increased SSRI prescribing in the population

Question 14

FDA recommendations for monitoring after starting SSRI in children/adolescents

Answer 14

weekly x 4 weeks
q 2 weeks x 4 weeks
at 12 weeks
prn thereafter

Question 15

period recommended of treatment with SSRI to ensure reduced risk of relapsed depression

Answer 15

6-12 months

Question 16

medication treatment of choice for child/adolescent anxiety disorders

Answer 16

SSRIs

Question 17

If patient with mood disorder has family history of bipolar disorder then…

Answer 17

get a psych consult before starting an SSRI (per CPS statement)

Question 18

difference between evidence for use of SSRIs for anxiety vs depression

Answer 18

anxiety evidence does not clearly show preference for one SSRI over another

Question 19

There is no evidence in literature for which SSRIs in treatment of anxiety disorders in children and adolescents

Answer 19

citalopram

escitalopram

Question 20

In regards to using SSRI with anxiety re suicidality risk

Answer 20

probably not a risk as the studies only studied children on sSRIs with depression, but monitoring for this side effect may be prudent

Question 21

before starting SSRI for anxiety disorders find out baseline….

Answer 21

somatic symptoms so they can’t blame them on side effects

Question 22

SSRIs research evidence for different anxiety disorders

Answer 22

GAD : fluoxetine, sertraline, fluvoxamine
selective mutism : fluoxetine
Social phobia: fluvoxamine, paroxetine
Separation anxiety : fluoxetine or fluvoxamine

Question 23

situations to consider early SSRI treatment in anxiety

Answer 23

if symptoms severe or significant impairment

other impairments preclude child or adolescent’s ability to benefit from psychotherapy