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Selective serotonin reuptake inhibitors (SSRIs)

SSRIs are used for the acute treatment of episodes of depression. There is a 55–70% response rate after a 10–20 day delay in onset from starting treatment1. SSRIs are useful in preventing relapse, possibly because of good
compliance.

Additionally, SSRIs are useful in the elderly with anxiety or OCD, those who are suicidal and possibly those with severe depression. Prescription monitoring studies13–15 show that older TCAs are commonly prescribed at lower than recommended doses, and for shorter than optimal periods.

SSRIs are nearly always prescribed at doses proven to be effective and appear more likely to be prescribed for longer periods. SSRIs may be preferable to older TCAs in the treatment of patients with a history of deliberate self-harm,
as SSRI overdose is only rarely associated with medical complications.

Occasional case reports have described the emergence or worsening of suicidal thoughts during SSRI treatment, but analyses of pooled data from randomized controlled trials have shown that SSRIs are not associated with increases in suicidality.

At present, there is no direct evidence that patients prescribed SSRIs have a better outcome than those on TCAs. The SSRIs are more expensive than older antidepressant drugs, but current pharmacoeconomic data do not favor initial treatment with one antidepressant over another.

SSRIs are rapidly absorbed and undergo hepatic metabolism. Some have active metabolites, but all are generally low in breast milk. Withdrawal effects are possible with drugs with a shorter half-life.

Advantages of SSRIs

• broad-spectrum efficacy (depression, panic disorder, obsessive compulsive disorder (OCD), social anxiety disorder and post-traumatic stress disorder);
• reduced adverse-event burden;
• safety in overdose;
• prescribed in therapeutic doses.

Disadvantages and Side Effects of SSRIs

• reduced efficacy in depressed inpatients;
• some common adverse events (gastrointestinal upset, sexual dysfunction, nervousness/agitation, discontinuation symptoms);
• pharmacokinetic interaction;
• serotonergic syndrome.

Problematic Interactions of SSRIs

• MAOIs
• L-tryptophan
• With fluvoxamine (due to CYP1A2 inhibition) caffeine, clozapine, theophylline
• With fluoxetine and paroxetine (due to CYP2D6 inhibition) beta blockers, neuroleptics, opiates, TCAs

Examples of SSRIs

• Fluoxetine
• Paroxetine
• Sertraline
• Citalopram
• Fluvoxamine

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Drugs for Depression

Amoxapine (Asendin)

Buspirone (BuSpar)

Clomipramine (Anafranil)

Clozapine (Clozaril)

Cymbalta

Haloperidol (Haldol)

Lorazepam (Ativan)

Pemoline (Cylert)

Venlafaxine (Effexor)

Paroxetine (Paxil)

Fluoxetine (Prozac)

Risperidone (Risperdal)

Methylphenidate (Ritalin)

Carbamazepine (Tegretol)

Diazepam (Valium)

Bupropion (Wellbutrin)

Sertraline (Zoloft)

Provigil

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