Contents
Introduction
Selective Serotonin Re-uptake Inhibitors (SSRIs) e.g. fluoxetine, paroxetine, sertraline, citalopram
These are the most common used antidepressant. They are:
- Just as effective as TCAs in mild / moderate depression
- Less effective than TCAs in severe depression
- Also used in OCD
- Not recommended in those under 18, efficacy is not proven, except for fluoxitine – but if used proceed with caution
- Should take them first thing in the morning – they disrupt the sleep pattern if you give them at night
Mechanism of action
Reduced neuronal reuptake of serotonin – but very little effect on noradrenaline
Have low affinity for muscarinic, histaminergic, and adrenergic receptors – and as a result have fewer side effects than the TCAs. They are also less dangerous in overdose than TCAs
Have low affinity for muscarinic, histaminergic, and adrenergic receptors – and as a result have fewer side effects than the TCAs. They are also less dangerous in overdose than TCAs
SSRIs cause:
- An initial increase in the concentration of serotonin around the somatodendritic and axon terminal areas. This results in a decrease in the number of 5-HT inhibitory receptors
- As a result of the downregulation of receptors, more 5-HT is then released from the axon terminal. This effect is more long-term, and results in even more 5-HT downregulation
Pharmacokinetics
- Well absorbed from gut
- Have long(ish) half lives – generally around 24 hours
- Beware the long half lives when giving MAOIs after a course of SSRIs. Recommended wait 5 weeks after fluoxetine and 2 weeks after other SSRIs. Also, you should not start an SSRI within a week of stopping an MOAI
- They take 2-4 weeks before clinical benefit is seen
- Paroxetine and fluoxetine should not be used in conjunction with TCAs because they can alter the hepatic metabolism of TCAs and lead to toxicity
- Should be taken in the morning to avoid sleep disturbance
Side effects
- Increased anxiousness
- Feeling of ‘emotional numbness’
- Headache
- Nausea
- Dry mouth / constipation (paroxetine)
- Weight loss / anorexia
- May also cause increased appetite and weight gain.
- Vomiting
- Insomnia
- Loss of libido / inability to achieve orgasm
- There is a small but real risk of increased suicidal and self harm thoughts – especially in children
- Hypersensitivity
Cautions
- Can impair skilled tasks – e.g. driving
- Caution in those with epilepsy, and undergoing ECT, as they can prolong a seizure.
- Can impair hepatic metabolism of other drugs
Interactions
MAOIs – used in conjunction with these, they can cause serotonin syndrome – which may involve tremor, hyperthermia, cardiovascular sx (potentially fatal!)
**SSRIs should not be used in bipolar disorder, and immediately discontinued if the patient enters a manic phase**
Addiction
This is debated. Although it is not thought there is ‘addiction’ in the true sense, withdrawal symptoms can occur, and the drug dose should be gradually reduced to avoid these. Symptoms can include:
- GI disturbance
- Headaches
- Anxiety
- Dizziness
- Parasthesia
- Sleep problems
- General fatigue / flu-like symptoms
- Sweating
References
- Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
- Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
- Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy