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Figure 3–1. Chemical structures of selective serotonin reuptake inhibitors (SSRIs).
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Note. FDA = U.S. Food and Drug Administration; GAD = generalized anxiety disorder; GI = gastrointestinal; MAOI = monoamine oxidase inhibitor; MDD = major depressive disorder; OCD = obsessive-compulsive disorder; PD = panic disorder; PMDD = premenstrual dysphoric disorder; PTSD = posttraumatic stress disorder; TCA = tricyclic antidepressant.

Selective serotonin reuptake inhibitors (SSRIs): overview

Efficacy

First-line treatment in

MDD (FDA approved for all except fluvoxamine), dysthymia

PD (FDA approved for fluoxetine, paroxetine, and sertraline)

OCD (FDA approved for all except citalopram and escitalopram)

Social anxiety disorder (FDA approved for sertraline, fluvoxamine, and paroxetine)

PTSD (FDA approved for sertraline and paroxetine)

Bulimia (FDA approved for fluoxetine)

GAD (FDA approved for paroxetine and escitalopram)

PMDD (FDA approved for fluoxetine [Sarafem only], paroxetine [controlled release only], and sertraline)

Side effects

GI side effects (nausea, diarrhea, heartburn)

Sexual dysfunction ( libido, delayed orgasm)

Headache

Insomnia/somnolence

Safety in overdose

Generally safe in overdose to 30–90 days' supply; manage with vital sign support, lavage

Seizures/status epilepticus (rare)

Dosage and administration

Citalopram, paroxetine, fluoxetine: qd dosing, starting at 10–20 mg, increasing to a maximum of 40 mg (citalopram), 50 mg (paroxetine), and 80 mg (fluoxetine).

Escitalopram: qd dosing, starting at 10 mg, increasing to 20 mg after minimum of 1 week.

Sertraline: starts at 25–50 mg and is increased, as needed, to 200 mg maximum.

Full benefits in 4–8 weeks

Discontinuation

Paroxetine, fluvoxamine, sertraline: discontinuation associated with parasthesias, nausea, headaches, flulike symptoms 1–7 days after sudden discontinuation

Drug interactions

MAOI (contraindicated): serotonin syndrome

TCA levels (paroxetine, fluoxetine)

Carbamazepine, phenobarbital, phenytoin levels

Haloperidol, clozapine levels (fluvoxamine)

Theophylline levels (fluvoxamine)

Encainide, flecainide levels (avoid)

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Table 3–1. Inhibition of cytochrome P450 enzymes by antidepressants
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Table 3–2. Pharmacokinetics of selective serotonin reuptake inhibitors (SSRIs)
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Table 3–3. Adjunctive agents for selective serotonin reuptake inhibitor (SSRI)–induced sexual dysfunction
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Table 3–4. Selective serotonin reuptake inhibitors (SSRIs) and other available antidepressants: names, formulations and strengths, and dosages

References

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