SSRI

When should you stop an SSRI trial for depression due to lack of efficacy?

30 yo woman with generalized anxiety disorder presents in her first major depressive episode. She is depressed, hopeless, sleeping poorly, exhausted, and losing weight (6 pounds in the last month). She has never taken psychiatric medications before. She would like to try a medication to treat both depression and anxiety (so bupropion is out).  You prescribe …

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How do you manage the side effects of SSRIs?

What do you do when a patient taking an SSRI presents with anorgasmia, bruxism, or hyponatremia? Firstly – believe your patient. Your 60 yo may experience an increase in suicidal thoughts even though the textbook says that she shouldn’t. In general, your options for managing side effects from medication are: The balance between the medication benefits …

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Which antidepressants are least likely to cause weight gain?

After almost 2 years of discussing pharmacotherapy, a 48 year old woman with severe generalized anxiety disorder (GAD) agrees to take medication. She starts taking escitalopram and increases the dosage. After 8 weeks on a daily dose of escitalopram 20mg, her anxiety symptoms are in remission. She has no side effects. However, when you see her 6 months …

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How do you choose an antidepressant?

You see a 24 yo woman in a severe major depressive episode and offer her sertraline and a referral to therapy. After the visit, the medical student rotating with you asks why you chose sertraline for this patient. He follows with, “I guess I’m asking…how do you choose an antidepressant?” You answer his question in three …

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Does this patient’s history of binging and purging make it unsafe to start bupropion?

Your patient is a 25 yo woman in a current major depressive episode. She was treated with escitalopram first, and then switched to sertraline. Each medication helped her depression and caused anorgasmia, which caused her to stop them.  She is moderately depressed, and wants to know if there is anything that she can take for depression that …

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Which SSRI should I choose?

What follows is a brief summary of the clinically important differences between the SSRIs, followed by 5 patient cases that ask, “Which SSRI?”   The five SSRIs most commonly used in the US for depression and anxiety are fluoxetine, paroxetine, sertraline, citalopram, and escitalopram.  The sixth SSRI, fluvoxamine, is mainly used to treat OCD.   All …

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What caused low energy in a patient whose other depressive symptoms were improving with escitalopram?

One year after the death of her spouse, a 75 yo woman with hypertension on hydrochlorothiazide presents in a first major depressive episode with prominent neurovegetative symptoms (difficulty sleeping, low appetite with a 10lb weight loss, low energy, mild psychomotor retardation).  You start her on escitalopram 2.5mg for 1 week, then increase to 5mg, and …

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