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 change could reduce anxiety in a patient with partial benefit from an SNRI?

A 62 yo woman has a history of chronic pain from osteoarthritis, severe sciatica, recurrent major depression, generalized anxiety, and insomnia. She takes chronic low-dose opioids for pain and an SNRI (duloxetine, titrated to 60mg BID) for pain, depression, and anxiety, with moderate improvement in pain and depression and mild improvement in anxiety.   She currently …

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What medication is FDA approved to help people drink less?

A 55-year old woman with a history of atrial fibrillation, cirrhosis from Hepatitis C, and at-risk alcohol use presents to the clinic for follow up. She takes her metoprolol and apixaban regularly. She has noticed occasional fatigue and nausea in the morning. You ask her about alcohol use. She says that with recent work stress …

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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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The opinions expressed in PsychSnaps do not necessarily represent the views and opinions of the University of California, San Francisco. The opinions in PsychSnaps should not be used as a substitute for medical advice from a qualified, board-certified practicing clinician.