Download Selective Serotonin Re-Uptake Inhibitors (SSRIs)

Presented by: Erika, Kristin and Nola
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History
How do SSRIs work?
Selected Indications and Dosages
Side effects/Interactions
Alternative uses for Children/Adolescents
Risks of SSRIs
• Relatively new class of anti depressant medications (Prozac was introduced
in the U.S. in 1987)
• Developed due to significant side effects of other antidepressants that
effected a broad range of neurotransmitters
• SSRI is a targeted medication-focused on serotonin
• Provides relief of symptoms with less side effects and less risk of overdose
• Considered first line treatment for anxiety disorders
• Most widely prescribed type of anti-depressant in the world
• In a typical brain, sufficient neurotransmitters are released to
stimulate neighbouring cells
• Neurotransmitters are consistently reabsorbed into the brain where
they are broken down by an enzyme called monoamine oxidase
• Depression, anxiety, and severe stress are associated with low
serotonin levels
• SSRIs act by blocking the re-uptake of serotonin. As a result the
levels of the neurotransmitter is increased by blocking their
reabsorption
SSRIs block the reuptake
of serotonin at the
presynaptic membrane
Increasing the
concentration in the
synaptic cleft that can
bind to the receptors
• Restores the balance of serotonin in the brain
• Treatment of: Major Depression and Panic Disorder
• Adult dose: 20-40mg per day
• Not deemed safe or effective for those under 18
• Slow onset
• Leaves system in 35 hours
• May improve: energy level and feelings of well-being
• Other Uses: Obsessive-compulsive Disorder (OCD), Panic Disorder
• Drug Specific Effects:
• Heart rhythm
• Fast or irregular heart beat
• Treatment of: Major Depression, OCD, Panic Disorder, PTSD, Bulimia Nervosa,
Premenstrual Dysphoric Disorder
• Adult dose: 20-60 mg/day, not to exceed 80mg/d
• Child dose: 10-20 mg/day
• Onset: slow
• Duration: 10 to 12 hours and leaves system in 1-3 days
• May improve: mood, sleep, appetite, energy level, restore interest in daily life
• May decrease:
• fear, anxiety, unwanted thoughts,
• premenstrual symptoms (irritability, increased appetite, depression),
• binging, purging, (bulimia)
• number of panic attacks, compulsions (hand-washing, counting, checking
• Liquid form contains alcohol
• Other Uses: Anorexia, Post Traumatic Stress Disorder (PTSD), Certain
nervous system/sleep disorders (Cataplexy, Narcolepsy)
• Drug Specific Effects:
• May effect blood sugar levels
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Treatment of: Obsessive Compulsive Disorder (OCD)
Adult dose: 50-300mg/d
Onset: rapid
Duration: 14-16 hours
• Leaves system in 13-15 hours
• Other Uses:
• Depression
• PTSD
• Drug Specific Effects:
• None listed
• Not deemed safe or effective for those under 18
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Treatment of: Major Depression, OCD, Panic Disorder
Can be used to treat GAD and Social Phobia
Adult dose: 20-50 mg/d
Child dose: not deemed safe or effective for those under 18
Onset: 5 hours
Duration: 12-16 hours
• Leaves system in 21 hours
• Other Uses:
• Premenstrual Dysphoric Disorder
• Drug Specific Effects:
• Weight gain
* Avoid alcohol
• Treatment of: Major Depression, OCD, Anxiety (with depression), Social
Anxiety Disorder, Panic Attacks, PTSD, Premenstrual Dysphoric Disorder
• Adult dose: 50-200mg/day
• Child dose: 25-200 mg/d for OCD
• Onset: 4-8 hours
• Duration: 12-20 hours
• Leaves system in 26 hours
• Other Uses:
• None listed
• Drug Specific Effects:
• None listed
* Avoid alcohol
• The effects of anti depressants occur after 10 to 14 days and may
take 6 to 8 weeks before full effect is observed
• Side effects are generally mild and brief, and subside in 1-2 weeks:
• Gastrointestinal disturbances, anxiety, headache, and restlessness
are most common
• May induce suicidal thinking in children and adults (or may increase
energy before elevating mood, allowing the depressed individual to
act on their depressed mood)
• Ending Treatment:
• F.L.U.S.H symptoms ending treatment
• Compared to tricyclics, SSRIs have fewer adverse anticholingergic
and cardiovascular effects and generally do not cause weight gain
• May cause disturbance in sexual functioning, which is the most
frequent reason for terminating treatment (10-15%)
• May cause drowsiness (recommended to take SSRI’s in the evening)
• Serotonin Syndrome/Toxicity:
• Too much serotonin
• Potentially life-threatening
• Caused by taking multiple drugs that increase serotonin and/or drug
interactions Taking
• St John’s wort or a MAOI
• Allergic Reaction:
• Rare
• Rash, itching, swelling (face, tongue, throat), severe dizziness, trouble
breathing
• Consuming caffeine may increase stimulant sensation
• Smoking may increase the metabolism of the SSRI
• Drinking alcohol may cause central nervous system (CNS) depression
• Used with caution for those with compromised liver functions
• One third of all medications prescribed in the United States are antidepressants
• An estimated 72% of cases do not have a psychiatric diagnosis
• Concerns regarding the increased risk of suicidality has been reported
• Fluoxetine (Prozac) - labeled for use with children has the highest efficacy of
all SSRIs and should be considered the first line of treatment
• Does untreated depression presents as a greater risk than its treatment?
• Alternate Uses:
• Anxiety
• Generalized Anxiety Disorder, Social Anxiety Disorder
• Good evidence to support the use of SSRIs in treatment
• PTSD
• Attributed to an overall improvement in quality of life
• Psychiatric Disorders
• Bipolar, OCD, Panic Disorder
• Bipolar studies are inconsistent
• Headaches
• To be used with caution for migraine prevention
• Considered an integral part of practice to use off-label medications to
treat complex headache conditions
• Bulimia
• Highly effective for treating bulimia
• Combination of psychotherapy and antidepressants was significantly
superior to psychotherapy alone
• Sleep Disorders
• Insomnia (late night insomnia)
• Not approved by FDA, but prescribed anyways
• Longer lasting effects than sleeping medication
• Pain
• Fibromyalgia
• Not yet approved
• Supports the transmission of pain signals through nerve fibers
• Majority of new SSRI medications remain relatively safe to use
• Studies indicate that nearly 85% of cases are not impacted by prenatal pharmacological use
• Concerns around:
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Low birth weight
Cardiovascular malformation
Premature births (low gestational age)
Behavioural issues
Neonatal adaptation difficulties
• Identification of the severity of depression should be explored prior
to medical intervention
• In 2003, the FDA warned against the use of SSRIs with pediatric patients
• Concerns included:
• Short-term risk of self harm
• Increased risk of suicide attempts
• Risk of self harm is highest during the initial month of intervention
• Close monitoring of symptoms is encouraged
• Children with depression noted higher suicidal tendency than those with other
psychiatric conditions
• Less than 1% of the pediatric population experienced suicidal ideations in
the studies reviewed
• SSRIs are the most commonly prescribed anti-depressant (antianxiety) medication
• Easy to prescribe, low risk of overdose, non addictive
• Multiple uses for various disorders
• Continued debate regarding use during pregnancy and with the
pediatric population
• Risks are still relatively unknown
• Aschenbrenner, D. S, & Venable, S. J. (2009). Drug Therapy in Nursing (3rd Ed.)
Philadelphia, PA: Wolters Kluwer Health and Lippincott Williams & Wilkins.
• Barry, C., & Busch, S.H. (2010). News coverage of FDA warnings on pediatric
antidepressant use and suicidality. Pediatrics, 125(1), 88-95. doi: 10.1542/
peds.2009-0792
• Breggin, P.R. (2005). Recent U.S, Canadian, and British regulatory agency actions
concerning antidepressant-induced harm to self and others: A review and analysis.
Ethical Human Psychology & Psychiatry, 7(1), 7-22.
• CNS Drugs. (2009). Effectiveness of lithium in children and adolescents with
disorder. Author, 23(1), 59-69.
• Einarson, A., Choi, J., Einarson, T.R., & Koren, G. (2010). Adverse effects of
antidepressant use in pregnancy: An evaluation of fetal growth and
birth. Depression & Anxiety, 27(1), 35-38. doi: 10.1002/da.20598
• Gentile, S. (2010). Neurodevelopmental effects of prenatal exposure to
psychotropic medications. Depression & Anxiety, 27(7), 675-686. doi:
10.1002/da.20706
conduct
preterm
• Hauser, W., Wolfe, F., Tolle, T., Uceyler, N., & Sommer, C. (2012). The role of
antidepressants in the management of fibomyalgia syndrome. CNS
Drugs,
26(4), 297-307
• Isacsson, G., Holmgren, P., & Ahlner, J. (2005). Selective serotonin reuptake
inhibitor antidepressants and the risk of suicide: A controlled forensic database
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10.1111/j.1600-0447.2004.00504.x
• Masi, G. (2004). Pharmacotherapy of pervasive developmental disorders in
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• Spina, E., Trifiro, G., & Caraci, F. (2012). Clinically significant drug interactions
with newer antidepressants. CNS Drugs, 26(1), 39-67, 29.
• Raman-Wilms, L. (Ed.) (2008) Canadian Pharmacists Association: The Canadian
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• Vitiello, B. (2008). An international perspective on pediatric psychopharmacology.
International Review of Psychiatry, 20(2), 121-126. doi:
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