Selective Serotonin Reuptake Inhibitors (SSRI)

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The most important step is to stop St John’s wort. The supply of tricyclic antidepressants is often restricted because they are dangerous in overdose. However, once it is safe to start SSRI treatment, the supply need not be restricted because the risk of serious adverse effects with an overdose of SSRIs is low.

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The herbal remedy, St John’s wort has serotonergic activity and must not be taken at the same time as an SSRI. Starting SSRI treatment a week after stopping St John’s wort minimises the risk of an interaction. Close monitoring of Jake’s mood during the week allows appropriate action to be taken if his depression worsens.

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The most important step is to stop St John’s wort. Even a small dose of SSRI could pose a risk if given before St John’s wort has been adequately eliminated from the body.

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The most important step is to stop St John’s wort. However, it is important to tell Jake about agitation and gastrointestinal effects when it is time to start SSRI treatment.

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Jake does not drink excessively and to seek total abstinence is unlikely to be helpful. However, it might be worth mentioning that alcohol, as a depressant itself, can impede the response to antidepressant treatment. Further, alcohol taken with antidepressants can possibly affect psychomotor function, concentration and alertness.

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1. To seek medical help immediately if Jake has suicidal thoughts or is reacting aggressively to routine events

Jake’s mood should be carefully assessed for any risk of suicide or harm; close monitoring or referral to specialist mental health services may be necessary.

2. Warn Jake that he may feel anxious and restless and get gastrointestinal side effects but these usually abate with continued treatment

Jake should be advised that these side effects usually wear off over two to three weeks, but he should seek help if they are distressing or intolerable.

3. It might take about a fortnight before he notices his mood lifting and full effect might take a month or slightly longer

Antidepressants generally take one to two weeks to start working and it may take up to six weeks for the full effect to develop.

5. SSRIs are known to affect sex drive and Jake should seek help if this is the case

Few patients report sexual side effects spontaneously. Discussion about sexual function before starting SSRI treatment and enquiries during treatment can help Jake raise any concerns.

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4. The dose of SSRI should be taken just once a day, always with breakfast

Except for fluvoxamine and paroxetine, the product literature does not recommend any specific time of day for taking the SSRI nor how to take the SSRI in relation to meals. The summary of product characteristics advises taking fluvoxamine as a single dose in the evening (but high doses can be taken as divided doses) and paroxetine as a single dose in the morning with food.

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Correct

5. Dispersible paracetamol tablets together with an antiemetic

From the options available, this is the best one. Paracetamol is safe in this setting; a dispersible formulation can be helpful because absorption may be impaired during migraine as a result of reduced peristalsis. Addition of a suitable antiemetic drug can help to treat nausea, a feature of migraine.

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1. A NSAID that is specifically licensed for treating acute migraine (eg diclofenac potassium, flurbiprofen, ibuprofen, naproxen sodium, or tolfenamic acid)

NSAID is not appropriate. Concomitant use of any NSAID with an SSRI increases the risk of gastrointestinal bleeding and should be avoided as far as possible.

2. A 5HT₁-receptor agonist (‘triptan’), preferably as a convenient quick-acting formulation

A 5HT₁-receptor agonist is not appropriate. Using a 5HT₁-receptor agonist during SSRI treatment introduces the risk of serotonin syndrome, a rare but very serious disorder. Drugs with serotonergic activity should be avoided in those being treated with SSRIs.

3. Tramadol with an antiemetic drug to help with the pain and nausea

Tramadol is not appropriate. Tramadol has serotonergic effect and can interact with SSRIs and introduce the risk of serotonin syndrome, a rare but very serious disorder.

4. Clonidine for migraine prophylaxis

Clonidine is not appropriate. Clonidine can aggravate depression and sleep disorders are common adverse effects.

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Correct

1. Counsel Jake about withdrawal effects and advise him of the usual time course for these events

Withdrawal effects can sometimes be distressing but counselling Jake about them in advance and about the time course of these reactions will prepare him better to face them, should they occur.

2. Consider switching to an SSRI with a long half-life during the withdrawal phase if troublesome discontinuation symptoms emerge

SSRI therapy is best withdrawn by decreasing the dose gradually. An SSRI which persists longer in the body facilitates smooth reduction of the dose.

3. Reduce the SSRI dose over several days

The SSRI should be withdrawn over at least one to two weeks; normally the dose is reduced over four weeks and, in some cases, longer.

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4. Consider introducing another class of antidepressant if features of depression reappear

If a particular SSRI has been effective, it can be reintroduced if treatment has been discontinued too soon or in case of a new episode. Introducing a different SSRI or another class of antidepressant before fully withdrawing the current SSRI runs the risk of producing a drug interaction (and serotonin syndrome).

5. Stop SSRI treatment and start a short course of benzodiazepine to treat anxiety and insomnia

Counselling and gradual dose reduction should be the principal strategies for managing withdrawal symptoms. The introduction of a benzodiazepine introduces the possibility of dependence on another class of drugs.

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