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Selective Serotonin Reuptake Inhibitors (SSRI)

7 Case study

Young man staring

Scenario 1

Jake Rowling, a 24-year-old man, has been taking St John’s wort because he has been feeling down ever since he broke up with his girlfriend ten months ago. He is diagnosed with moderately severe depressive illness. Jake is a keen sportsman. His medical history and physical examination are unremarkable. He does not smoke and drinks about four to six units of alcohol a week. SSRI treatment is considered suitable.

What is the most appropriate action at this initial consultation? Select the single best answer.

When prescribing the SSRI for Jake which of the following points are appropriate to discuss?

  1. To seek medical help immediately if Jake has suicidal thoughts or is reacting aggressively to routine events
  2. Warn Jake that he may feel anxious and restless and get gastrointestinal side effects but these usually abate with continued treatment
  3. It might take about a fortnight before he notices his mood lifting and full effect might take a month or slightly longer
  4. Regardless of the SSRI chosen, the dose should be taken just once a day, always with breakfast
  5. SSRIs are known to affect sex drive and Jake should seek help if this is the case

Choose your answers as follows:

Scenario 2

A couple of months after starting treatment, Jake is doing well and the early nausea and anxiety are settling. His mood is improving and he agrees that it is worthwhile continuing SSRI treatment. However, he is now consulting you about migraine attacks about every three to four weeks. Over-the-counter analgesics have been of some help. In addition to advice on avoiding foods and situations that can provoke migraine, you feel Jake should also have access to effective medicines.

Which of the following migraine treatments might be most suitable?

  1. A NSAID that is specifically licensed for treating acute migraine (eg diclofenac potassium, flurbiprofen, ibuprofen, naproxen sodium, or tolfenamic acid)
  2. A 5HT1-receptor agonist (‘triptan’), preferably as a convenient quick-acting formulation
  3. Tramadol with an antiemetic drug to help with the pain and nausea
  4. Clonidine for migraine prophylaxis
  5. Dispersible paracetamol tablets together with an antiemetic

Choose your answers as follows:

Scenario 3

Jake’s depression has responded very well to the SSRI treatment. Having taken antidepressants for about 15 months, you and Jake agree that it is time to start planning withdrawal of antidepressant treatment.

What preparations need to be made for withdrawing antidepressant treatment?

  1. Counsel Jake about withdrawal effects and advise him of the usual time course for these events
  2. Consider switching to an SSRI with a long half-life during the withdrawal phase if troublesome discontinuation symptoms emerge
  3. Reduce the SSRI dose over at least one to two weeks
  4. Consider introducing another class of antidepressant if features of depression reappear
  5. Stop SSRI treatment and start a short course of benzodiazepine to treat anxiety and insomnia

Choose your answers as follows: