SSRIs and FDA Warnings on Antidepressants

FDA Warnings on Antidepressants

• All antidepressants carry increased risk of suicidal thoughts and behavior, especially in children, adolescents, and young adults (up to 24 years of age) during the first two months of treatment.
• Depression and psychiatric illness are risk factors.

SSRI Medications

• Specific Medications: Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline
• Fluoxetine: First in the USA to be approved for depression; inhibits CYP450
• Fluvoxamine: Approved for OCD in the USA; inhibits CYP450
• Paroxetine: Inhibits CYP450
• Monitoring: Closely monitor patients for the first 2-3 weeks after starting treatment for suicidal ideation.

Herbs Interacting with SSRIs

• Ginkgo Biloba

• St. John's Wort

• Garcinia cambogia (HCA)

• L-tryptophan (or 5-HTP)

• SAMe (S-adenosyl-methionine) supplements

• These can increase the risk of serotonin syndrome.

Onset and Mechanism of Action of SSRIs

• Onset: Two weeks to 12 weeks for maximum benefit; half-life of 16-36 hours
• Mechanism: Block the reuptake of serotonin, increasing its concentration in the synaptic cleft. This prevents serotonin from being reabsorbed by the presynaptic nerve, increasing availability and potentially improving mood
• More serotonin is available to bind with the postsynaptic receptors, which triggers the next action potential.

Indications for SSRI

• Depression
• Anxiety
• Fluvoxamine is not indicated for anxiety.

Other Medications

• SNRIs: Desvenlafaxine, Duloxetine, Levomilnacipran, Venlafaxine.

• MOA of Desvenlafaxine: Block the reuptake of serotonin and norepinephrine: degree of this block depends on dosage.

• Side effects: Common side effects for SNRIs like Venlafaxine and Duloxetine include CNS effects, nausea, constipation, dry mouth and sexual side effects.

• Tricyclic antidepressants: Imipramine, Trimipramine, Nortriptyline, Doxepin, Desipramine, Amitriptyline, Clomipramine, Protriptyline, Amoxapine.

• Indications: Depression, panic disorder, preventing migraine, treating chronic pain syndrome.

• Mirtazapine: An atypical antidepressant: side effects include sedation, increased appetite, and weight gain.

Anxiolytics

• Some medications used for anxiety (like Zoloft) also treat depression.

Sleep Aids

• Zolpidem, triazolam, ramelteon, temazepam, eszopiclone - short-acting medications for sleep onset insomnia.
• Zolpidem extended release, eszopiclone, temazepam, lorazepam, eszopiclone, low dose doxepin, suvorexant - longer-acting medications for sleep maintenance insomnia.

Pain Medications

• Gabapentin/Pregabalin: Anticonvulsants used for neuropathic pain,
• Carbamazepine: First-line therapy for trigeminal neuralgia; prevents repeated nerve discharges
• Ketamine: Can reduce NMDA receptor firing, used to treat chronic opioid use
• Lidocaine: Topical anesthetic that blocks nerve impulses in localized neuropathic pain.
• Capsaicin cream: Repeated application depletes substance P in neurons for chronic pain relief.

Other Medications and Substances

• Lamotrigine, topiramate, valproic acid, ethosuximide: Antiepileptics
• COX-2 inhibitors: Used for pain but have potential side effects
• Opioids: Used for moderate to severe pain
• NSAIDs: For mild to moderate pain, inflammation, strains
• Melatonin receptor agonists: Have associated side effects like headache, increased liver function tests and abnormal dreams.
• 5-alpha reductase inhibitors: Used for BPH, with associated side effects.
• Anti-estrogen (like raloxifene): Prevents osteoporosis, primarily for post-menopausal women
• Progesterone-based medications: Terminates pregnancy, and are also used in contraceptive methods

This quiz covers the essential aspects of SSRIs, FDA warnings, and their implications on mental health. It touches on the risks associated with these medications, especially regarding suicidal ideation in younger populations, as well as interactions with herbal supplements. Test your knowledge on these crucial topics related to antidepressant therapy.