Assistant Clinical Professor
Department of Psychiatry and Human Behavior
University of California, Irvine, College of Medicine

Clinical Professor
Department of Psychiatry and Human Behavior
University of California, Irvine, College of Medicine

Associate Professor and Vice Chair
Department of Psychiatry and Human Behavior
University of California, Irvine, College of Medicine

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Indications for medications contained in this book sometimes may not be approved by the FDA. Varying degrees of empirical evidence exist for the effectiveness of medications for non- FDA approved uses. The authors have included those off-label indications where sufficient research has been completed to warrant the consideration of these agents as treatment alternatives.

the most widely prescribed class of antidepressants. SSRIs have proven efficacy in the treatment of major depression, dysthymia, obsessive-compulsive disorder (OCD), panic disorder, bulimia nervosa, post-traumatic stress disorder, generalized anxiety disorder and social phobia (social anxiety disorder).

depression and premenstrual dysphoric disorder. They may have some efficacy in the treatment of pain syndromes, such as migraine headaches and chronic pain. There is some evidence that they be effective in impulse control disorders. These agents have also been used to treat behavioral compon- ents of borderline personality disorder.

hours for the parent compound. Fluoxetine, however, has a half-life of 2-4 days, and its active metabolite, norfluoxetine, has a 7-10 day half-life. Thus it takes fluoxetine over a month to reach steady-state plasma concentrations while the other SSRIs take approximately 5 days.

highly bound to plasma proteins. SSRIs have significantly less effect on muscarinic, histaminic, and adrenergic receptors, compared to tricyclic antidepressants (TCAs), and the SSRIs are generally better tolerated.

dosing. The dosage of fluoxetine, citalopram, and paroxetine is 20 mg per day; the dosage should be decreased to 10 mg per day in the elderly. The initial dose of escitalopram is 10 mg/day. Sertraline and fluvoxamine are dosed at 50 mg per day, but the dosage is decreased to 25 mg per day in elderly patients. There is no linear relationship between SSRI dose and response. For many patients, the dosage does not need to be increased.

Higher dosages of SSRIs, such as 60-80 mg of fluoxetine or 200-300 mg of sertraline, have been used to treat obsessive-compulsive disorder and bulimia. While high doses may be necessary in some patients, many patients will respond to standard dosing after 6-12 weeks. When greater than 40 mg a day of fluoxetine is given, the dosage should be divided into two doses to minimize side effects.

be started at a low dosage to prevent exacerbation of anxiety in the initial weeks of treatment. Patients should start at 12.5- 25 mg of sertraline, 5-10 mg of paroxetine, 10-20 mg of citalopram, 5-10 mg of escitalopram, and 5 mg of fluoxetine. After 1-3 weeks, the dosage may be increased gradually to standard dosages.

to alleviate symptoms of depression and treatment should continue for 6-8 weeks before a patient is considered treatment refractory.

plasma concentrations of SSRIs and clinical efficacy. Measuring plasma levels is not clinically indicated.

orthostatic hypotension because they do not block alpha-1 adrenergic receptors as the tricyclic agents do.

dry mouth, constipation, blurred vision, and urinary retention because they have minimal effect on muscarinic cholinergic receptors.