How would you initiate treatment with the newly recommended Selective Serotonin Reuptine Inhibitor (SSRI) for a patient?

From the Guidelines

I would initiate treatment with a newly recommended Selective Serotonin Reuptake Inhibitor (SSRI) by prescribing a low initial dose and gradually increasing it to minimize side effects, as recommended in the clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders 1. When starting a patient on an SSRI, it is essential to consider the potential for drug-drug interactions and discontinuation syndrome.

• For sertraline (Zoloft), I would begin with 25-50mg daily for one week, then increase to 50-100mg daily as tolerated, based on the guideline's suggestion to increase the dose in the smallest available increments at approximately 1- to 2-week intervals 1.
• For fluoxetine (Prozac), I would start with 10-20mg daily, considering its longer half-life and potential for interactions with drugs metabolized by CYP2D6 1.
• For escitalopram (Lexapro), 5-10mg daily is an appropriate starting dose, given its relatively low propensity for drug interactions compared to other SSRIs 1. I would advise the patient to take the medication at the same time each day, preferably in the morning if it causes insomnia or in the evening if it causes drowsiness.
• I would warn them about potential initial side effects, including nausea, headache, insomnia, and increased anxiety, which typically improve within 1-2 weeks 1.
• I would explain that therapeutic benefits may take 2-6 weeks to become apparent and encourage them to continue the medication even if they don't feel immediate improvement. Regular follow-up appointments would be scheduled at 2 weeks, 4 weeks, and then monthly to assess response and side effects, as part of a conservative medication trial to optimize the benefit-to-harm ratio and achieve remission 1.

From the FDA Drug Label

Adult — In controlled trials used to support the efficacy of fluoxetine, patients were administered morning doses ranging from 20 to 80 mg/day. Studies comparing fluoxetine 20, 40, and 60 mg/day to placebo indicate that 20 mg/day is sufficient to obtain a satisfactory response in major depressive disorder in most cases Consequently, a dose of 20 mg/day, administered in the morning, is recommended as the initial dose. Treatment should be initiated with a dose of 10 or 20 mg/day. After 1 week at 10 mg/day, the dose should be increased to 20 mg/day.

The recommended initial dose of fluoxetine is 20 mg/day, administered in the morning. For some patients, treatment may be initiated with a dose of 10 mg/day and increased to 20 mg/day after one week.

• The dose may be increased after several weeks if insufficient clinical improvement is observed.
• A lower or less frequent dosage should be used in patients with hepatic impairment.
• A lower or less frequent dosage should also be considered for the elderly, and for patients with concurrent disease or on multiple concomitant medications.
• Dosage adjustments for renal impairment are not routinely necessary 2, 3.

From the Research

Initiating Treatment with SSRI

To initiate treatment with a newly recommended Selective Serotonin Reuptake Inhibitor (SSRI) for a patient, consider the following:

• The SSRIs are a class of effective, well-tolerated antidepressants with benefits including improved safety in overdose, reduced side-effect burden, and uncomplicated dosing regimens 4.
• Unlike tricyclic antidepressants (TCAs), SSRIs typically do not require dose titration, as many patients find the initial dose effective 4.
• The recommended dose ranges for the five SSRIs (citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline) should be considered when initiating treatment 4.
• SSRIs are the treatment of choice for many indications, including major depression, dysthymia, panic disorder, obsessive-compulsive disorder, eating disorders, and premenstrual dysphoric disorder, due to their efficacy, good side-effect profile, tolerability, and safety in overdose 5.

Potential Side Effects and Considerations

When initiating treatment with an SSRI, be aware of potential side effects, including:

• Gastrointestinal disturbances, headache, sedation, insomnia, activation, weight gain, impaired memory, excessive perspiration, paresthesia, and sexual dysfunction 5.
• The incidence of sexual dysfunction with different SSRIs, with paroxetine provoking more delay of orgasm or ejaculation and more impotence than fluvoxamine, fluoxetine, and sertraline 6.
• The potential for dose-related side effects and the importance of monitoring patients for these effects 4.

Dosing and Administration

Consider the following when determining the dosing and administration of an SSRI:

• The pharmacokinetic profiles of paroxetine, sertraline, and fluvoxamine, which have shorter elimination half-lives and are less likely to interact with other drugs 7.
• The potential for once-weekly dosing of fluoxetine in the maintenance of remission in panic disorder, which may allow for considerable cost savings and convenience 8.
• The importance of monitoring patients for potential side effects and adjusting the dose as needed to minimize these effects 4, 5, 7, 6.