Psychiatry passmedicine
Selective serotonin reuptake inhibitors
Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for
the majority of patients with depression.
● citalopram (although see below re: QT interval) and fluoxetine are currently
the preferred SSRIs
● sertraline is useful post myocardial infarction as there is more evidence for its
safe use in this situation than other antidepressants
● SSRIs should be used with caution in children and adolescents. Fluoxetine is
the drug of choice when an antidepressant is indicated
Adverse effects
● gastrointestinal symptoms are the most common side-effect
● there is an increased risk of gastrointestinal bleeding in patients taking SSRIs.
A proton pump inhibitor should be prescribed if a patient is also taking a
NSAID
● patients should be counselled to be vigilant for increased anxiety and
agitation after starting a SSRI
● fluoxetine and paroxetine have a higher propensity for drug interactions
Citalopram and the QT interval
● the Medicines and Healthcare products Regulatory Agency (MHRA) released a
warning on the use of citalopram in 2011
● it advised that citalopram and escitalopram are associated with
dose-dependent QT interval prolongation and should not be used in those
with: congenital long QT syndrome; known pre-existing QT interval
prolongation; or in combination with other medicines that prolong the QT
interval
● the maximum daily dose is now 40 mg for adults; 20 mg for patients older
than 65 years; and 20 mg for those with hepatic impairment
Interactions
● NSAIDs: NICE guidelines advise 'do not normally offer SSRIs', but if given
co-prescribe a proton pump inhibitor
● warfarin / heparin: NICE guidelines recommend avoiding SSRIs and
considering mirtazapine
● aspirin
● triptans - increased risk of serotonin syndrome
● monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome
,Following the initiation of antidepressant therapy patients should normally be
reviewed by a doctor after 2 weeks. For patients under the age of 25 years or at
increased risk of suicide should be reviewed after 1 week. If a patient makes a good
response to antidepressant therapy they should continue on treatment for at least 6
months after remission as this reduces the risk of relapse.
When stopping a SSRI the dose should be gradually reduced over a 4 week period
(this is not necessary with fluoxetine). Paroxetine has a higher incidence of
discontinuation symptoms.
Discontinuation symptoms
● increased mood change
● restlessness
● difficulty sleeping
● unsteadiness
● sweating
● gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
● paraesthesia
SSRIs and pregnancy
- BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
- Use during the first trimester gives a small increased risk of congenital heart defects
- Use during the third trimester can result in persistent pulmonary hypertension of the
newborn
- Paroxetine has an increased risk of congenital malformations, particularly in the first
trimester
Charles-Bonnet syndrome
Charles-Bonnet syndrome (CBS) is characterised by persistent or recurrent complex
hallucinations (usually visual or auditory), occurring in clear consciousness. This is
generally against a background of visual impairment (although visual impairment is
not mandatory for a diagnosis). Insight is usually preserved. This must occur in the
absence of any other significant neuropsychiatric disturbance.
Risk factors include:
● Advanced age
● Peripheral visual impairment
● Social isolation
● Sensory deprivation
● Early cognitive impairment
, CBS is equally distributed between sexes and does not show any familial
predisposition. The most common ophthalmological conditions associated with this
syndrome are age-related macular degeneration, followed by glaucoma and cataract.
Well-formed complex visual hallucinations are thought to occur in 10-30 per cent of
individuals with severe visual impairment. Prevalence of CBS in visually impaired
people is thought to be between 11 and 15 per cent.
Around a third find the hallucinations themselves an unpleasant or disturbing
experience. In a large study published in the British Journal of Ophthalmology, 88%
had CBS for 2 years or more, resolving in only 25% at 9 years (thus it is not generally
a transient experience).
Cox (2014) Negative outcome Charles Bonnet Syndrome. Br J Ophthalmol
Palliative care prescribing: pain
NICE guidelines
In 2012 NICE published guidelines on the use of opioids in palliative care. Selected
points are listed below. Please see the link for more details.
Starting treatment
● when starting treatment, offer patients with advanced and progressive
disease regular oral modified-release (MR) or oral immediate-release
morphine (depending on patient preference), with oral immediate-release
morphine for breakthrough pain
● if no comorbidities use 20-30mg of MR a day with 5mg morphine for
breakthrough pain. For example, 15mg modified-release morphine tablets
twice a day with 5mg of oral morphine solution as required
● oral modified-release morphine should be used in preference to transdermal
patches
● laxatives should be prescribed for all patients initiating strong opioids
● patients should be advised that nausea is often transient. If it persists then an
antiemetic should be offered
● drowsiness is usually transient - if it does not settle then adjustment of the
dose should be considered
Selective serotonin reuptake inhibitors
Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for
the majority of patients with depression.
● citalopram (although see below re: QT interval) and fluoxetine are currently
the preferred SSRIs
● sertraline is useful post myocardial infarction as there is more evidence for its
safe use in this situation than other antidepressants
● SSRIs should be used with caution in children and adolescents. Fluoxetine is
the drug of choice when an antidepressant is indicated
Adverse effects
● gastrointestinal symptoms are the most common side-effect
● there is an increased risk of gastrointestinal bleeding in patients taking SSRIs.
A proton pump inhibitor should be prescribed if a patient is also taking a
NSAID
● patients should be counselled to be vigilant for increased anxiety and
agitation after starting a SSRI
● fluoxetine and paroxetine have a higher propensity for drug interactions
Citalopram and the QT interval
● the Medicines and Healthcare products Regulatory Agency (MHRA) released a
warning on the use of citalopram in 2011
● it advised that citalopram and escitalopram are associated with
dose-dependent QT interval prolongation and should not be used in those
with: congenital long QT syndrome; known pre-existing QT interval
prolongation; or in combination with other medicines that prolong the QT
interval
● the maximum daily dose is now 40 mg for adults; 20 mg for patients older
than 65 years; and 20 mg for those with hepatic impairment
Interactions
● NSAIDs: NICE guidelines advise 'do not normally offer SSRIs', but if given
co-prescribe a proton pump inhibitor
● warfarin / heparin: NICE guidelines recommend avoiding SSRIs and
considering mirtazapine
● aspirin
● triptans - increased risk of serotonin syndrome
● monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome
,Following the initiation of antidepressant therapy patients should normally be
reviewed by a doctor after 2 weeks. For patients under the age of 25 years or at
increased risk of suicide should be reviewed after 1 week. If a patient makes a good
response to antidepressant therapy they should continue on treatment for at least 6
months after remission as this reduces the risk of relapse.
When stopping a SSRI the dose should be gradually reduced over a 4 week period
(this is not necessary with fluoxetine). Paroxetine has a higher incidence of
discontinuation symptoms.
Discontinuation symptoms
● increased mood change
● restlessness
● difficulty sleeping
● unsteadiness
● sweating
● gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
● paraesthesia
SSRIs and pregnancy
- BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
- Use during the first trimester gives a small increased risk of congenital heart defects
- Use during the third trimester can result in persistent pulmonary hypertension of the
newborn
- Paroxetine has an increased risk of congenital malformations, particularly in the first
trimester
Charles-Bonnet syndrome
Charles-Bonnet syndrome (CBS) is characterised by persistent or recurrent complex
hallucinations (usually visual or auditory), occurring in clear consciousness. This is
generally against a background of visual impairment (although visual impairment is
not mandatory for a diagnosis). Insight is usually preserved. This must occur in the
absence of any other significant neuropsychiatric disturbance.
Risk factors include:
● Advanced age
● Peripheral visual impairment
● Social isolation
● Sensory deprivation
● Early cognitive impairment
, CBS is equally distributed between sexes and does not show any familial
predisposition. The most common ophthalmological conditions associated with this
syndrome are age-related macular degeneration, followed by glaucoma and cataract.
Well-formed complex visual hallucinations are thought to occur in 10-30 per cent of
individuals with severe visual impairment. Prevalence of CBS in visually impaired
people is thought to be between 11 and 15 per cent.
Around a third find the hallucinations themselves an unpleasant or disturbing
experience. In a large study published in the British Journal of Ophthalmology, 88%
had CBS for 2 years or more, resolving in only 25% at 9 years (thus it is not generally
a transient experience).
Cox (2014) Negative outcome Charles Bonnet Syndrome. Br J Ophthalmol
Palliative care prescribing: pain
NICE guidelines
In 2012 NICE published guidelines on the use of opioids in palliative care. Selected
points are listed below. Please see the link for more details.
Starting treatment
● when starting treatment, offer patients with advanced and progressive
disease regular oral modified-release (MR) or oral immediate-release
morphine (depending on patient preference), with oral immediate-release
morphine for breakthrough pain
● if no comorbidities use 20-30mg of MR a day with 5mg morphine for
breakthrough pain. For example, 15mg modified-release morphine tablets
twice a day with 5mg of oral morphine solution as required
● oral modified-release morphine should be used in preference to transdermal
patches
● laxatives should be prescribed for all patients initiating strong opioids
● patients should be advised that nausea is often transient. If it persists then an
antiemetic should be offered
● drowsiness is usually transient - if it does not settle then adjustment of the
dose should be considered
