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Clinical Atlas Prestige · Evidence-first

Psych MEQs / SAQsPsychopharmacology — SSRIs

Psych MEQs / SAQs · Psychopharmacology — SSRIs

SSRI selection, black box, QTc and discontinuation (MEQ)

FRANZCP-style MEQ on SSRI class prescribing: agent choice, black-box monitoring, QTc ceilings, and discontinuation syndrome.

20 marks20 min
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
A 22-year-old university student with moderate–severe unipolar MDD (PHQ-9 = 19), no bipolar history, and no prior antidepressants is referred for pharmacological treatment. They also have panic attacks. (i) Justify an SSRI choice with an adult oral starting dose and titration plan, including early review structure. (ii) Explain the black-box warning in plain language appropriate for consent. (iii) Contrast citalopram/escitalopram QTc dosing rules with sertraline. (iv) Three months later they stop paroxetine abruptly after a community switch and develop dizziness and electric-shock sensations — diagnose and manage. (20 marks)

Model answer

Reveal model answer

(i) Choice and plan. Moderate–severe unipolar MDD with panic supports SSRI first-line pharmacology within stepped care, ideally with psychological therapy access.[2][9] Reasonable first agents: sertraline 50 mg oral daily (or 25 mg if activation-prone) titrating toward 50–150 mg as tolerated, or escitalopram 10 mg toward 10–20 mg, or fluoxetine 20 mg. Document bipolar screen, suicide risk and means, sexual baseline, concurrent serotonergic drugs, and sodium if risk factors. Review within 1–2 weeks for activation/suicidality, then 2–4–6 weeks for efficacy; adequate trial ~4–8 weeks at therapeutic dose.[1][2][4]

(ii) Black box. In young people, antidepressants can increase thoughts of self-harm in a minority, especially early after starting or increasing dose — this is why we review soon and make a safety plan, not because the medicine is banned or “always dangerous.” Absolute suicide risk of untreated depression also matters; shared decision balances both.[3][4]

(iii) QTc. Citalopram has the clearest dose-related QTc regulatory attention — many adults max 40 mg daily; older adults often 20 mg. Escitalopram adult max commonly 20 mg with higher-dose caution. Sertraline is often preferred when cardiac/QTc risk is a concern among SSRI options, though no agent is risk-free with polypharmacy. ECG when risk stacks (cardiac disease, electrolytes, other QT drugs).[5][6]

(iv) Discontinuation. Classic SSRI discontinuation syndrome after abrupt paroxetine stop (short half-life): dizziness, sensory shocks, insomnia, irritability — usually early, not addiction.[7][8][10] Restart previous dose or cross-taper/slow taper; educate; distinguish from true depressive relapse which evolves differently over weeks. Consider fluoxetine bridge in selected cases given long half-life.

Common errors

  • Starting high-dose SSRI without early review in a 22-year-old.[3][4]
  • Claiming citalopram 60–80 mg is fine “if depressed enough.”[5][6]
  • Labelling discontinuation as “addiction” or “weakness.”[7][10]
  • Omitting panic comorbidity when choosing and counselling activation risk.[2]

References

  1. [1]Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis Lancet, 2018.PMID 29477251
  2. [2]Malhi GS, Bell E, Bassett D, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders Aust N Z J Psychiatry, 2021.PMID 33353391
  3. [3]Hammad TA, Laughren T, Racoosin J Suicidality in pediatric patients treated with antidepressant drugs Arch Gen Psychiatry, 2006.PMID 16520440
  4. [4]Stone M, Laughren T, Jones ML, et al. Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to US Food and Drug Administration BMJ, 2009.PMID 19671933
  5. [5]Castro VM, Clements CC, Murphy SN, et al. QT interval and antidepressant use: a cross sectional study of electronic health records BMJ, 2013.PMID 23360890
  6. [6]Beach SR, Kostis WJ, Celano CM, et al. Meta-analysis of selective serotonin reuptake inhibitor-associated QTc prolongation J Clin Psychiatry, 2014.PMID 24922496
  7. [7]Schatzberg AF, Blier P, Delgado PL, et al. Antidepressant discontinuation syndrome: consensus panel recommendations for clinical management and additional research J Clin Psychiatry, 2006.PMID 16683860
  8. [8]Rosenbaum JF, Fava M, Hoog SL, et al. Selective serotonin reuptake inhibitor discontinuation syndrome: a randomized clinical trial Biol Psychiatry, 1998.PMID 9646889
  9. [9]Kennedy SH, Lam RW, McIntyre RS, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 3. Pharmacological Treatments Can J Psychiatry, 2016.PMID 27486148
  10. [10]Fava GA, Gatti A, Belaise C, et al. Withdrawal Symptoms after Selective Serotonin Reuptake Inhibitor Discontinuation: A Systematic Review Psychother Psychosom, 2015.PMID 25721705