Selective serotonin reuptake inhibitors — consultant viva · Psych Vivas

Prompt

Examiner cards: six SSRI names, black-box age bands, citalopram 60 mg script, paroxetine stop day 3 symptoms, fluoxetine-to-phenelzine day 7 plan, Hunter clonus stem, Montejo sexual rates, elderly Na 124.

Station structure

Time: 8–10 minutes. Depth: consultant teaching registrar. Expect named doses, black-box operationalisation, QTc ceilings, discontinuation vs relapse, Hunter rules, and fluoxetine MAOI washout without undergraduate waffle.[2][4][7]

Core questions and model points

Define SSRI and list six agents. SERT-selective reuptake inhibitors: fluoxetine, sertraline, citalopram, escitalopram, paroxetine, fluvoxamine. Class first-line for many MDD/anxiety indications; ranks modest between agents (Cipriani).[1][11]
Black box. Paediatric meta-analysis increased suicidality signal; adult age interaction (younger higher relative signal). Practice: early review, safety plan, treat activation — not absolute ban.[2][3]
Doses. Sertraline 50→50–200 mg; escitalopram 10→20 mg max adults; citalopram 20→40 mg adults (20 mg many elderly); fluoxetine 20→20–60 mg; paroxetine 20→20–50 mg. Adequate trial 4–8 weeks.[11]
QTc. Critique citalopram 60 mg script; cite dose-related QTc data; prefer lower dose or alternative (often sertraline) and ECG if risk stacks.[4][5]
Discontinuation. Paroxetine classic; electric shocks/dizziness; taper/restart; not addiction; fluoxetine smoother stop.[6]
Serotonin toxicity. Hunter criteria with serotonergic agent; stop agents; support; benzos; differentiate NMS.[7][8]
Washout. Fluoxetine ~5 weeks before irreversible MAOI; most others ~2 weeks; never combine.[8][11]
Sexual and sodium. Montejo high rates — ask; Movig hyponatraemia — check Na in elderly confusion/falls.[9][10]
After SSRI failure. STAR*D switch: sertraline ≈ bupropion ≈ venlafaxine for remission — choose by side-effects.[12]

Examiner traps

“SSRIs never need early review if TADS-positive agent.”[2]
Starting MAOI one week after fluoxetine.[8]
Calling discontinuation “proof of addiction.”[6]
Ignoring citalopram ceiling on a high-dose script.[4]

References

[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]Hammad TA, Laughren T, Racoosin J Suicidality in pediatric patients treated with antidepressant drugs Arch Gen Psychiatry, 2006.PMID 16520440
[3]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
[4]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
[5]Beach SR, Kostis WJ, Celano CM, et al. Meta-analysis of selective serotonin reuptake inhibitor-associated QTc prolongation J Clin Psychiatry, 2014.PMID 24922496
[6]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
[7]Dunkley EJ, Isbister GK, Sibbritt D, et al. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity QJM, 2003.PMID 12925718
[8]Boyer EW, Shannon M The serotonin syndrome N Engl J Med, 2005.PMID 15784664
[9]Montejo AL, Llorca G, Izquierdo JA, et al. Incidence of sexual dysfunction associated with antidepressant agents: a prospective multicenter study of 1022 outpatients J Clin Psychiatry, 2001.PMID 11229449
[10]Movig KL, Leufkens HG, Lenderink AW, et al. Association between antidepressant drug use and hyponatraemia: a case-control study Br J Clin Pharmacol, 2002.PMID 11966666
[11]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
[12]Rush AJ, Trivedi MH, Wisniewski SR, et al. Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression N Engl J Med, 2006.PMID 16554525

Core questions and model points

Define SSRI and list six agents. SERT-selective reuptake inhibitors: fluoxetine, sertraline, citalopram, escitalopram, paroxetine, fluvoxamine. Class first-line for many MDD/anxiety indications; ranks modest between agents (Cipriani).[1][11]

Black box. Paediatric meta-analysis increased suicidality signal; adult age interaction (younger higher relative signal). Practice: early review, safety plan, treat activation — not absolute ban.[2][3]

Doses. Sertraline 50→50–200 mg; escitalopram 10→20 mg max adults; citalopram 20→40 mg adults (20 mg many elderly); fluoxetine 20→20–60 mg; paroxetine 20→20–50 mg. Adequate trial 4–8 weeks.[11]

QTc. Critique citalopram 60 mg script; cite dose-related QTc data; prefer lower dose or alternative (often sertraline) and ECG if risk stacks.[4][5]

Discontinuation. Paroxetine classic; electric shocks/dizziness; taper/restart; not addiction; fluoxetine smoother stop.[6]

Serotonin toxicity. Hunter criteria with serotonergic agent; stop agents; support; benzos; differentiate NMS.[7][8]

Washout. Fluoxetine ~5 weeks before irreversible MAOI; most others ~2 weeks; never combine.[8][11]

Sexual and sodium. Montejo high rates — ask; Movig hyponatraemia — check Na in elderly confusion/falls.[9][10]

After SSRI failure. STAR*D switch: sertraline ≈ bupropion ≈ venlafaxine for remission — choose by side-effects.[12]

Examiner traps

“SSRIs never need early review if TADS-positive agent.”[2]

Starting MAOI one week after fluoxetine.[8]

Calling discontinuation “proof of addiction.”[6]

Ignoring citalopram ceiling on a high-dose script.[4]

References

[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]Hammad TA, Laughren T, Racoosin J Suicidality in pediatric patients treated with antidepressant drugs Arch Gen Psychiatry, 2006.PMID 16520440
[3]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
[4]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
[5]Beach SR, Kostis WJ, Celano CM, et al. Meta-analysis of selective serotonin reuptake inhibitor-associated QTc prolongation J Clin Psychiatry, 2014.PMID 24922496
[6]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
[7]Dunkley EJ, Isbister GK, Sibbritt D, et al. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity QJM, 2003.PMID 12925718
[8]Boyer EW, Shannon M The serotonin syndrome N Engl J Med, 2005.PMID 15784664
[9]Montejo AL, Llorca G, Izquierdo JA, et al. Incidence of sexual dysfunction associated with antidepressant agents: a prospective multicenter study of 1022 outpatients J Clin Psychiatry, 2001.PMID 11229449
[10]Movig KL, Leufkens HG, Lenderink AW, et al. Association between antidepressant drug use and hyponatraemia: a case-control study Br J Clin Pharmacol, 2002.PMID 11966666
[11]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
[12]Rush AJ, Trivedi MH, Wisniewski SR, et al. Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression N Engl J Med, 2006.PMID 16554525