Evidence-Based Reviews

When and how to use SSRIs to treat late-life depression

Current Psychiatry. 2003 January;2(1):43-47

References

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Cytochrome P450 1A2 is the liver isoenzyme responsible for dealkylating theophylline, caffeine, and phenacetin. This enzyme system also metabolizes tacrine and clozapine. Of the SSRIs, fluvoxamine is the most potent inhibitor of the 1A2 enzyme, while escitalopram is a negligible inhibitor.¹⁷

Cytochrome P450 2C is a subfamily of isoenzymes that includes 2C9, 2C10, 2C19, and others. This system metabolizes some antidepressants as well as warfarin, phenytoin, and diazepam. Inhibitors of this system include fluvoxamine, fluoxetine, sertraline, and paroxetine.¹⁸

MAO inhibitors. Concomitant use of serotonin-acting drugs and monoamine oxidase inhibitors should be avoided. When used in combination, SSRIs and MAO inhibitors can cause a serotonin syndrome, with potential hyperpyretic crises, seizures, coma, and death. When switching medications, it is important to eliminate any serotonin-acting drug before starting an MAO inhibitor.²

In young adults, a 7-day washout is needed when switching from fluvoxamine and 14 days when switching from sertraline, citalopram, or paroxetine. With fluoxetine, the washout period is 35 days in young adults. Because medication half-lives in older patients may be prolonged two- to three-fold, it is advisable to proceed conservatively and extend these washout periods accordingly.

Related resources

National Institute of Mental Health. Older adults: Depression and suicide facts. www.nimh.nih.gov/publicat/elderlydepsuicide.cfm
WebMD Health/depression. http://my.webmd.com/condition_center/dep
Salzman C, Wong E, Wright BC. Drug and ECT treatment of depression in the elderly, 1996-2001: a literature review. Biol Psychiatry 2002;52(3):265-84.

Drug brand names

Alprazolam • Xanax
Citalopram • Celexa
Clozapine • Clozaril
Diazepam • Valium
Escitalopram • Lexapro
Fluoxetine • Prozac
Fluvoxamine • Luvox
Paroxetine • Paxil
Sertraline • Zoloft
Tacrine • Cognex
Triazolam • Halcion

Disclosure

Dr. Kasckow reports that he receives grant/research support from, serves as a consultant to, or is on the speakers bureau of Eli Lilly and Co., Forest Laboratories, Pharmacia Corp., Solvay Pharmaceuticals, AstraZeneca Pharmaceuticals, Organon, Janssen Pharmaceutica, and Pfizer Inc.

Dr. Mohamed reports that she receives grant/research support from Forest Laboratories and serves on the speakers bureau of Eli Lilly and Co.

Dr. Herman reports that he serves as a consultant to Eli Lilly and Co.

Other co-authors report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.