A 27-year-old man comes to the office due to new-onset depression symptoms. The patient recently earned his master's degree but has struggled to find employment. Over the last 3 months, he has developed worsening dysphoria and often struggles to get out of bed in the morning. He sleeps 14-16 hours each night, feels exhausted throughout the day, has very little appetite, and feels profoundly hopeless and worthless. The patient used to enjoy playing guitar and socializing with friends but has been unable to enjoy these activities recently. He has no history of anxiety or depression and does not use alcohol or other recreational substances. His father has a history of generalized anxiety disorder. The patient takes no medications and has no known drug allergies. Physical examination is within normal limits. A decision is made to start fluoxetine. Which of the following side effects should the physician discuss with this patient prior to prescribing this medication?

Question

A 27-year-old man comes to the office due to new-onset depression symptoms.  The patient recently earned his master's degree but has struggled to find employment.  Over the last 3 months, he has developed worsening dysphoria and often struggles to get out of bed in the morning.  He sleeps 14-16 hours each night, feels exhausted throughout the day, has very little appetite, and feels profoundly hopeless and worthless.  The patient used to enjoy playing guitar and socializing with friends but has been unable to enjoy these activities recently.  He has no history of anxiety or depression and does not use alcohol or other recreational substances.  His father has a history of generalized anxiety disorder.  The patient takes no medications and has no known drug allergies.  Physical examination is within normal limits.  A decision is made to start fluoxetine.  Which of the following side effects should the physician discuss with this patient prior to prescribing this medication?

Quizplus · Accepted Answer

The informed consent process for prescribing selective serotonin reuptake inhibitors (SSRIs) involves counseling patients on short- and long-term side effects. Common early side effects of SSRIs that typically resolve with time include headache, nausea, insomnia/sedation, anxiety, and dizziness. Long-term side effects that may be more persistent include sexual dysfunction and weight gain. Agent-specific drug interactions and side effects (eg, citalopram dose-related QTc prolongation) should also be discussed. Patients age 18-24 should be informed that studies of their age group have demonstrated an increased risk of suicidality during the initial weeks of SSRI treatment; however, this information should be tempered with information about the risks associated with untreated mental illness. Other important guidelines to review prior to prescribing SSRIs include time to response and discontinuation considerations. Patients should be counseled that although some individuals respond after 2 weeks of pharmacotherapy, most take 4-6 weeks to respond. Patients should be informed that SSRIs must be taken daily and that missed doses or abrupt discontinuation may be associated with SSRI discontinuation syndrome (eg, anxiety, dysphoria, flu-like symptoms). For this reason, patients should be informed that if they wish to discontinue their SSRI, they will need to undergo a supervised taper process. (Choice A) Anxiety, heat intolerance, and tachycardia are potential side effects of levothyroxine. (Choice B) Cough, dizziness, and hyperkalemia are known side effects of ACE inhibitor antihypertensives. (Choice C) Diarrhea, lactic acidosis, and weakness are potential side effects of metformin. (Choice D) Dyslipidemia, hyperglycemia, and sedation are known side effects of second-generation antipsychotics (eg, olanzapine). (Choice E) Fatigue, palpitations, and peripheral edema are potential side effects of calcium channel blocker antihypertensives. (Choice G) New-onset type 2 diabetes mellitus, hepatic dysfunction, and myalgia are known side effects of HMG-CoA reductase inhibitors (ie, statins). Educational objective: Prior to prescribing selective serotonin reuptake inhibitors, common early side effects (eg, headache, nausea, insomnia/sedation, anxiety, dizziness) and late side effects (eg, sexual dysfunction, weight gain) should be discussed. Patients should be advised to avoid abrupt discontinuation and be informed that response typically requires 4-6 weeks of continued use. References: The safety, tolerability and risks associated with the use of newer generation antidepressant drugs: a critical review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/27508501) A practical approach to prescribing antidepressants. (http://www.ncbi.nlm.nih.gov/pubmed/24085807)

A 27-Year-Old Man Comes to the Office Due to New-Onset