initiation/Ongoing Treatment

Baseline investigations are not needed before starting SSRIs. If clomipramine, an SRI, is started, an ECG/EKG at baseline is advised. Serum blood levels of clomipramine should be taken to monitor blood levels of clomipramine and desmethylclomipramine to avoid cardiac and CNS toxicity (where such testing is available). If using high dose citalopram/escitalopram, check the QTc is acceptable via an ECG.

If someone responds to an SSRI, a course of treatment should be for at least one year. Similarly, if depression or anxiety is co-occurring, medication management for at least one year is likely to be indicated.

Before starting CBT, the clinician should make sure the patient knows the intended number of therapy sessions, the need to perform homework assignments, and the need for some home visits.

risks/Side Effects

The clinically most common side effects from SRI medications include: nausea, dry mouth, headache, diarrhea, nervousness, agitation or restlessness, reduced sexual desire or difficulty reaching orgasm, inability to maintain an erection (erectile dysfunction), rash, increased sweating, weight gain, drowsiness, or insomnia.

Rarer but serious side effects include: arrhythmias are possible with clomipramine and therefore EKGs need to be performed after each dose change or when adding other medications, paying attention to the QTc. In general, clomipramine should be avoided when using concomitant paroxetine, fluoxetine, or fluvoxamine as they may dramatically increase clomipramine blood levels. Seizures have been reported with the use of clomipramine (1%). Citalopram/ escitalopram may lengthen the QTc at higher doses.

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