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Case #17B

1. 病識の欠如, 精神治療薬を服用することへの抵抗感, 薬局で処方してもらうことを恥ずかしく思う, 副作用の恐れ, 経済的理由. 特に日本では「薬はなるべく飲まないほうが良い」という思い込みが高齢者に強い.

2.

主な副作用: 嘔気 (4.9%), 傾眠 (3.6%), 食欲不振 (1.3%), めまい (1.3%).

重大な副作用: セロトニン症候群 (1%未満), 悪性症候群 (1%未満) (c)錯乱・幻覚・せん妄・けいれん (1%未満), SIADH (頻度不明), 重篤な肝機能障害 (頻度不明).

3.

Faculty Comments

1.    Prozac (fluoxetine) - given in the morning due to stimulatory effect, half life of 2-4 days, most problematic side effects are agitation, motor restlessness and insomnia.

2.    Zoloft (sertraline) - half life of 25 hours, more GI side effects than fluoxetine, less activating than fluoxetine, Category C, like all SSRIs, but Prozac and Zoloft are the most studied, and therefore most used, SSRIs in pregnancy and breast feeding.

3.    Paxil (paroxetine) - half life of 24 hours, more sedating and constipating than other SSRIs, strong antianxiety effects.

4.    Luvox (fluvoxamine) - half life of 15 hours, greater frequency of emesis compared to other SSRIs, useful in OCD.

5.    Celexa (citalopram)  half life of 35 hours, nausea, dry mouth and somnolence are most common side effects.

6.    Lexapro (escitalopram)  the S-enatiomer of citalopram, half life of 27-32 hours, overall less side effects than Celexa, which it is replacing. Significant anti-anxiety effects, and approved for Generalized and Social Anxiety Disorder.

日本国内で承認されているのは, パキシルとルボックスの2.

While there are general differences among the SSRIs, keep in mind that each patient's reaction to a medication is individualized.

起こりうる副作用とその対処についての十分な説明が, 服薬を維持させるためには必要であろう. 例えば, 便秘は特に女性にとって特に重要な問題であり, 処方時に予め副作用として便秘があることを説明し, 必要ならば下剤も処方することが望ましいと思う.

4. Faculty Comments

Among antidepressants, the SSRIs are more likely to cause delayed orgasm or anorgasmia in both males and females - reports vary from 1 to 15% among the SSRIs. Decreased libido has also been reported. As patients may be reluctant to report this side effect, asking the patient directly about this and other side effects at a follow-up visit is recommended. However, since many depressed patients experience decreased libido prior to initiation of treatment, this decreased libido may not be a true side effect of the SSRI. If sexual side effects do occur, the patient may wish to switch to an antidepressant with a lower incidence of sexual side effects. Considerations include: Wellbutrin (bupropion), Effexor (venlafaxine) and Remeron (mirtazapine).