SSRIs-Related Behavioural Syndromes in Children and Adolescents.

Dear Editor: Selective Serotonin Reuptake Inhibitors (SSRIs) have become increasingly the mainstay of treatment for a wide array of depressive and anxiety disorders in Child and Adolescent Psychiatry (CAP) reflecting efficacy coupled with reasonable safety and tolerabilityunlike its predecessors; tricyclic antidepressants (TCAs). Dire shortage of clinicians trained in Child and Adolescent psychotherapy renders SSRIs a default first-line treatment. FDA-approved SSRIs in CAP are sertraline, fluvoxamine, fluoxetine, and, escitalopram. Apart from expected somatic side-effect profile of SSRIs related to excess serotonin in the synaptic cleft stimulating post-synaptic 5HT2A, 5HT2c, and 5HT3 receptors, behavioural syndromes are now more frequently encountered in clinical practice that mandate special characterization. Here, I delineate eight of these syndromesmostly based on clinical experience, as there is dearth of pertinent data in literature notably regarding CAP. Its neurobiologic correlates are yet to be defined. 1. SSRI-Activation Syndrome (Reinblatt, dosReis, Walkup, & Riddle, 2009): • It is more in CAP populations; • It is commonplace; • Tends to occur early-on during course of treatment; • Mostly manifests as agitation, dysphoria or akathisia, but with no striking mood changes; • It is not indicative of latent bipolarity; • And responds to dose reduction or slower titration. 2. SSRI-Manic/Hypomanic Switch (Joseph, Youngstrom, & Soares, 2009): • It is less common than the activation syndrome; • It is usually of later onset; • Manifests striking mood changes, with hyperactivity; • Might continue symptomatic after stopping SSRI; • And indicative of bipolar (III) disorder; • Cycle acceleration is also possible; • Stopping culprit agent is mandatory or cautious use under umbrella of mood-stabilization. 3. SSRI-Discontinuation Syndrome (Hosenbocus, & Chahal, 2011): • It occurs with prolonged use (at least 1 month); • Follows abrupt cessation; • It takes place within 1-7 days of stopping of offending agent; • Notably manifest when higher doses employed; • More likely with short half-life agents; • It presents in form of dizziness, insomnia, electric shock-like sensations, nightmares, flu-like symptoms; • Paroxetine is notorious in this regard; • Gradual tapering, benzodiazepine coverage or switch to fluoxetine is all helpful avoiding stopping it “cold turkey”. 4. SSRI-Emotional Blunting (Reinblatt, & Riddle, 2006): • It shows as apathy or indifference; • Might be related to resultant secondary dopamine deficiency with boosting 5-HT tone;