Selective serotonin reuptake inhibitors, or serotonin-specific re-uptake inhibitor (SSRIs), are a class of chemical compounds that have application as antidepressants and in the treatment of depression and other psychiatric disorders. SSRIs are therapeutically useful in the treatment of panic disorder (PD), posttraumatic stress disorder (PTSD), social anxiety disorder (also known as social phobia), obsessive-compulsive disorder (OCD), premenstrual dysphoric disorder (PMDD), and anorexia. There is also clinical evidence of the value of SSRIs in the treatment of the symptoms of schizophrenia and their ability to prevent cardiovascular diseases.
SSRIs primarily inhibit serotonin transporter (SERT) in the brain and have negligible effects on dopamine transporter (DAT) and norepinephrine transporter (NET). Inhibiting the binding of the neurotransmitter serotonin (5-HT) to SERT results in increased 5-HT concentration in the synaptic cleft leading to increased binding of 5-HT to postsynaptic receptors. This was once thought to be the mechanism that resulted in improvement of depression symptoms, however more recent systematic review of the academic literature has established that there is no correlation between 5-HT concentration or activity in the brain and depressive symptoms.
SSRIs have dominated the market for antidepressants and are recommended by the National Institute for Health and Clinical Excellence (NICE) as a first-line treatment of depression, because they tend to have fewer adverse effects than other type of antidepressants with the same effectiveness.
Development history
Before the discovery of SSRI drugs, the treatments for mood disorders were relatively limited. Now, however, there are dozens of antidepressants on the market for the treatment of depression. Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs) were the first drugs to be developed for the treatment of depression, dating back to the early 1950s. Because of their undesirable adverse-effect profile and high potential for toxicity, due to their non-selective pharmacological effects, strict regimens were needed for taking the drugs, which limited their use. Because of this, researchers looked for other alternatives with similar effectiveness but fewer adverse effects e.g. drugs that did not cause cardiac conduction abnormalities in overdoses or have the tendency to cause seizures, which led to the discovery of the SSRI drugs. The SSRIs are the most significant class of antidepressants marketed in recent years and are one of the major medicinal discoveries of the last few decades. SSRIs were the first drugs to establish a theoretical pathophysiological role for 5-HT in affective illnesses and in the broad spectrum of anxiety disorders. Likewise, they were the first to confirm the inhibition of neurotransmitter re-uptake as an important therapeutic principle.
The SSRIs are the first rationally designed class of psychotropic medications. The strategy behind rational drug design is to develop a new drug that is capable of affecting a specific biological target, or in this case a special neural site of action (uptake pumps, receptors), while trying to avoid effects on other site of actions. The goal in such development is to produce pharmacological agents that are more efficacious, safer and better tolerated than older medications.
An initial success was achieved when medicinal chemists set out in search of the ideal SSRI with the chemical synthesis of zimelidine (figure 1) from the antihistamine drug brompheniramine, which exhibited selective inhibition of 5-HT re-uptake with minimal inhibition of norepinephrine (NE) re-uptake. Most importantly, zimelidine did not come with the adverse effect profile as the TCAs and therefore it became the template for the second generation SSRIs. Zimelidine was the first SSRI to be marketed, but several cases of Guillain–Barré syndrome were associated with the use of the drug which led to withdrawal from the market in 1983. Subsequently, several non-tricyclic SSRIs were discovered and marketed.
Fluoxetine, which was FDA approved in 1987, is usually thought to be the first SSRI to be marketed. The work which eventually led to the discovery of fluoxetine began at Eli Lilly and Company in 1970 as a collaboration between Bryan Molloy and Ray Fuller. It was known at that time that the antihistamine diphenhydramine showed some antidepressant-like properties. 3-Phenoxy-3-phenylpropylamine, a compound structurally similar to diphenhydramine, was taken as a starting point. Molloy and fellow Eli Lilly chemist Klaus Schmiegel synthesized a series of dozens of its derivatives. Hoping to find a derivative inhibiting only serotonin reuptake, another Eli Lilly scientist, David T. Wong, proposed to retest the series for the in vitro reuptake of serotonin, norepinephrine and dopamine, using a technique developed by neuroscientist Solomon Snyder. This test showed the compound later named fluoxetine to be the most potent and selective inhibitor of serotonin reuptake of the series.
Introduction of fluoxetine to the market is hailed as a miracle drug for the treatment of depression because it had fewer adverse effects, simpler dosing strategies and greater margin of safety when overdoses were consumed and thus it had better adherence, compared to the older antidepressants (TCAs and MAOIs). Fluoxetine paved the way for the next generation of SSRIs, serving as a prototype for them. Since then the number of drugs in the SSRI class has become bigger and there are now six (fluoxetine, paroxetine, citalopram, escitalopram, sertraline, and fluvoxamine), as demonstrated in table 1.
+ Table 1: SSRI drugs used to treat depression. fluoxetine sertraline paroxetine fluvoxamine citalopram escitalopram Pharmaceutical forms Capsules, soluble- or dispersible tablets, oral solution Tablets, oral concentrate Tablets, oral suspension Tablets, oral solution, capsules Tablets, oral solution Tablets, oral solution Brand name Prozac, Fontex, Seromex, Depex, Seronil, Flutop, Fluctin Zoloft, Sertral, Lustral, Asentra, Tresleen Paxil, Seroxat, Paroxat, Paxetin, Aropax, Deroxat Luvox Celexa, Cipramil, Cipram, Citox, Oropram, Sepram Lexapro, Cipralex, Esopram, Seroplex FDA approval date December 29, 1987 December 30, 1991 December 29, 1992 December 5, 1994 July 17, 1998 August 14, 2002
Mechanism of action Precise mechanism of antidepressant activity of SSRIs remains somewhat uncertain, but a number of biochemical functions associated with SSRI treatment have been established. SSRIs primarily inhibit SERT in the brain and have negligible effects on DAT and NET. The SSRIs also have less affinity for α1, α2, H1 and muscarinic receptors, which might explain the differences of adverse events between TCAs and SSRIs.
Although SSRIs arrive rapidly to the brain after administration and the effects on 5-HT re-uptake can be measured instantly, it takes about 2–4 weeks to get therapeutic effects. The SSRIs have very high and selective affinity for SERT and after administration they inhibit SERT immediately. SERT inhibition is implicated in the antidepressant activity of SSRIs. 70-80% inhibition of SERT is usually necessary to induce antidepressant effects and higher dosage does not induce greater antidepressant effects for average patients. Higher dosage does, however, increase the incidence and severity of adverse events associated with excessive 5-HT re-uptake inhibition.
SSRIs prevent 5-HT from binding to SERT which prevents absorption of 5-HT back into the presynapse terminal, where it is metabolized by monoamine oxidase or stored in secretory vesicles. As a result, the 5-HT concentration increases at the somatodendritic area of the 5-HT neuron but not so much at the axon terminal area (demonstrated in figure 2). This increase in 5-HT concentration causes desensitization of somatodendritic 5-HT1A autoreceptors. When these 5-HT1A autoreceptors have been downregulated, they will no longer restrict the impulse flow of the 5-HT neuron. The impulse flow is turned on and as a result 5-HT is released at the axon terminal. However, this increase of 5-HT does not happen quickly compared to the increase of 5-HT at the somatodendritic area of the 5-HT neuron. This delay is caused by the time it takes 5-HT to downregulate 5-HT1A autoreceptors and turn on the neuro impulse flow of the 5-HT neuron. This delay can explain the reason why antidepressants do not have effect on depression immediately. This can also be the reason why the antidepressant mechanisms can be connected to the increasing neuro impulse flow from 5-HT neurons, where as the concentration of 5-HT increases at the axon terminal before SSRIs start to work properly. When SSRIs have (1) inhibited the re-uptake pump, (2) increased somatodendritic 5-HT, (3) desensitized somatodendritic 5-HT1A autoreceptors, (4) turned on the impulse flow and (5) increased the release of 5-HT from axon terminal, the last step might be desensitization of postsynaptic 5-HT receptors. This desensitization could be the reason for reduction of adverse effects of SSRIs as tolerance develops.
Adverse effects Although generally well tolerated and numerous advantages over other antidepressants, SSRIs are not devoid of adverse effects. The adverse effects of SSRIs are usually predictable from a knowledge of their pharmacology and are dose related. Such adverse effects are gastrointestinal dysfunction (nausea, diarrhea, epigastric discomfort), effects on the central nervous system (CNS) (anxiety, fatigue, tremor), anticholinergic effects (dry mouth, blurred vision, drowsiness, difficulty in urination) and sexual dysfunction (anorgasmia, low to no libido, erectile dysfunction, numb genitals, retrograde ejaculation, loss of erotic dreams or delayed ejaculation). Occasionally symptoms of sexual dysfunction persist after discontinuation of SSRIs.http://pi.lilly.com/us/prozac.pdf Page 14. SSRIs adverse effects are generally mild and temporary and are more of a discomfort than a serious threat in terms of systemic toxicity. Therefore, the adverse effect profile of the SSRIs may offer certain therapeutic advantages in the management of depression.
Pharmacology SSRIs are well absorbed in the gastrointestinal tract and reach peak plasma levels within 1–8 hours. During absorption SSRIs bind to proteins and are widely distributed throughout the body, including the brain, whereas they are lipophilic. Metabolism and elimination takes place mainly in the liver and most of the SSRIs produce pharmacologically active metabolites, as demonstrated in table 3 among with other pharmacology properties of the SSRIs.
Table 3 Comparative pharmacology of SSRIs