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Subtle differences among SSRIs should also be considered.

The half-lives reported for fluoxetine (Prozac) and its active metabolite are long (84 and 146 hours, respectively).12 Because of fluoxetine's long half-life and the persistence of side effects (sometimes for weeks after discontinuation), this drug is generally not recommended for use in elderly patients.

The Omnibus Budget Reconciliation Act (OBRA) of 1987 limited the use of psychotropic medications in residents of long-term care facilities.

Updates of OBRA guidelines have liberalized some dosing restrictions, but documentation of necessity and periodic trials of medication withdrawal are still emphasized.

Paroxetine (Paxil), which has no active metabolite, also has a considerably shorter half-life (24 hours) than fluoxetine.1213Most SSRIs are associated with significant drug interactions.Fluoxetine, paroxetine and, to a lesser extent, sertraline inhibit the metabolism of warfarin (Coumadin), cisapride (Propulsid), benzodiazepines, quinidine, tricyclic antidepressants, theophylline and some statins.12 In patients at risk for these interactions, citalopram (Celexa), a new SSRI now available in the United States, may offer an advantage.Studies have shown that compared with other SSRIs, citalopram has less of an inhibitory effect on the cytochrome P450 system.14 Citalopram is as effective as fluoxetine and sertraline in the treatment of depression.14Trazodone and nefazodone (Serzone) are also recommended for use in the elderly.In the elderly, antipsychotic medications can cause serious side effects, such as extrapyramidal symptoms and tardive dyskinesia.Newer antipsychotic drugs are less often associated with these side effects, but they should be used only for specific diagnoses and when behavioral and environmental measures are unsuccessful.

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