Urinary selective serotonin reuptake inhibitors across critical windows of pregnancy establishment: a prospective cohort study of fecundability and pregnancy loss.

OBJECTIVE: To prospectively investigate the association of selective serotonin reuptake inhibitor (SSRI) exposure through critical windows of pregnancy establishment with fecundability and pregnancy loss. DESIGN: Prospective cohort study using longitudinal urine measurements of common SSRIs while women are actively trying to conceive. SETTING: Four clinical sites. PATIENT(S): A total of 1,228 women without uncontrolled depression/anxiety, attempting natural conception while participating in a randomized trial of preconception-initiated low-dose aspirin. INTERVENTIONS(S): Not applicable. MAIN OUTCOME MEASURE(S): Urinary SSRIs (fluoxetine, sertraline, escitalopram/citalopram) were measured while trying to conceive and, for women who became pregnant, at weeks 0, 4, and 8 of pregnancy. Fecundability odds ratios and incidence of pregnancy loss and live birth were estimated. RESULT(S): A total of 172 women (14%) were exposed to SSRIs while trying to conceive. SSRI exposure was associated with 24% reduced fecundability, and accordingly, a nonsignificant 9% lower live birth incidence, with significantly lower live birth in fluoxetine-exposed women. SSRI exposure was not associated with subsequent pregnancy loss, whether exposure was before conception or at 0, 4, or 8 weeks of gestation, although estimates varied by specific SSRI drug. CONCLUSION(S): Women using SSRIs may have more difficulty becoming pregnant, and although SSRI exposure overall was not associated with pregnancy loss, fluoxetine deserves caution and future study. CLINICAL TRIAL REGISTRATION NUMBER: NCT00467363.

Ultrasound-assisted dispersive liquid-liquid microextraction coupled with field-amplified capillary electrophoresis for sensitive and quantitative determination of fluoxetine and norfluoxetine enantiomers in biological fluids.

A rapid, simple, and sensitive technique for the quantitative detection of fluoxetine and norfluoxetine enantiomers in biological fluids was developed based on the combination of field-amplified sample stacking (FASS)-related capillary electrophoresis (CE) with ultrasound-assisted dispersive liquid-liquid microextraction (UA-DLLME). The extraction efficiency of UA-DLLME was strongly related to extraction time, salt concentration, type of extraction and dispersion solvents, and volume of extraction and dispersion solvents. The extracted fluoxetine and norfluoxetine enantiomers in a mixture of 50% methanol and 50% deionized water were efficiently stacked using FASS and then separated using cyclodextrin-modified CE. Under optimal conditions of FASS (chiral selector, 3 mM trimethyl-ß-cyclodextrin; and background electrolyte, 100 mM phosphate buffer) and UA-DLLME (extraction solvent, 200 µL of acetone; and dispersed solvent, 50 µL of C2H2Cl4 in 1 mL of the sample solution), the obtained enrichment factors of fluoxetine and norfluoxetine enantiomers reached approximately 2000. The linear ranges for the quantification of fluoxetine and norfluoxetine enantiomers were 0.3-150 and 0.6-150 nM, respectively. The relative standard deviations in peak areas and migration time for four analytes were less than 3.3% and 6.3%, respectively. The proposed system provided limits of detection (signal-to-noise ratio of 3) for four analytes corresponding to 0.1 nM. The precision and accuracy for urine and serum samples were less than 6.8 and 8.3%, respectively. These findings suggested that the proposed system exhibited a high potential for the reliable determination of fluoxetine and norfluoxetine enantiomers in clinical samples. Graphical abstract.

Recent advances in liquid chromatographic methods for the determination of selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors.

Depression is now the second largest public health burden throughout the world. Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) have replaced older antidepressants to become first-line medications to treat this disease with increased remission rates and markedly decreased incidence of severe adverse events. Traditional and modern bioanalytical strategies for SSRI and SNRI determination are being continuously improved. There has also been a recent increase in the use of unconventional sample preparation methods. This review critically evaluates the development of SSRI and SNRI liquid chromatographic analytical methods published between 2014 and mid-2019, with special attention to novel sample preparation methods.

An experimental ninhydrin design approach for the sensitive spectrofluorimetric assay of milnacipran in human urine and plasma.

Women are the most ones who susceptible to a common syndrome called fibromyalgia syndrome, up to 90% of all people with fibromyalgia are women. It affects mainly muscles and soft tissue and cause for them muscle pain, sleep problems and painful tender points. Milnacipran is acting as a serotonin-norepinephrine reuptake inhibitor (SNRI) therefore, it is recommended for the treatment of this syndrome. The widespread use of this compound in our market requires the development and validation of a simple, sensitive, cheap, fast and reproducible spectrofluorimetric method for the assay of milnacipran hydrochloride in its pure state, pharmaceutical tablets and spiked human urine and plasma. In the current work ninhydrin and phenylacetaldehyde in Teorell and Stenhagen buffer (pH 7) reacts with the amino moiety of milnacipran through a sensitive condensation reaction resulting in formation of a fluorescent product, which exhibits its fluorescence emission intensity at 465 nm after excitation at 390 nm. It is observed that, in the concentration range 0.5 to 3.0 µgmL-1, the constructed calibration curve was linear with a good correlation coefficient (0.9998). The condensation reaction was successfully applied for the assay of the studied drug in Avermilan® tablets, spiked human urine and plasma without interference from the components of the sample matrix with average percentage recoveries of 101.73 ±â€¯0.56 and 100.55 ±â€¯0.64 for urine and plasma, respectively.

Identification and characterization of vilazodone metabolites in rats and microsomes by ultrahigh-performance liquid chromatography/quadrupole time-of-flight tandem mass spectrometry.

RATIONALE: Vilazodone is a selective serotonin reuptake inhibitor (SSRI) used for the treatment of major depressive disorder (MDD). An extensive literature search found few reports on the in vivo and in vitro metabolism of vilazodone. Therefore, we report a comprehensive in vivo and in vitro metabolic identification and structural characterization of vilazodone using ultrahigh-performance liquid chromatography/quadrupole time-of-flight tandem mass spectrometry (UPLC/Q-TOF/MS/MS) and in silico toxicity study of the metabolites. METHODS: To identify in vivo metabolites of vilazodone, blood, urine and faeces samples were collected at different time intervals starting from 0 h to 48 h after oral administration of vilazodone to Sprague-Dawley rats. The in vitro metabolism study was conducted with human liver microsomes (HLM) and rat liver microsomes (RLM). The samples were prepared using an optimized sample preparation approach involving protein precipitation followed by solid-phase extraction. The metabolites have been identified and characterized by using LC/ESI-MS/MS. RESULTS: A total of 12 metabolites (M1-M12) were identified in in vivo and in vitro matrices and characterized by LC/ESI-MS/MS. The majority of the metabolites were observed in urine, while a few metabolites were present in faeces and plasma. Two metabolites were observed in the in vitro study. A semi-quantitative study based on percentage counts shows that metabolites M11, M6 and M8 were observed in higher amounts in urine, faeces and plasma, respectively. CONCLUSIONS: The structures of all the 12 metabolites were elucidated by using LC/ESI-MS/MS. The study suggests that vilazodone was metabolized via hydroxylation, dihydroxylation, glucuronidation, oxidative deamination, dealkylation, dehydrogenation and dioxidation. All the metabolites were screened for toxicity using an in silico tool.

Dispersive liquid-liquid microextraction combined with acetonitrile stacking through capillary electrophoresis for the determination of three selective serotonin reuptake inhibitor drugs in body fluids.

Dispersive liquid-liquid microextraction was combined with acetonitrile stacking in capillary electrophoresis for the identification of three selective serotonin reuptake inhibitors (citalopram, fluoxetine, and fluvoxamine) in human fluids such as urine and plasma. Parameters that affect the extraction and stacking efficiency, such as the type and volume of the extraction and disperser solvent, extraction time, salt addition for dispersive liquid-liquid microextraction, and sample matrices, pH, and concentration of the separation buffer for stacking, were investigated and optimized. Under optimum conditions, the enrichment factors were in the range of 1195-1441. Limits of detection ranged from 1.4 to 1.7 nM for the target analytes. Calibration graphs displayed satisfied linearity with R2 greater than or equal to 0.9978, and relative standard deviations of the peak area analysis were in the range of 2.9-5.0% (n = 3). The recoveries of all tricyclic antidepressant drugs from urine and plasma were in the range of 77-117 and 79-106%, respectively. The findings of this study show that dispersive liquid-liquid microextraction acetonitrile-stacking capillary electrophoresis is a rapid and convenient method for identifying tricyclic antidepressant drugs in urine and plasma.

NMR-based metabonomic analysis of normal rat urine and faeces in response to (±)-venlafaxine treatment.

(±)-Venlafaxine, a bicyclic antidepressant of the serotonin-norepinephrine reuptake inhibitor (SNRI) class, is prescribed for the treatment of depression and anxiety disorders. As is the case with other antidepressants, its precise mechanisms of action are still unknown. Pharmacometabonomic approaches allow for the detection of diverse metabolites, unlike classic methods for analysing drug interaction based on single metabolites and linear pathways. This provides a global view of the state of homeostasis during treatment and an insight into the mechanisms of action of a drug. Accordingly, the final outcome of treatment is characterised by the network of reactome pathways derived from the on-target and off-target effects of the drug. Regarding antidepressants, the drug network may be located in the gut-microbiome-brain-liver-kidney-immune-cardiovascular system axis (GMBLKICA), implying that neurotransmitters participate as signalling molecules in bidirectional communication. If their bioavailability is increased, this communication and the state of homeostasis may be disrupted. With a pharmacometabonomic approach using NMR in combination with different chemometric methods, a determination was made of subtle changes in the metabolic profile (metabotype) of urine and faeces in normal Wistar rats following a single administration of pharmacological doses of (±)-venlafaxine hydrochloride. Based on the drug-response metabotypes observed, (±)-venlafaxine had effects on gut microbial co-metabolites and osmolytes. Hence, it can be hypothesized that bidirectional communication in the multiorgan axis was perturbed by this drug, and very likely by its active metabolite, (±)-desvenlafaxine. This disrupted signalling could be related not only to therapeutic and adverse effects, but also to the lag period in treatment response.

Pharmacokinetics, metabolism, and excretion of nefopam, a dual reuptake inhibitor in healthy male volunteers.

1. The disposition of nefopam, a serotonin-norepinephrine reuptake inhibitor, was characterized in eight healthy male volunteers following a single oral dose of 75 mg [(14)C]-nefopam (100 µCi). Blood, urine, and feces were sampled for 168 h post-dose. 2. Mean (± SD) maximum blood and plasma radioactivity concentrations were 359 ± 34.2 and 638 ± 64.7 ngEq free base/g, respectively, at 2 h post-dose. Recovery of radioactive dose was complete (mean 92.6%); a mean of 79.3% and 13.4% of the dose was recovered in urine and feces, respectively. 3. Three main radioactive peaks were observed in plasma (metabolites M2 A-D, M61, and M63). Intact [(14)C]-nefopam was less than 5% of the total radioactivity in plasma. In urine, the major metabolites were M63, M2 A-D, and M51 which accounted for 22.9%, 9.8%, and 8.1% of the dose, respectively. An unknown entity, M55, was the major metabolite in feces (4.6% of dose). Excretion of unchanged [(14)C]-nefopam was minimal.

Determination of selective serotonin reuptake inhibitors in plasma and urine by micellar liquid chromatography coupled to fluorescence detection.

Citalopram, paroxetine and fluoxetine are selective serotonin reuptake inhibitor (SSRIs) currently used in the treatment of psychiatric disorders. We present an analytical method using micellar liquid chromatography to quantify these three drugs in pharmaceutical formulations, plasma and urine. The resolution was performed using a mobile phase of 0.075 M SDS - 6% (v/v) butanol buffered at pH 7 running through a C18 column under isocratic mode at 1 mL/min at 25°C. The analytes were eluted in less than 20 min. The fluorescence detection was programmed at the maximum excitation (236, 295 and 230 nm) and emission (310, 350 and 305 nm) wavelengths for citalopram, paroxetine and fluoxetine, respectively. The experimental procedure was expedited to 1/5 dilution of the sample in the micellar mobile phase and filtration, thus avoiding clean-up and extraction steps. An aliquot of 20 µL was injected after 80 min of preparation, to obtain maximum sensitivity. The method was validated according to the guidelines of the Food and Drug Administration (FDA) in terms of calibration range (20-500 ng/mL; r(2)>0.999), sensitivity, accuracy (91.3-103.2%), precision (<9.3%), and robustness (<6.1%). The suitability of the method was successfully evaluated by analyzing plasma and urine samples from patients treated with SSRIs and checking the content of the active principle in tablets. Thus, the method can be applied to pharmacokinetics studies and in forensic cases, as well as in quality control of commercial pharmaceutical formulations.

Simultaneous monitoring of selective serotonin reuptake inhibitors in human urine, plasma and oral fluid by reverse-phase high performance liquid chromatography.

A simple and rapid reverse-phase high-performance liquid chromatography method is developed for the simultaneous determination of selective serotonin reuptake inhibitors (sertraline, citalopram, paroxetine and fluoxetine) in urine, plasma and oral fluid. Separation was performed on a Crestpack-18 column (4.6 × 250 mm × 5 µ) within 17.5 min. The mobile phase was composed of water (50 mL) [with glacial acetic acid (0.15 mL) + triethyl amine (0.30 mL)]-acetonitrile (40 mL)-methanol (10 mL), delivered isocratically (0.6 mL/min) at 270 nm. Liquid-liquid extraction was performed for isolation of analytes from biofluids. The developed methodology was validated in terms of sensitivity, linearity, accuracy, precision, stability and selectivity. The calibration curves were linear in the range of 5-1,000 ng/mL for all the compounds in three matrices, with coefficients of determination between 0.9991 to 0.9998. The average extraction recoveries for all the four analytes were above 90%. The limits of detection and limits of quantification were in the ranges of 0.02-1.20 and 0.12-2.51 ng/mL, respectively. The intra-day and inter-day variation coefficients were less than 8.0 and 11%, respectively. Moreover, the results were compared statistically for each analyte in three matrices and found to be equivalent, which signifies the absence of matrix effect. Thus, the method can be applied for the determination of selective serotonin reuptake inhibitors in urine, plasma and oral fluid for routine therapeutic and toxicological screening.

Sensitive determination of sertraline by capillary electrophoresis with dispersive liquid-liquid microextraction and field-amplified sample stacking.

A novel method for the determination of sertraline using dispersive liquid-liquid microextraction (DLLME) coupled with capillary electrophoresis (CE) was developed. Acetone and dichloromethane were used as the disperser solvent and extraction solvent, respectively. A mixture of the extraction and disperser solvents was rapidly injected into a 1.0 mL aqueous sample to form a cloudy solution. After the extraction, sertraline was analyzed using CE that was equipped with UV detection. A 74-fold improvement in the sensitivity was observed when DLLME was used to extract sertraline. Since the DLLME extract residue was redissolved with 5 µL of water that contained 20% methanol, the detection sensitivity was further enhanced through the use of field-amplified sample stacking (FASS). A 11-fold improvement in the sensitivity was obtained when FASS was used to on-line concentrate sertraline. Under optimal extraction and stacking conditions, the calibration curve, which ranged from 0.01 to 1 µM was observed to be linear. The limit of detection (LOD) at a signal-to-noise ratio of 3 was 2.5 nM for sertraline. An approximately 814-fold improvement in the sensitivity was observed for sertraline compare with injection of standard solution without the DLLME and FASS procedures. This developed method was successfully applied to the determination of sertraline in human urine samples.

Arrays of SnO2 nanorods as novel solid phase microextraction for trace analysis of antidepressant drugs in body fluids.

The arrays of tin oxide nanorods-solid phase microextraction (ATN-SPME) fibre coupled with the high performance liquid chromatography (HPLC) method was developed for simultaneous determination of selective serotonin reuptake inhibitors (SSRI), citalopram and fluoxetine, in human urine and plasma samples. The variables of interest in the Direct-SPME (D-SPME) were extraction time, pH, ion strength or salt percentage and desorption time of analytes from the fibre. These factors were optimised by using a Box-Behnken design and the response surface equations were developed. The optimal experimental conditions obtained from this statistical evaluation included: the salt percentage (30%, w/v), NaOH volume (6.5 µl from a 1 M solution), extraction time (10 min) and desorption time (30 min) for drugs in the plasma sample and The salt percentage (30%, w/v), NaOH volume (100 µl from a 1 M solution), extraction time (18 min) and desorption time (23 min) for drugs in the urine sample. A satisfactory reproducibility for the extraction from urine and plasma samples (R.S.D.<10%) was obtained. The linearity for urine and plasma ranged from 1 to 5×10(5) ng ml(-1) with a detection limit of 0.2 ng ml(-1) for citalopram and 0.5 ng ml(-1) for fluoxetine, which covered the typical urinary concentrations obtained for citalopram and fluoxetine.

Excretion and metabolism of milnacipran in humans after oral administration of milnacipran hydrochloride.

The pharmacokinetics, excretion, and metabolism of milnacipran were evaluated after oral administration of a 100-mg dose of [¹4C]milnacipran hydrochloride to healthy male subjects. The peak plasma concentration of unchanged milnacipran (∼240 ng/ml) was attained at 3.5 h and was lower than the peak plasma concentration of radioactivity (∼679 ng Eq of milnacipran/ml) observed at 4.3 h, indicating substantial metabolism of milnacipran upon oral administration. Milnacipran has two chiral centers and is a racemic mixture of cis isomers: d-milnacipran (1S, 2R) and l-milnacipran (1R, 2S). After oral administration, the radioactivity of almost the entire dose was excreted rapidly in urine (approximately 93% of the dose). Approximately 55% of the dose was excreted in urine as unchanged milnacipran, which contained a slightly higher proportion of d-milnacipran (∼31% of the dose). In addition to the excretion of milnacipran carbamoyl O-glucuronide metabolite in urine (∼19% of the dose), predominantly as the l-milnacipran carbamoyl O-glucuronide metabolite (∼17% of the dose), approximately 8% of the dose was excreted in urine as the N-desethyl milnacipran metabolite. No additional metabolites of significant quantity were excreted in urine. Similar plasma concentrations of milnacipran and the l-milnacipran carbamoyl O-glucuronide metabolite were observed after dosing, and the maximum plasma concentration of l-milnacipran carbamoyl O-glucuronide metabolite at 4 h after dosing was 234 ng Eq of milnacipran/ml. Lower plasma concentrations (<25 ng Eq of milnacipran/ml) of N-desethyl milnacipran and d-milnacipran carbamoyl O-glucuronide metabolites were observed.

Synthesis of molecularly imprinted polymer as a sorbent for solid phase extraction of citalopram from human serum and urine.

This paper describes a new method for the determination of citalopram in biological fluids using molecularly imprinted solid-phase extraction as the sample cleanup technique combined with high performance liquid chromatography. The molecularly imprinted polymers were prepared using methacrylic acid as functional monomer, ethylene glycol dimethacrylate as crosslinker, chloroform as porogen and citalopram hydrobromide as the template molecule. The novel imprinted polymer was used as a solid-phase extraction sorbent for the extraction of citalopram from human serum and urine. Effective parameters on citalopram retention were studied. The optimal conditions for molecularly imprinted solid-phase extraction consisted of conditioning with 1 mL methanol and 1 mL of deionized water at neutral pH, loading of citalopram sample (50 µg L(-1)) at pH 9.0, washing using 1 mL acetone and elution with 3 × 1 mL of 10 % (v/v) acetic acid in methanol. The MIP selectivity was evaluated by checking several substances with similar molecular structures to that of citalopram. Results from the HPLC analyses showed that the calibration curve of citalopram using MIP from human serum and urine is linear in the ranges of 1-100 and 2-120 µg L(-1) with good precisions (2.5 and 1.5 % for 10.0 µg L(-1)), and recoveries (between 82-86 and 83-85 %), respectively.

Quantification of antidepressants using gas chromatography-mass spectrometry.

Antidepressants are of great interest to clinical and forensic toxicologists as they are frequently used in suicidal gestures; they can be the source of drug interactions and some have narrow therapeutic indices making the potential for toxicity more likely. There are five categories of antidepressants based on function and/or structure. These are monoamine oxidase inhibitors (MAOI), cyclic antidepressants including tricyclic and tetracyclic compounds (TCA), selective serotonin reuptake inhibitors (SSRI), serotonin-norepinephrine reuptake inhibitors (SNRI), and atypical compounds. This method is designed to detect the presence of antidepressant drugs in blood/serum, urine, and tissue specimens using gas chromatography/mass spectrometry (GC/MS) following liquid-liquid extraction (LLE) and identified by relative retention times and mass spectra.

Gas chromatography-mass spectrometry detection of a norfluoxetine artifact in hydrolyzed urine samples may falsely indicate tranylcypromine ingestion.

In several cases, fluoxetine, its metabolites, its known artifacts, and supposedly tranylcypromine were detected in urine using the authors' systematic toxicological analysis (STA) procedure based on acid hydrolysis, extraction, and acetylation. As fluoxetine and tranylcypromine are absolutely contraindicated drugs and in none of the cases was tranylcypromine prescribed, the question of whether the detected compound might have been formed by fluoxetine and/or its metabolites arose. Therefore, rat urine taken after dosing with fluoxetine was screened in the same way. In addition, aqueous solutions of fluoxetine, norfluoxetine, tranylcypromine, and a mixture of the latter two drugs were worked-up and analyzed according to the STA and without hydrolysis. In urine specimens obtained from rats dosed with fluoxetine, tranylcypromine was detected as well as in the solution of worked-up norfluoxetine including hydrolysis. Its underlying mass spectrum could be identified by detailed interpretation of the fragmentation patterns as acetylated 3-phenyl-propyl-2-ene-amine. This compound could be postulated as hydrolysis product of norfluoxetine formed by ether cleavage and water elimination. Although this spectrum shows nearly the same fragmentation patterns as that of acetylated tranylcypromine, both compounds could finally be differentiated by their retention indices and by using the positive-ion chemical ionization mode.

Electro-oxidation and determination of trazodone at multi-walled carbon nanotube-modified glassy carbon electrode.

A simple and rapid electrochemical method was developed for the determination of trace-level trazodone, based on the excellent properties of multi-walled carbon nanotubes (MWCNTs). The MWCNT-modified glassy carbon electrode was constructed and the electrochemical behavior of trazodone was investigated in detail. The cyclic voltammetric results indicate that MWCNT-modified glassy carbon electrode can remarkably enhance electrocatalytic activity towards the oxidation of trazodone in neutral solutions. It leads to a considerable improvement of the anodic peak current for trazodone, and allows the development of a highly sensitive voltammetric sensor for the determination of trazodone. Trazodone could effectively accumulate at this electrode and produce two anodic peaks at about 0.73 V and 1.00 V. The electrocatalytic behavior was further exploited as a sensitive detection scheme for the trazodone determination by differential-pulse voltammetry. Under optimized conditions, the concentration range and detection limit are 0.2-10 microM and 24 nM, respectively for trazodone. The proposed method was successfully applied to trazodone determination in pharmaceutical samples. The analytical performance of this sensor has been evaluated for detection of analyte in urine as a real sample.

Rapid HPLC method for the simultaneous monitoring of duloxetine, venlaflaxine, fluoxetine and paroxetine in biofluids.

A simple and rapid HPLC method is developed for the determination of two serotonin-norepinephrine-reuptake inhibitors (duloxetine and venlaflaxine) and two selective serotonin-reuptake inhibitors (fluoxetine and paroxetine) in human biofluids. Separation was performed on an Inertsil ODS-3 column (250 x 4.0 mm, 5 µm) with acetonitrile-ammonium acetate (0.05 M, 41:59 v/v) at 235 nm, within 7 min. SPE on Oasis(®) HLB cartridges was applied for the isolation of analytes from biofluids. The developed methodology was validated in terms of sensitivity, linearity, accuracy, precision, stability and selectivity. Relative standard deviation was less than 10.4%. Limit of detection was 0.2-0.6 ng/µl in blood plasma and 0.1-0.8 ng/µl in urine. The method was successfully applied to biofluids from a patient under duloxetine treatment.

Escitalopram effects on insula and amygdala BOLD activation during emotional processing.

RATIONALE: The amygdala and insular cortex are integral to the processing of emotionally salient stimuli. We have shown in healthy volunteers that an anxiolytic agent, lorazepam, dose-dependently attenuates activation of limbic structures. OBJECTIVE: The current study investigated whether administration of a selective serotonin reuptake inhibitor (SSRI), escitalopram, alters the activation of limbic structures. We hypothesized that subchronic (21 days) SSRI treatment attenuates the activation of the amygdala and insula during processing of emotional faces. MATERIALS AND METHODS: Thirteen healthy volunteers participated in a double-blind, placebo-controlled, crossover, randomized study. After 21 days of treatment with either escitalopram or placebo, participants underwent functional magnetic resonance imaging (fMRI) during which all subjects completed an emotion face assessment task, which has been shown to elicit amygdala and insula activation. RESULTS: Subjects activated the bilateral insula and amygdala after treatment with both escitalopram and placebo. In subjects who were adherent to the protocol (as evidenced by sufficiently high urine concentrations of escitalopram), a reduction in amygdala activation was seen in the escitalopram condition compared to placebo. CONCLUSION: The current investigation provides further evidence for the mechanism of action of SSRIs through the attenuation of activation in brain regions responsible for emotion processing and provides support for the use of blood oxygenation level-dependent fMRI with pharmacological probes to help identify the specific therapeutic effect of these agents in patients with anxiety and mood disorders.

The distribution of fluoxetine in human fluids and tissues.

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that was introduced in 1986. Certain side effects of this medication-drowsiness, dizziness, abnormal vision, diarrhea, and headache-could affect pilot performance and become a factor in an aviation accident. Our laboratory has determined the distribution of fluoxetine and its desmethyl metabolite, norfluoxetine, in various postmortem tissues and fluids from 10 fatal aviation accident cases. When available, 11 specimen types were analyzed for each case, including blood, urine, vitreous humor, bile, liver, kidney, skeletal muscle, lung, spleen, heart muscle, and brain. Blood fluoxetine concentrations in these 10 cases ranged from 21 to 1480 ng/mL. The distribution coefficients for both fluoxetine and norfluoxetine, expressed as specimen/blood ratios, were determined. The distribution coefficients for fluoxetine were determined to be 0.9 +/- 0.4 for urine, 0.10 +/- 0.03 for vitreous humor, 9 +/- 1 for bile, 38 +/- 10 for liver, 60 +/- 17 for lung, 9 +/- 3 for kidney, 20 +/- 5 for spleen, 2.2 +/- 0.3 for muscle, 15 +/- 3 for brain, and 10 +/- 2 for heart. To our knowledge, this is the first report presenting the distribution of fluoxetine in humans at therapeutic concentrations.