SSRI Overview

SSRIs stand for selective serotonin reuptake inhibitors. They are the most commonly prescribed class of medications in psychiatry and treat a variety of ailments including:

1. Depression (MDD)
2. Generalized Anxiety Disorder
3. Social Anxiety
4. Panic Disorder
5. Specific Phobias
6. OCD
7. premenstrual dysphoric disorder
8. PTSD
9. Premature ejaculation ‍

How do SSRIs work? 
‍SSRIs fight both anxiety & depression by increasing the amount of serotonin the neurons in the brain have access to by keeping it from being reabsorbed by the neuron that secreted it. 

The names of the SSRIs, in alphabetical order, (brand name in parentheses), along with their dose ranges, are: 
Citalopram (Celexa): 20-40mg 
Escitalopram (Lexapro): 10-30mg
Fluoxetine (Prozac): 20-100mg
Fluvoxamine (Luvox): 50-300mg, often dosed 2x/day
Paroxetine (Paxil CR): 25-62.5mg 
Sertraline (Zoloft): 25-300mg 

Why are these medications considered first, when there are so many antidepressant medications out there?
SSRIs are considered “first line” when treating depression in children, adolescents, and adults. This is because they have fewer side effects than most other classes of antidepressants and they tend to work very well for many people. 

How long will it take for the medicine to kick in for my anxiety or depression?
‍Like almost all antidepressants (except for ketamine, which is given only at specialty clinics, not at home), the benefit from these medications takes many weeks (up to 6 weeks in some cases, and the full benefit may not be realized until week 12 in some cases). 
In some cases, depression may be treated at lower doses and it can take higher doses to treat anxiety. 

How quickly is the dose increased?
‍This is decided on a case by case basis but we often consider starting at a low dose and slowly titrating up for: 
Children & teens
Those with no previous medication treatment
For those with higher anxiety that causes physical symptoms—studies show that those with more somatic anxiety have more perceived side effects to medications. 

How do you decide which SSRI to choose? 
This is also done on a case by case basis, but some factors we think about are: 

1. Lexapro, Zoloft, and Prozac all have various forms of FDA approval for children (age 12+ for MDD, 8+ for MDD, and 6+ for OCD, respectively). 
2. If you look at the largest studies done in adults, Lexapro tends to be the most effective of them all. 
3. We also want to know what medications the patient or the patient’s family has tried previously because there is a genetic component to how people respond to them. 
4. Most SSRIs are considered weight neutral, but some patients do complain of slow and insidious weight gain. Among all of the SSRIs, Prozac is the one that hast the lowest risk of weight gain.
5. Paxil is one we almost never use, as it has the most side effects and is hardest to get off of. It can be very sedating. 
6. Luvox/fluvoxamine tends to have the most GI upset among the SSRIs. 
7. Prozac/fluoxetine is the easiest one to get off of and it has the longest half life, so if 1 or 2 doses are missed per week, it’s not the end of the world. 
8. Prozac/fluoxetine tends to be the most energizing but this can feel “too activating” for a small % of clients. 
9. Lexapro has the least drug-drug interactions for those on other medications. 
10. Luvox is used less because it has to be given 2x/day (and tends to cause more GI upset).
    

‍Do these medications increase suicidal thinking? 

1. There is a 1/132 chance that those under the age of 30 can have a response to these medicines that makes them more irritable & depressed, and even worsen suicidal thinking. However, this is rare and it’s often easily spotted— if this is the reaction you have early on in treatment (usually noticed in the first 3 weeks of treatment), then stop the medicine immediately and inform your provider. Once you stop the medication, the suicidal ideations should resolve.
2. For the vast majority of people, these antidepressants will NOT increase suicidal thinking. In fact, when this warning came out in the early 2000’s, there was a temporary decrease in prescribing of these medications that led to an increase in depression and suicides because people weren’t being treated as much. 
   

What are the most common side effects of SSRIs?
‍Side effects are uncommon and tend to affect only 1 out of 20 patients. These include: 

1. GI or stomach upset that often resolves after 1 to 3 weeks
2. Nausea— a little more common with sertraline/zoloft than others
3. Insomnia 
4. Apathy 

Very rare side effects include: 

1. Bleeding such as bruising on legs
2. Stomach bleeding when combined with frequent use of NSAIDs
3. Geriatric patients have to watch for rare issues with low sodium and decreased platelet activity (which can cause bleeding)
   

So if I get headaches or stomach upset, should I keep taking the SSRI? 

1. This depends on how severe those issues are. Many do get those symptoms and the majority of patients see those symptoms dissipate after 2-3 weeks. If possible, try to stick with it. If it is too extreme, stop the medicine and inform your provider.
2. If we do have to stop the first SSRI, sometimes trying a different SSRI or a lower dose of the SSRI can be helpful in these cases. 
   

What about sexual side effects of SSRIs? 

1. Sexual side effects such as decreased libido and longer time to have an orgasm are, unfortunately, relatively common. These are somewhat dose dependent but can occur at lower doses too. They occur in about 35% of patients. 
2. There are some things that help with the sexual side effects of the medications: 
   https://www.health.harvard.edu/womens-health/when-an-ssri-medication-impacts-your-sex-life
   

How long do I need to stay on a SSRI? 

1. This is also complicated and there is no one size fits all answer, but we like to shoot for 4 to 8 months of symptom relief before considering coming off of the medication. 
2. Studies show that the average length of a depressive episode is 8 to 12 months, so that is also a rough estimate of how long a patient may stay on these medicines. 
3. The time of year and outside stressors, in addition to the patient response to therapy, meditation, and exercise also play a role in this decision. 
   

Are SSRIs addictive or “bad for the brain” in any known ways? 

1. No, these medications are not addictive (although other classes of psychiatric medications can be, these are not). 
2. Studies show that these medications can promote new neuronal growth and something called “neural plasticity”, which means the neurons are more interactive, in a positive way. 
   

Is it OK to just stop taking the SSRI? 

1. While it is not physically unsafe to stop taking these medications, it is better to wean off of them slowly once you have been on them for over 3-4 weeks. 
2. If there are severe side effects like bleeding or suicidality, they should be stopped right away. 
3. But they are usually considered fairly easy to get off of-- we usually like to wean off of them over the course of 2 weeks to 4 months, depending on how long, and what dose, someone was taking. 
   

Is it OK to drink alcohol on SSRIs? 

1. It is generally ok to consume alcohol at responsible levels when on SSRIs. Just remember alcohol is a depressant and induces a higher level of anxiety when it wears off so we would generally prefer alcohol be avoided when patients are suffering from depression or anxiety.