SSRI's (Selective Serotonin Reuptake Inhibitors)

Depressed people often have low serotonin levels in the brain. SSRIs increase levels of serotonin fairly quickly; the actual benefits on mood take longer. So far, this cannot be explained. The exact mechanism by which SSRIs and other types of antidepressants work remains unknown. SSRIs don't actually cause an increase in the production of serotonin, they increase levels of serotonin in the brain by inhibiting its reuptake; SSRI is an acronym for Selective Serotonin Reuptake Inhibitor. SSRIs are also used for OCD (obsessive compulsive disorder). SSRIs are currently the most commonly prescribed antidepressant.

Although all the SSRIs inhibit the uptake of serotonin, each SSRI has its own unique chemical composition. A person may have intolerable side effects from one SSRI and yet to be able to take another SSRI with no problems. One SSRI may fail to alleviate one's symptoms, while another SSRI may be effective. Every person also has a unique system. What medication works for one person may not work for another.

Side Effects of SSRIs

Common side effects that usually go away after the first few weeks of treatment are nausea, diarrhea, headaches, anxiety, insomnia, and drowsiness. A fairly common side effect that often does not go away (until the drug is withdrawn) is problems with sexual functioning. Not all people experience the same side effects.

SSRI WARNINGS:

INCREASED RISK OF SUICIDE FROM ANTIDEPRESSANTS
There is small but serious risk of an increase in suicidal thoughts ands behaviors in children, adolescents, and young adults between the ages of 18 and 24 taking any antidepressant medication (not just SSRIs), particularly when beginning medication or increasing the dosage.
Click here for more information on Antidepressants and Increased Risk of Suicidal Behavior.

BLEEDING PROBLEMS
SSRIs Increase the Risk of Bleeding Problems, especially if taken with aspirin, NSAIDs (nonsteroidal anti-inflammatory drugs, such as ibuprofen and naproxen), or other drugs that affect bleeding.

INFANT PERSISTENT PULMONARY HYPERTENSION
Taking SSRIs during second half of pregnancy may increase the risk of Infant Persistent Pulmonary Hypertension.

SEROTONIN SYNDROME:
Combining SSRI's (or SNRI's) and triptans may result in a life-threatening condition called Serotonin Syndrome.

Triptan medications are used to treat migraine. SSRIs (and SNRIs) and triptan medications increase serotonin levels on their own. Taken together, serotonin levels may become dangerously high. Risk is greatest during treatment initiation or dosage increase.

Serotonin syndrome symptoms may include restlessness, hallucinations, loss of coordination, fast heart beat, rapid changes in blood pressure, increased body temperature, overactive reflexes, nausea, vomiting, and diarrhea.

This does not mean that a person on an SSRI cannot take a triptan, but that caution should be used and one should be aware of the symptoms of Serotonin Syndrome. Seek medical attention immediately if you experience symptoms of Serotonin Syndrome. All healthcare providers should be informed of all medications you are taking.

Drug Names (each drug listed below increases serotonin levels on its own)

SSRI Drug Names

Celexa (citalopram)
Fluvoxamine
Lexapro (escitalopram)
Paxil (paroxetine)
Prozac (fluoxetine)
Symbyax (olanzepine/fluoxetine)
Zoloft (sertraline)

Combination Drug Containing an SSRI

Cymbalta (duloxetine)
Effexor (venlafaxine)
Meridia (sibutramine) - a weight loss drug

Triptans

Amerge (naratriptan)
Axert (almotriptan)
Frova (frovatriptan)
Imitrex (sumatriptan)
Maxalt and Maxalt-MLT (rizatriptan)
Relpax (eletriptan
Zomig and Zomig ZMT(zolmitriptan)

For more information on Serotonin Syndrome see FDA Public Health Advisory.

*Some people on SSRIs report waking up with a clenched jaw or having twitches (Prozac in particular) - taking magnesium and calcium supplements may help. Switching medications may be necessary.

Taking antidepressant medication helps the majority of depressed people. However it doesn't help all people and may even worsen depression for a small percentage of people. Given the negative thinking that goes along with depression, many depressed people who do not respond positively to the first or second medication they try assume they fall into the small percentage of people who don't respond to medication and may give up on medication too soon. It is important to have hope. If medication doesn't work, there are other treatment options available.

Other Antidepressants

Other neurotransmitters that affect mood are norepinephrine and dopamine. Bupropion, also used to help people quit smoking, is an antidepressant that inhibits the reuptake of dopamine and norepinephrine, while having a minimal affect on serotonin. Bupropion has a lower risk of sexual side effects than SSRIs but cannot be taken with people with seizure disorder.

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Antidepressant Medication Concerns

Antidepressant medications usually take several days to several weeks to take effect. It takes several weeks to evaluate a medication’s effectiveness. Sometimes, people have to try two, three, or more medications before they find one that is effective. Some people say that their medication is not working, yet family and friends notice they are more responsive. For some people, medication relieves symptoms, but doesn’t bring about full remission of the symptoms. A combination of medication and psychotherapy is usually more effective.

People who can identify one particular event (divorce, retirement, etc.) as the cause of their depression are likely suffering from an adjustment disorder. Antidepressant medication is not usually prescribed for adjustment disorders, as the symptoms are generally short-lived. However, an adjustment disorder may trigger an episode of major depression.

If one is suffering from prolonged stress brought on by distress over a personal problem counseling is essential. Medication is still helpful for 'normalizing' levels of neurotransmitters in the brain and reducing the symptoms of depression. Medication may also help the person from overreacting to stress. But counseling can help one learn to deal with personal problems, which reduces stress - a major factor in depression. Learning coping skills and gaining new insight on personal issues can help keep stress at a manageable level and reduce the risk of depression recurring.

Some people don’t like to take medication and go off their medication once they feel better. However, going off antidepressants too soon increases the chances of it recurring. Studies have shown that people (whose medication is working for them) who stay on antidepressant medication for at least 9 months are less likely to relapse within the year after discontinuation than patients who take them for less time. Major depression is a recurring condition. In some people there are years between episodes of depression. Others have more frequent reoccurrences.

Many people worry about the long-term side effects of medication, which is a valid concern. However, the long-term effects of depression can be substantial. Recurring or long lasting depression can have an affect on someone’s entire life – jobs, relationships, and quality of life in general.

Choosing to discontinue antidepressants because the long-term side effects are unknown is reasonable - choosing to discontinue a medication that is working because you feel it is a crutch is not. Antidepressants are no more a crutch than insulin is a crutch to a diabetic. Antidepressants help control the symptoms of an illness - antidepressants are not happy pills

Antidepressant Discontinuation Syndrome

Some people worry that they will become addictive. Antidepressants aren’t addictive in the sense that you need to take them for a ‘fix’. In fact, many people who are doing well on antidepressant medication have trouble remembering to take their pills. But your body adjusts to the medication and when stopped abruptly, withdrawal may occur.

Even tapering down gradually can cause withdrawal symptoms, although to a lesser degree. The severity of withdrawal seems to vary from medication to medication and from person to person.

If you and your doctor decide you are ready to go off your medication, taper off very slowly, as the withdrawal symptoms make some people very sick, physically and mentally. Depending on the medication, withdrawal symptoms may come on gradually - with SSRIs they may begin after a couple of days of not taking the medication.

Some withdrawal symptoms can mimic symptoms of depression. There is no point in going off ‘cold turkey’ – in fact in increases your chances of going back on the drug because one can’t handle the withdrawal symptoms.

Prozac stays in the body for so long that is least likely of the SSRIs to cause withdrawal symptoms. Some physicians will switch a person who is having problems tapering off another SSRI to Prozac, because it washes out of the body slowly, over several weeks, giving the body a chance to adjust. Other physicians are not aware of or won't acknowledge the level of discomfort some patients experience when going off antidepressants.

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Placebo Effect?

In studies involving antidepressant medications, about a third of people taking a placebo respond positively. The placebo effect is real. The improvement in mood is real. It is demonstrative of the connection between mind, body, and emotions and the power of suggestion. For some people, it may be that just taking the step to get help and the act of participation in one's well being makes one feel more positive and in control. In some cases, the timing of a study may have coincided with a person’s natural recovery, as each episode of major depression usually goes away within a year without treatment.

Studies have shown that about two thirds of people taking a particular antidepressant will respond favorably. Of course, out of those two thirds, a third are likely having a placebo effect. This means that only about 45% (two-thirds of two-thirds) of people respond to a particular antidepressant drug, yet studies show that between 80 and 90 percent of people will find an effective medication.

Increasing Response Rates to Antidepressants

If the first drug doesn’t work, then a second or third probably will. At times a combination of drugs are used. Thyroid hormone is sometimes added to an antidepressant drug to augment its effect (even if the thyroid is functioning normally). Folate may increase the effectiveness of antidepressant medication therapy.

If one cannot find an effective medication, or does not wish to take medication, psychotherapy takes on more importance. Some people are more open to taking herbal supplements for depression than prescription antidepressants.

Is Antidepressant Medication For Everyone

Antidepressant medication is usually the first line of treatment for depression. But other methods of treatment are available. Many people only have partial relief of their depressive symptoms while on medication. Studies have shown a combination of medication and psychotherapy is more effective than either medication or psychotherapy alone. One form of psychotherapy in particular - cognitive behavior therapy - involves challenging negative and distorted patterns of thinking and has been helpful for many people with depression. As more medications are developed, more people may find an antidepressant medication that works well for them.

Click here to read: Are Antidepressants Over Prescribed?

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