Someone I care a lot about (and no, it really isn’t me) has been dealing with what I would call mild depression and anxiety. It’s been an issue for this person their whole life, but due to a very stressful (and very good) job, they’ve been struggling a bit more with it.
After a consult with a psychiatrist an SSRI is being suggested (I don’t recall which one). I want this person to get the help they need, and I’m all for whatever is best.
Of course I’ve read on SSRIs and they seem generally regarded as a safe approach. Some of the side effects sound a little concerning.
So I’m just looking for any thoughts or anecdotes people have with them. I know we’ve got some docs here, and I’d be happy to hear their thoughts as well.
I’m not a doctor but since you’re asking for anecdotes I can give you mine. I was on Lexapro for depression maybe 20 years ago. I would say it didn’t help me very much (of course YMMV). The only troublesome side effect was sexual dysfunction. It became very difficult or impossible to reach orgasm. Also, weaning off of the drug was quite unpleasant. I had serious brain zaps for a couple of weeks while tapering down.
I’ve recently (a few months ago) started taking an SSRI in response to chronic moderate depression. It’s still early days and the doctor and I are figuring out whether I’m on the right one and what the best dosage is, but on the whole it’s going well so far and there’s definitely an overall significant mood uplift.
Side effects I’ve had:
Drowsiness. Initially I was nodding off during the day but it gradually lessened. I still tend to conk out earlier in the evenings than I used to, but on the plus side I’m sleeping much better at night than I used to.
Reduced libido/orgasm - Not much fun, to put it mildly, but again this side effect has faded over a few weeks with me.
Upset digestive system and reduced appetite - this is the one that is lingering the longest. Although it’s not at a harmful or incapacitating level it is rather annoying.
On the whole the positives are outweighing the negatives so far.
I also took Lexapro for about a year and it seemed to be moderately helpful in managing some perpetual low-level anxiety. I must be one of the lucky ones but I didn’t experience any notable side effects. I wouldn’t say it CHANGED MY LIFE but it was a helpful safety net for a while.
I’ve actually been considering going back on for reasons similar to OP. Which I guess brings up a related question… are people expected to take SSRIs for the rest of their lives or is it a 6-month or 1-year cycle a common thing?
There is one perspective (and a body of research that appears to support it) arguing that SSRIs, if used for a prolonged period, provoke a compensating response in the brain. An SSRI inhibits reuptake, resulting in more serotonin, but over time the brain responds to that by developing and maintaining fewer of the responsive targets that react to serotonin, which has the general effect of reversing what was accomplished by having more serotonin running around in the system, and also of course creates a dependency on the SSRI.
For more details, I direct you to the writings of Robert Whitaker. You’re welcome to conclude that he, and the research that he cites, are wrong or dismissably biased or whatever, but you should read them first.
Despite 30 years in pharmaceuticals, I get nervous about certain classes of drugs. In particular, anything that alters mood. Many lives have been ruined because of drug abuse that starts with a perfectly legitimate prescription.
SSRIs didn’t do much for me and I had the sexual dysfunction side effects until being off them for 6 months. Didn’t realize that was a potential cause while it was happening which was rather frustrating at the time.
Had bad brain zaps when I accidentally didn’t take any for a couple days. Didn’t have them when tapering off according to doctor’s instructions.
Wellbutrin works pretty well for me, especially after switching to extended release. The effect is more gradual/less spiky and I don’t need to refuel mid-day.
I also take buspirone for anxiety now.
No SSRIs (or SNRIs) have any notable addiction potential so that, at least, is not a concern. There are a wide array of potential side effects and there is really no way to determine their propensity to occur, proper dosage, or indeed effectivity of pharmaceutical treatment other than by ‘experimenting’ with the drug and then increasing dosage or switching to another drug. Most of the side effects do not have potentially life-threatening in the way that other anti-depressant drugs like MAOIs can have although certain SSRIs (and potentially the entire class of drugs as they all work on the same hypothesized mechanism) can cause a small percentage of people to increase in anxiety or experience suicidal ideation. This should call for regular surveillance when first introducing the drug or significantly increasing the dosage; unfortunately, because of a shortage of psychiatrists these are often issued by general practicioners (or in some states even psychologists) who are not really qualified to evaluate efficacy and adverse effects, and even psychiatrists rarely schedule the at least twice-weekly meetings that are really necessary to evaluate trends in mood, relying on patients to raise a flag in the case of adverse reactions.
A few things to bear in mind are that these drugs often take weeks before they start having observable effects on mood, often have much lower efficacy than pharmaceutical companies would have you believe from their cherry-picked studies, and can have significant withdrawal effects such as the “brain zaps” described above in addition to memory/recall problems, severe anxiety and possible suicidal ideation, general gastrointestinal (GI) issues, lethargy and suppressed mood, agitation and irritability, et cetera. While they can be a real boon to people with persistent melancholia or dysthymia, they were never intended to be used as long term or for people suffering extreme depression, and what extended studies exist suggest a marked reduction in efficacy with extended use or against persistent depressive mood. As @AHunter3 notes, there is research that seems to indicate that there may be compensatory mechanisms that cause the effectiveness of the drug to wane over time, but once you start digging into that you get to an even deeper realization that there isn’t actually any solid evidence for how SSRIs function at all; the hypothetical mechanism is that they prevent absorption (“reuptake”) of serotonin and/or norepinephrine and thus allows the ‘pleasure circuits’ in the brain to function more efficiently but that has never been demonstrated in any practical sense, and indeed is essentially inferred from measuring serotonin output in stool samples, which has so many methodological issues as a measurement that it is really meaningless.
Nonetheless, people have reported improvement of mood and reduction of depressive symptoms when taking SSRIs, and it is a valid treatment option given the caveats. However, it should be understood as a palliative treatment that suppresses symptoms but does not treat the underlying causes of emotional dysfunction, which may require various forms of treatment such as various forms of psychotherapy, exposure therapy, EMDR, or just removal of emotional stressors that are causing ongoing emotional dysregulation. SSRIs are noted for being particularly ineffective in dealing with PTSD (including cPTSD) and personality disorders even though they are often prescribed as a first-line and ongoing treatment.
“Mild” but chronic depression and anxiety are genuine problems that not only reduce quality of life but have real physical manifestations in terms of stress response, hormonal balance, dietary regulation, cardiopulmonary issues, so seeking treatment should be encouraged. An SSRI might a part of that, especially to help break the logjam of emotional dysfunction but obviously shouldn’t be the only approach. You mention a stressful job, and while it is often impractical to advise just leaving the job or vocation entirely it may be very useful to research coping strategies, support groups (if applicable, especially if in a front-line type of job like first responder or medical), or just negotiating job responsibilities (both externally with management and ‘internally’ in what tasks and responsibilities they are willing to accept) to reduce stressors.
In addition to Whitaker, I’d recommend Johann Hari’s Lost Connections and perhaps Dr. Jonice Webb’s Running On Empty which delve into some of the deeper social and relationship issues that have caused an epidemic of chronic anxiety and depression (and in the former case, while long-term treatment with anti-depressants is actually counterproductive). Looking into additional treatment and support is definitely a good idea even if your friend has a good response with SSRIs because it is anyone’s guess as to how long that will be effective or what other side effects may arise.
I’ve been on many SSRI’s. Currently, I’m on Paxil. It is IMO a wonder drug. However, my depression and anxiety was severe. I’m leery of screwing with somebody’s neurochemistry due to mild depression. What else has been tried?
I’ve had sexual side effects from premature ejaculation to the inability to orgasm. Due to an insurance problem, I once ran out of Paxil. I went through withdrawal. It was every bit as unpleasant as it sounds.
I’ve had issues with PMS since menarche. That makes me the healthy one, as major depression runs in my family.
After my father died, and when i had a crappy boss, i became more seriously depressed. I told me doctor it felt like PMS, and asked about taking hormones. He suggested SSRIs, saying they are safer than hormones. So i went on Prozac.
It worked within hours. I felt like the thick gray clouds had lifted from my brain, and felt less apathetic. This is apparently not uncommon for “PMS-like” depression. I did have annoying side effects. It gave me insomnia, and dry mouth. But it also gave me the energy to find a new job and to improve other aspects of my life.
I kept taking lower doses to avoid the side effects. I finally decided to try a different SSRI, and to be safe, tapered off the Prozac, first. After tapering off it, i realized i didn’t need it any more, so i never took the other drug.
A couple years ago i was again suffering from depression, and was going to ask my doctor about trying to Prozac again, but i kind of randomly decided to try estrogen for my menopausal hot flashes, first. And the depression lifted withing an hour of taking that first pill. I’ve been on estrogen ever since.
Note that estrogen isn’t a selective serotonin re-up take inhibitor, it’s an unselective one. But it does have similar SRI activity to the SSRIs
I first started taking SSRIs in 1988, starting with Prozac. I had increased anxiety, and no effect on my depression. In the mid 90’s, I tried other antidepressants such as Welbutrin, Zoloft, Paxil, Effexor, and Serzone, with effects ranging from nothing to unbearable side effects. None had any therapeutic effect on my depression.
In 2016, I underwent genetic testing to determine what drugs were appropriate for my genotype. It revealed I was a CYP2D6 poor metabolizer. This means my liver doesn’t produce the enzyme necessary to metabolize a wide range of medications, including many SSRIs and SNRIs. This can result in no antidepressant effects and increased side effects. Approximately 5% of patients are poor metabolizers.
I would highly recommend genetic testing before trying any antidepressant therapy. It can save a lot of time and exposure to debilitating side effects. Otherwise, your doctor will just use trial-and-error to find a drug that works for you. Approximately 30% of patients treated for major depression get no relief from any antidepressants.
Even within one family. My sister takes Wellbutrin, after trying several others. One brother takes other antidepressants. The other brother tried several and gave up.
Any thoughts and anecdotes? I have a few of those. And since others have done an excellent job (usual Straight Dope response) of factual analysis and providing links to references, I’ll stick to the anecdotes - which are all positive.
Long ago girlfriend (Looong-ago, as in: Prozac was brand new.) was was crippled by frequent panic attacks. Prozac kept these under control, but she hated taking any medications long-term and kept trying to wean herself off it. No go. Panic attacks invariably resumed. She resigned herself to lifelong SSRI use and, as far as I know she is still on them. And, as far as our casual, now-and-again contact lets me tell, she is still one of the sanest, best-adjusted people I know.
Mother in law is not sane or well adjusted, but is mostly OK to talk to and sometimes very thoughtful, helpful, etc. As long as she’s on her meds (which include and SSRI). Let her go off them for any length of time, and watch out !
Older of two daughters: more than normal teenage tsuris. Eventually we found most of it was due to fears and anxieties that she hadn’t wanted to talk about. Therapy was failing to dispel these. I hated the idea of medicating a kid, but she herself hated it three times more. After much discussion with her counselor, we got her onto Lexipro. Night and day difference! Even kiddo recognizes the benefit. Getting her off meds without sacrificing the improvement is the next big project.
A physician friend told me SSRIs aren’t supposed to be anti-psychotics, but she has more than once prescribed one for what she thought was simple depression, only to have the patient tell her, “since I started this medication, I don’t hear the voices anymore.” Yow !
There you go, nothing but anecdotes. Unscientific, but maybe a few data points. Good luck to you and the person you care about.
Make sure your insurance covers this first, or that the doctor makes it seem necessary. It’s not a terribly expensive test, but they don’t tell you that.
I’ve been on a bunch, most do not much. The genetic test didn’t show any big issues, I tried a folic acid supplement alongside but I can’t tell if it worked. Otherwise trial and error, and antidepressants can have quite different effects, even closely related ones.
Most of what I’ve seen these days argues that the paradoxical effect is exactly what SSRI treatment depends on. That’s why they don’t work right away. SSRIs immediately increase serotonin in the brain, but they don’t immediately work. This suggests that it is the eventual downregulation of serotonin receptors that is actually therapeutic.
That’s not to say there isn’t a tachyphylaxis or “poop out.” (I’m not sure I’m not actively facing it right now, giving me MS-like symptoms but no MS). But, assuming the above is correct, it seems unlikely to be to due downregulation of serotonin receptors.
I experienced exactly that with SSRIs: my anxiety would build intolerably to the point I couldn’t function. Several were tried, all made it worse. A very dark time for me. Eventually I was put on an atypical antipsychotic which produced near immediate relief (after a somewhat intense adjustment period of weird blurry vision for about a week). Other side effect was memory issues, which I’ve adjusted to fairly well.
Yes, this is also a problem for me. If I take my time solo I can get release, but with someone else it’s very very difficult. Mostly I just concentrate on pleasing my partner. I wonder if this is also just because I’m an older man (60).
I disliked Prozac for the “flat” emotional state. I was just neutral, never sad nor happy. Just living, not an ideal state of mind.
Sex was good, it took me a really long time to orgasim, which meant my girlfriend got a lot more attention.
What was worthwhile was, after I stopped using Prozac and still had a spare supply, was taking one before and after taking MDMA, a serotonin agonist. MDMA floods your brain with serotonin, with everything you have in reserve, so using an SSRI means there is time to recover.
I am currently on Lexamil, which is the local name for Lexapro. Its OK. No obvious side effects. But no great praise for its efficacy.
fwiw, I had exactly the opposite experience. When I was depressed, I had a mostly flat emotional state, except it was brittle, and if something went badly, I could get very upset, or burst into tears, rather than being able to deal with it. But there were no “ups”, nothing seemed bright or shiny. Prozac (and estrogen) allowed me to feel joy again, as well as sadness, without just falling apart.
While many people see long-term improvement of depression symptoms on SSRIs, there obviously is such a thing as breakthrough depression - and it doesn’t have to be caused by the development of serotonin receptor insensitivity. There are numerous reasons why an antidepressant may become less effective or stop working - and these include new forms of stress, development of another medical condition, interference with the SSRI by a new medication etc.
Approaches to overcoming diminished effectiveness of SSRIs including increasing the dose, and adding or substituting a new antidepressant that works on a different biochemical basis.
In general, it seems like a bad idea to me to place someone on an antidepressant for “acute mild” depression without having tried non-pharmaceutical therapies. Then again, it can be difficult for others to confidently weigh in on what “mild” depression is.