SSRI s 101
One Woman’s Questions
By Shelley McIntire, LPC and Dr. Dan Dulaney, DNP/CRNP
When Kaitriona (name changed for privacy) was diagnosed with moderate to severe major depression, her therapist suggested that she try an antidepressant; an SSRI, to be specific. Kaitriona was concerned. She thought it would make her “seem like a zombie,” and felt ashamed “I could not work out my depression without medication.” She also worried it would create other issues such as dependency, side effects and weight gain. She was concerned that “they won’t really work.”
A Brief SSRI History
SSRIs came on the medication scene in 1987 with the introduction of Prozac, or Fluoxetine, as it is known generically. Before SSRIs, or Selective Serotonin Reuptake Inhibitors, were introduced, the medications used to treat depression were known as tricyclics. These medications typically had more side effects. SSRIs target more specific receptors in the brain; therefore, they have fewer side effects than tricyclics.
Serotonin is a chemical in the brain that assists the information being passed between the synapses. SSRIs work by keeping more serotonin in the brain by stopping our brain cells from reabsorbing it into the cells.
Kaitriona Agrees to a Psychiatric Evaluation
Sounds scary? In reality, it is just a meeting with a psychiatrist to discuss her symptoms, struggles, medical history and goals. Then various types of medication for major depressive disorder and their effectiveness are reviewed. The psychiatric medication provider will leave it up to her on whether she wants to get started. The plan will be to methodically work up to a full dose.
The psychiatrist also discussed side effects, risks, benefits, and alternatives to medication. Kaitriona was warned to not stop her prescription without notifying the office due to risks of Serotonin Syndrome. Serotonin syndrome, or serotonin toxicity, occurs when there is too much serotonin in the body. Mild symptoms such as diarrhea and shivering, can occur as well as more severe symptoms such as confusion, seizures, agitation, fever, and muscle rigidity*.
Kaitriona and her psychiatrist also reviewed the need to refrain or reduce the use of alcohol while taking medication, as alcohol, a depressant, can make depression worse. In addition, alcohol can increase the side effects of SSRI antidepressant medication, such as drowsiness. The combination of alcohol and SSRIs can increase the normal effects of alcohol alone. Using alcohol when taking SSRI antidepressants can increase already slowed reaction time, lack of coordination, and impaired judgement. *
“Alcohol affects our entire body, from the skin on our scalp to our tippy toes and all the squishy stuff inside. There is no bodily system spared from the effects of alcohol. A general rule of thumb is that alcohol interacts with all medicine. Alcohol is a depressant. If someone is taking an SSRI to treat depression, and they consume alcohol, they are working at cross purposes to their treatment and the treatment will suffer and not be as effective.” – Dr. Dan Dulaney, DNP/CRNP
Kaitriona asks Good Questions
“How long does it take for the medication to begin to make a difference in my mood?”
The psychiatrist shared that SSRI antidepressants typically take anywhere from four to six weeks to begin to work fully. The first few weeks are used to attain a therapeutic dose.
“Some medicines take time to work, a long time, and if the patient is expecting a quick fix, this needs to be addressed promptly. I have seen time and time again, patients switching from one medicine to another, before efficacy is even established. A noticeable response from an SSRI is not expected until four to eight weeks after initiation of [medication] therapy.” – Dr. Dan Dulaney, DNP/CRNP
“What about side effects?”
Her psych med provider reviewed potential side effects, some of which usually decrease over several weeks and some which may not. She mentioned that Kaitriona may experience anxiety, irritability, and restlessness when first starting this type of medication. They also reviewed potential ongoing side effects such as weight gain, sexual dysfunction, and sleep issues.
“I don’t know, is this really worth it?”
Her psychiatrist conveyed that SSRIs are generally effective for more chronic, moderate to severe depression; however, finding the right medication and dosage may not always happen with the first trial. The goal would be to start Kaitriona on a drug that is generally found to be effective for many patients and that is well-tolerated. She was asked if there were any side effects that she would rather avoid (such as stomach upset versus sexual side effects), and if there is a perception that possible benefits would outweigh possible side effects.
“Should I keep seeing my therapist?”
Yes. The psych med provider encouraged continued therapy, explaining that the skills learned in counseling can often be better utilized when the medication trial is effective.
“There have been numerous studies done that prove therapy, specifically cognitive behavior therapy (CBT), in conjunction with medication therapy is the most useful and effective treatment for many mental health disorders. The two work synergistically. The goal of medication is to provide symptom relief, increase energy, improve mood; once the “dark cloud” is lifted, persons are ready to tackle and process their current situation.” – Dr. Dan Dulaney, DNP/CRNP
Kaitriona Decides to Move Forward
After considering all of the pros and cons, Kaitriona decided to try a low dose of the SSRI antidepressant. The psychiatrist provided her contact information for any questions or concerns. She was scheduled with a follow-up appointment in one month.
For Kaitriona, starting an SSRI antidepressant seemed worth it to her to decrease her symptoms of depression. She felt comfortable knowing that she would be able to discuss her hesitancy and her concern around the stigma with taking antidepressants with her therapist, and, if this medication was not a right fit for her, that she and her psychiatrist would work together to find one that would.
*If a person who suffers from problematic alcohol use is in need of treatment with an SSRI, alcohol use should be reduced gradually over time and under the supervision of a health care professional and not abruptly stopped to avoid serious withdrawal concerns including a hypertensive crisis, seizure, and even death.