What we’ve said about SSRIs

“What do I go for first? Easy. SRIs. Why? Well, they're low risk risk. and they are higher efficacy, and the side effect profile is not too bad”

“I like to use Zoloft or Lexapro because they tend to have less med-med interactions, but really any SSRI is fine. I avoid Paxil because Paxil tends to cause weight gain”

“a 40-year-old woman who comes in with her first episode of major depression all day, every day, low mood, low motivation, early awakenings, leaden paralysis. You put that lady on a little Zoloft, she's going to start responding right away”

“That's the attachment system. And that is mediated, among other things, by serotonin. So the SSRIs are helpful with anxiety and depression that results from separation anxiety and depression. But there's also in the brain the fear system”

“SSRIs can help with some of the anxiety and the depression. But of course, it's not going to fix the core issue. And one of the big goals of treatment is to be connecting the symptoms to the interpersonal problems”

“find out if they've had anything like it before. And if they have, then you'll know. around what kind of dose they might start to see effects from. And if they haven't, then start low, go slow, but try to follow up soon so that you can address anything that's going on”

“It really depends on the severity of the depression and how soon I can see the patient. So let's pretend we can see people in four weeks and it's moderate severity, right? For that, I would probably try to get them to 50 milligrams before the next visit”

“I get them to 10 pretty fast. It's just it's almost psychological on my part in that, you know, it's I've had problems with getting five milligram tablets from pharmacies locally. So often I don't have that option”

“the people who might have a little bipolarity, even if they'll never have a real bipolar disorder or have very high levels of anxiety, then yeah, going too quickly on the medication like Lexapro can definitely, uh, cause some reactions there”

“it's completely variable. Patient to patient, You never know what's going to happen necessarily. So I often tell patients, if it makes you sleepy, take it at night. If it activates you, take it during the daytime”

“when you persist with SSRI in someone with bipolarity, that's where it becomes more harmful and dangerous. And there are other treatment options”

“if you see substantially worsening sleep and physiologically improbable sleep, like three, four, five hours in somebody, especially when they don't have a trauma disorder, You really need to start considering the possibility of bipolar”

“I'm of the camp that anyone with a manic depressive illness bipolar disorder, regardless of their comorbidities, should not be treated with an SRI whenever possible”

“most adverse effects in most people that have unipolar depression only, it's just nausea and diarrhea. You're going to get a little bit of that stomach cramping. It's going to last three to five days and get better and come back briefly with each dose increase until it gets better again”

“I try and bring up emotional blunting. I hear a lot of patients, especially if you get into the, I think the more borderline or the more severe end of it, that because they're so prone to feeling things so intensely, they're very prone to reporting the emotional blunting”

“For sexual side effects, main ones, buspar and bupropion. Those are going to be most helpful. and otherwise switching of the medication or lowering the dose are pretty much your choices”

“Now, the bruxism, tooth grinding. You know, Honestly, probably the safest thing would be a mouth guard, which would be quite annoying, but it would protect your teeth. You could consider maybe using a sleeper of some kind”

“SSRIs have not been shown to specifically reduce suicidality. Though, of course, they have far less side effects and are much safer than older antidepressants”

“You should be advising patients about risk of suicidal ideation and agitation from SSRIs. Again, this is really primarily probably in bipolarity, but it is a risk”

“I personally try to disregard the hard numbers found in population studies because the population studies can't differentiate between weight gain as a direct metabolic cause of a medication and weight gain as a consequence of treatment”

“the data shows like on average, patients going to gain five pounds over a long term treatment. um i do find even patients that are trying their best implementing changes they can gain five pounds that are really tough to come off of”

“paroxetine, which makes people a little sleepy because of the anticholinergic. It causes a little weight gain, so I tend to not use it”

“SSRIs in people without major depressive disorder are actually disruptive to sleep. Same thing with low-dose BuSpar. Basically, the serotonin mechanism will suppress REM sleep and also cause more nighttime awakenings”

“If I'm seeing more insomnia lasting than that from an SSRI, I'm pulling them off of the SSRI. Okay. Again, I want the sleep to be stable first”

“if it's sufficiently mild and I'm not concerned that it's some kind of a mixed state, then I just add any of my standard all-covered sleepers, basically. And I have them move the SSRI to the daytime”

“OCD medications are expected to reduce symptoms somewhere in the range of 30 to 40 percent. We're not curing OCD. We're not getting rid of their symptoms. We're reducing them so they can better engage in therapeutic interventions”

“for true OCD, especially moderate to severe, it is warranted to increase the SSRI dose beyond the FDA maximum that we are used to for major depressive disorders. Okay, so we're talking Zoloft 300 or even 400, Lexapro 30 to 40. I always get an EKG with that, that kind of thing”

“In general, OCD will require a higher dose than depression. And you still have to follow common sense regarding side effects and tolerability. And as we know, like 100 milligrams of Zoloft is not the same across different people”

“let's say you start off with a Zoloft. And if you have a partial response, you can consider raising to a super therapeutic dose. Yeah. If you feel like you want to switch for whatever reason, then I typically switch to Luvox”

“for OCD, please get a Weibach score of some kind, track it across visits, see if it's changing over time with increased doses, even though it takes a longer time, maybe for anxiety and OCD to respond to SSRI medication”

“Typically, I use an SSRI. That doesn't work. I'll switch to another SSRI. We're talking augmenting agents, considering buspirone or gabapentin. If their patient's still unresponsive to, you know, a bunch of these things, you can start kind of going off patient characteristics. If there's a lot of sleep issues, I'll consider mirtazapine”

“I see it kind of like OCD where it's a biological cause, but that the psychological solution is better. I'm more likely to use SSRIs, or second, third line agents for anxiety, high doses of SSRIs”

“the medications don't solve your problems to make it easier for you to grow and change. And so even if you're going to use medications as a first-line treatment in a GAD phenotype”

“I don't think that an SSRI directly treats a panic disorder. I think an SSRI basically lowers the severity of the panic disorder to the extent that the patient will automatically start living their life again”

“start with an SSRI. If that doesn't work, switch to another SSRI. And I'm talking about without any nuance involved in these, you know, like your clean cut patients. SSRI, if that doesn't work, switch to another SSRI. If that doesn't work, you can add a second-gen antipsychotic”

“if somebody has PTSD and they're coming in to see the psychiatrist and they're not just either remitting on their own slowly or working through it with a counselor or a psychotherapist, it's because the sleep is severely disrupted”

“8 out of 10 anger, not 10 out of 10 anger. I don't know. You'll have to tell me what you feel. This might be a good effect. If you have one less big fight with your partner a week where you yell at your kids less, this might be a good medication for you”

“Don't be afraid to just switch to another SSRI. The mechanisms are not totally the same even theoretically. And one person cannot respond to one SSRI and they can respond to another”

“a lot of practitioners just assume SNRI is a much stronger medication that you should reach for whenever something doesn't work. The number needed to treat is actually pretty big regards to if you use an SNRI compared to an SSRI. And it comes with risks. It comes with side effects”

“I don't like venlafaxine because its improvement over SSRIs is relatively small. So it's not like it's this big hit medication. It can raise blood pressure. It can raise heart rate”

“if I saw someone do okay on an SSRI but not great and, you know, they failed too, and when I say failed, like you didn't see a huge dent but you saw a little bit, I think an SNRI is appropriate”

“The combo that is a little famous is the California rocket fuel as coined by Stephen Stahl, which is mirtazapine and venlafaxine. Anyone who's using an SSRI and SNRI, stop it. Stop it”

“for a patient who doesn't want the SSRI side effects of a little bit of weight gain or sexual side effects, then I am fine with bupropion. And then mirtazapine for a patient where sleep is a big issue and patients either underweight or not concerned with their weight. I would say underweight”

“none of these respond to an SSRI. None of these respond to an antidepressant, primarily. So do not just think someone is suicidal or depressed, give an SSRI. You need to have a formulation, diagnosis, and treatment plan before you prescribe things”

“You really got to know what the general effect size of SSRI is. You shouldn't oversell it, right? Because if you oversell it, you're going to give people the false impression that this is a powerful medication that's going to change your problems”

“The side effects are going to be certain side effects are going to be as bad as they're going to be when you first start the medication. And it takes about three days for it to kind of level out. And usually about one week until you start to feel a little bit normal”

“You want to process those emotions and reorient towards the major purpose of the mindfulness practice, which is long term change. Just like the way we counsel patients on that, you know, this SSRI is not supposed to make you feel happy right away”