Selective serotonin reuptake inhibitors (SSRIs) are a frontline antidepressant due to their low risk of side effects and overdose, as well as their efficacy. SSRI antidepressants are chosen over all other classes in the treatment of depression and anxiety in children, teens and the elderly.
This doesn't mean that SSRIs are the only worthwhile antidepressant, of course. Research has shown the older antidepressant medications (tricyclics) are just as effective as SSRIs but, on the whole, the newer ones seem to have fewer side-effects.
Researchers also note that the SSRI medications don't work for up to 50% of the depressed or anxious people who try them -- the same failure rate as for the older antidepressants.
Which is the Best SSRI?
No single SSRI is best, although escitalopram (Lexapro) has been shown to have superior efficacy in cases of severe depression. Each SSRI has a certain profile of its own particular side effects often including common SSRI side effects like nausea and headache. Of course, none of the SSRIs are any sort of wonder drug.
Cost of Selective Serotonin Reuptake Inhibitors
One of the biggest problems with some newer SSRIs is their cost. The branded versions are much more expensive than the generic versions of older drugs like some of the SSRIs, MAOIs or tricyclic antidepressants. Generic versions of the older antidepressants are available because their patents have expired.
Even if you find the best SSRI for you, if you can't afford it, it's not going to do you much good. The high cost of the SSRIs can be a real hardship for someone with no insurance, or whose insurance doesn't cover drugs. With some SSRI antidepressants costing $4 - $11 per pill, the pharmacy bill can be overwhelming.
SSRI Antidepressants, Suicidal Feelings and Young People
Young people taking SSRIs may have increased suicidal thoughts and behaviors. In fact, in 2004, the FDA ordered the strongest safety warning possible known as a black box warning on SSRI and other antidepressants:
Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of Major Depressive Disorder (MDD) and other psychiatric disorders. Anyone considering the use of [drug name] or any other antidepressant in a child, adolescent, or young adult must balance this risk with the clinical need.
Short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24; there was a reduction in risk with antidepressants compared to placebo in adults aged 65 and older.
Depression and certain other psychiatric disorders are themselves associated with increases in the risk of suicide. Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber.
SSRI Medical Cautions
Severe kidney or liver disease could result in higher-than-normal blood levels of SSRIs. In addition, SSRIs shouldn't be used in the treatment of patients with mania.SSRIs may not be the best treatment in those with a history of seizures or bipolar disorder.
SSRI Side Effects
SSRI side effects are usually mild and manageable, although once in a while a sensitive person gets a severe reaction. There have been reports of episodes of aggression, although these are rare.
Common SSRI side effects include:
- Nausea (may be improved by taking SSRI with food)
- Dry mouth
- A variety of sexual dysfunctions
- Menstrual changes
The list of SSRI side effects looks worrying - there is even more information about these on the leaflets that come with SSRI medication. However, most people get a small number of mild side-effects (if any). More serious SSRI side effects - problems with urinating, difficulty in remembering, falls, confusion - are uncommon in healthy, younger or middle-aged people. You can learn more about antidepressant side effects and how to manage them here.
Side effects of SSRIs usually wear off over a couple of weeks as your body gets used to the medication. It is important to have the whole SSRI side effect list, though, so you can recognize side effects if they happen and discuss them with your doctor.
It is common, if you are depressed, to think of harming or killing yourself. Tell your doctor - suicidal thoughts should pass once the depression starts to lift.
Drug Interactions with SSRI Medications
SSRI medications are fairly safe, but like all other medications, interactions can occur. Some drugs that can interact with SSRIs include:
- Blood-thinners like Warfarin or Aspirin
- Other antidepressants, including MAOIs
- Other medications that increase serotonin levels causing a serious illness called serotonin syndrome.
Taking an SSRI medication within two weeks of an MAOI may cause serious side effects.You should wait at least two weeks between stopping MAOIs and starting an SSRI, or at least five weeks after stopping an SSRI and starting an MAOI. Learn more about switching antidepressants here.
SSRIs and Pregnancy / Breast-Feeding
It is always best to take as little as possible in the way of medication during pregnancy. However, some mothers have to take SSRI antidepressants during pregnancy. Most SSRIs in pregnancy are considered category C drugs which are to be used with caution and only when the benefits outweigh the risks.
Most SSRIs, however, haven't been studied in nursing mothers or pregnant women. Animal studies have suggested taking SSRIs during pregnancy can pose risk to the fetus. SSRI medication is present in breast milk and use of SSRIs during breast feeding should be avoided if possible.
Paroxetine (Paxil) should not be taken during pregnancy as it may produce some birth defects.
(also read: Antidepressants for PMS Symptoms)
Other Disorders Treated by SSRI Antidepressant Medications
SSRIs can be an effective treatment in medical and psychiatric disorders besides depression. Some SSRIs have been approved for treating various disorders such as:
- Anxiety disorders including panic attacks, obsessive-compulsive disorder, post-traumatic stress and social anxiety disorder
- Eating disorders
- Chronic pain
- Premenstrual dysphoric disorder
SSRI antidepressant medications don't cause the addictions that you get with tranquilizers, alcohol or nicotine, in the sense that:
- You don't need to keep increasing the dose to get the same effect
- You won't find yourself craving them if you stop taking them
However, in spite of not having the symptoms of addiction described above, some people who stop SSRIs have withdrawal symptoms; sometimes referred to as antidepressant discontinuation syndrome. SSRI withdrawal is more common for people who have taken medication for longer than six weeks.
SSRI withdrawal symptoms may include:
In most people, these withdrawal effects are mild, but for a small number of people they can be quite severe. SSRI withdrawal is most likely seen with paroxetine (Paxil). It is generally best to taper off the dose of any antidepressant rather than stop it suddenly.
Some people have reported that, after taking an SSRI for several months, they have difficulty managing once the drug has been stopped. This is most likely the symptoms of the original disorder (depression, anxiety) returning.
The Committee of Safety of Medicines in the UK reviewed the evidence in 2004 and concluded,
"There is no clear evidence that the SSRIs and related antidepressants have a significant dependence liability or show development of a dependence syndrome according to internationally accepted criteria."