Tag Archives: SNRIs

Let’s Get Real About Antidepressant Side Effects

By Sean Hagey
The Mighty

Your doctor just wrote you a prescription for your depression. You were probably given some info on what the drug is, what they hope it will do for you and (if your situation is like mine) they may have mentioned “some mild side effects” may occur.

Maybe they don’t really know, or maybe they don’t want to frighten you, but I’ve found an alarming amount of doctors don’t inform you on just how common side effects are. In my experience, they certainly don’t tell you about the really intense stuff.

I remember coming back to the doctor after that very first prescription and had this interaction:

Me: I’ve been having a lot of headaches and stomach issues since I started taking that medicine.

Doctor: Yes, that’s unfortunately very common.

I didn’t say it out loud, but I definitely remember thinking, “That would have been good to know before I started taking this!”

Drowsiness and fatigue can also be common, which is wonderful because we depressives already struggle with fatigue and lack of motivation.

Weight gain is reported from many antidepressants. Great, now I have a body image issue to add to the mix. What kind of sick joke is this!

My journey through this valley of cupcakes and rainbows has basically been a cruel game of “Would You Rather?”

Nausea and other gastrointestinal issues are common. Fantastic. Now I can’t even enjoy my damn ice cream without feeling like it’s going to violently come back up.

It’s taboo to talk about, but sexual dysfunction is very common. It’s as high as 50% — or more! — in some studies. For guys, that can mean erectile dysfunction. For men and women, this likely means difficulty or inability to achieve orgasm. As if being depressed wasn’t already bad enough.

And last, but not least, there’s other weird stuff. Dry mouth, lightheadedness, dizziness, agitation and my all-time favorite, “brain zaps.” Yes, I’m talking about this really freaky sensation that I’ve only had when taking a type of antidepressant known as an SNRI (serotonin and norepinephrine reuptake inhibitors, such as Cymbalta, Effexor and Pristiq). My brain says, “You know what would really lighten up the mood around here? An electrical shock!” At that moment, a bolt of lightning starts in my brain and zaps out into my face, hands and feet. It’s like a party — in hell.

My journey through this valley of cupcakes and rainbows has basically been a cruel game of “Would You Rather?”

I’ve pretty much run the whole gamut. I don’t know if there’s some sort of prize for my achievements, but I figure I should at least be considered for the hall of fame of side effects. Perhaps I should start calling myself the Babe Ruth of depressives. Please, no requests for autographs though. I’m tired, nauseous and agitated, with a dry mouth and headache from dealing with these damn brain zaps.

Sometimes you have to laugh about it or else you’ll cry. And I’ve already met my lifetime quota on that. Plus, I’ve already written about how serious, scary and horrible it is to have a major depressive episode here.

Sean Hagey is a physical therapist assistant and technology consultant who writes about his battle with depression. He runs the blog, Mental Health Matters, which focuses on mental health advocacy and education.

This article was originally published on The Mighty. Reprinted with permission of the author.

Antidepressants May Boost Risk of Death in COPD Patients

Older patients with COPD (chronic obstructive pulmonary disease) should take precautions when using certain antidepressants because they may increase the risk of death.

Researchers analyzed 28,360 new users of serotonergic antidepressants – such as SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin norepinephrine reuptake inhibitors) – that had COPD and were aged 66 and older, then matched them to 28,360 non-users. SSRIs and SNRIs are among the most commonly prescribed antidepressants.

The results, published in the European Respiratory Journal, indicated that new users of these antidepressants have a 20% increased risk of death related to respiratory issues, as well as death overall compared to non-users of the medication.

Also, antidepressant use among those with COPD – a progressive lung disease characterized by breathlessness – was associated with a 15% increased risk of hospitalization and emergency room visits due to related symptoms. The results demonstrate a strong association, but not a definite cause and effect, the researchers caution.

According to lead author Nicholas Vozoris, MD, a respirologist at St. Michael’s Hospital in Toronto, the findings were not surprising because “there are biological reasons why antidepressants could lead to respiratory issues.

“These drugs can cause sleepiness, vomiting and can negatively impact immune system cells. This increases the likelihood of infections, breathing issues, and other respiratory adverse events, especially in patients with COPD.”

Researchers noted that the findings shouldn’t alarm COPD patients who are currently using antidepressants, but rather increase awareness among users and prescribers.

Concerns About Using Your Antidepressant Long-Term? Talk to Your Doctor

By Marc Manseau

On April 8, 2018, The New York Times published a front-page article titled “The Murky Perils of Quitting Antidepressants After Years of Use.” The day before, the online version, “Many People Taking Antidepressants Discover They Cannot Quit,” was the most-shared article on its website.

In this analysis, Benedict Carey and Robert Gebeloff described a growing trend over the past few decades in which millions of people have been taking prescription antidepressant medications long-term. For instance, they cite data showing that over 15 million Americans have taken antidepressants for 5 years or more.

They go on to attribute this phenomenon mostly to antidepressants causing “dependence and withdrawal,” rather than people needing long-term antidepressants to manage psychiatric illness or choosing to remain on them because of their benefits.

While Carey and Gebeloff do cite a few studies looking at rates of withdrawal after stopping long-term antidepressant use, they only mention one survey from New Zealand that shows that withdrawal is even a common complaint among individuals taking antidepressants. Most of their argument is based on individual stories (i.e., anecdotal evidence) combined with critiques of how antidepressants have been studied.

While the individual stories are compelling and the critiques of research may be valid, this approach makes their case linking long-term antidepressant use to supposed widespread withdrawal circumstantial at best.

Fortunately, several psychiatric care providers and even patients quickly responded to counter this somewhat misleading article. To be fair, the authors do point out that antidepressants have greatly helped millions of people, and they quote psychiatrists who are expert in treating depression, such as Dr. Peter Kramer.

However, overall, the piece uses logically and scientifically shaky arguments to trigger suspicion and fear of antidepressants among the general public and mental health patients alike. Given that depression and other mental illnesses that antidepressants treat (e.g., anxiety disorders) are very common, highly impairing, sometimes dangerous, and exceedingly undertreated, this type of journalism is risky.

The fact is, antidepressant medications are effective, especially for moderate to severe depression, and while all medications have side effects, newer antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are far more tolerable than older versions. In addition, the past few decades have seen a growing consensus that depression (and many other mental illnesses) is a chronic condition requiring long-term treatment, like diabetes and hypertension. (No one would say that millions of people are on long-term blood pressure medications for hypertension because of fear of withdrawal.)

Therefore, many psychiatrists recommend (and many patients readily choose) long-term antidepressant treatment to avoid relapse once a person has had more than one depressive episode. “Withdrawal” from antidepressants — actually called discontinuation syndrome — is in fact a well-known and not-rare phenomenon. However, it is usually very mild and can be managed with a slow taper in the medication’s dose.

For the relatively rare, more severe cases, a good psychiatrist can almost always reduce or eliminate it with various interventions such as adding low-dose Prozac (fluoxetine) for a while (due to its long half-life) and/or using other prescription drugs in a time-limited manner to treat discontinuation symptoms.

Just like in any medical specialty, not all psychiatric care providers are attentive, responsive or skilled enough to avoid or successfully manage discontinuation syndrome, but that’s a different problem that can’t be solved by avoiding antidepressant treatment to begin with. So, rather than an inability to stop meds due to “withdrawal,” doesn’t it seem much more likely that growing numbers of people are on antidepressant treatment long-term either because they need the medication to prevent symptoms from returning and/or choose to remain on the medication because of low side effect burden and protection against relapse?

The article does make some valid and important points. The research on antidepressants mostly involves relatively short-term studies, so there is a great need to examine the longer-term efficacy and adverse effects of these prescription drugs. And the discontinuation syndrome has received far too little research attention.

These deficits in the science are indeed likely due to pharmaceutical companies having little incentive to investigate prescription drugs that have gone generic or to emphasize problems with the products they produce and market. However, it is unfortunate that these valid critiques were packaged into a misleading and highly public message that has the potential to discourage people from seeking treatment for mental illness and encourage patients to stop their medications.

Here’s some advice from this psychiatrist: Discuss your goals for treatment and any problems with medications with your healthcare provider before changing or stopping them on your own. No one – not even your doctor – can force you to stay on a medication that you no longer want to take, but only an experienced professional can help you to change medications in a safe and healthy way.

This article was first published by JustCareUSA.com. Reprinted by permission.

Combining Migraine Meds With Antidepressants Safe

Taking certain migraine medications in combination with antidepressants does not increase the risk of serotonin syndrome, according to a new study published in JAMA Neurology. In 2006, the FDA issued an advisory about triptan migraine drugs being associated with serotonin syndrome when combined with selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs), which are both a common class of antidepressants. However, researchers are suggesting that the advisory should be reconsidered based on new findings.

Over the course of 14 years, researchers analyzed over 47,000 people who were prescribed triptan migraine drugs. Out of that demographic, 21% to 29% of people took antimigraine meds and antidepressants at the same time.

The results indicated that serotonin syndrome was rare in patients who took antimigraine drugs in combination with SSRIs and SNRIs. Serotonin syndrome was suspected in 17 patients. Only 2 patients were classified as having definite serotonin syndrome, while 5 patients were classified as having possible serotonin syndrome. Based on the new findings, the researchers believe that the 2006 FDA advisory is invalid.

Do Your Psychiatric Drugs Keep You Up at Night?

If you take a medication for a psychiatric condition, you may have experienced troubled sleep — insomnia, daytime sleepiness, or any other numbers of sleep-related disorders. I have treated patients with myriad sleep difficulties who take antidepressants, antipsychotics and even medications to treat attention deficit/hyperactivity disorder (ADHD).

While no one wants to experience a poor night of sleep, it’s important to recognize whether the sleep problem you are having is a result of a side effect of a drug (or drugs) you are taking, or something completely independent of medication. That is why if you are on psychiatric medication – or any drug for that matter – and you find yourself having difficulty catching some Zs, it’s important to talk to your primary doctor, who may change your medication or refer you to a sleep specialist for further evaluation. In many cases, the benefits of a drug may outweigh the sleep-deficit side effects. Your physician can work with you to minimize the impact of them.

However, it’s a good idea to know what some of the sleep-related side effects are that have been reported with different types of drugs which act upon the brain. Let’s start with antidepressants. The most commonly prescribed ones are known as SSRIs (selective serotonin reuptake inhibitors) and have names including Prozac (fluoxetine), Zoloft (sertraline), and Paxil (paroxetine). Complaints of both insomnia and daytime sleepiness have been reported in patients with depression on SSRIs. Prozac’s impact on sleep has been the most widely studied. Interestingly, it has been shown to have both a sedating and energizing effect depending on the individual. Prozac can also cause decreased sleep efficiency, awakenings during the night, and interrupted REM (rapid eye movement) sleep, an important period during the sleep cycle that allows a person to dream vividly.

Antidepressants and Vivid Dreams

Another class of antidepressants, SNRIs (serotonin norepinephrine reuptake inhibitors), are known to cause sleep problems similar to those in SSRIs, as well as vivid dreams. Common SNRIs are Effexor (venlafaxine), Pristiq (desvenlafaxine) and Cymbalta (duloxetine).

Treatment with Effexor has also been associated with a condition known as dyskinesia that is characterized by occasional movement of one’s limbs, repetitive and involuntary movements of the extremities – typically the legs – usually during or just before falling asleep. There have also been cases where these involuntary movements have been seen a week after a person stopped taking Effexor.

One antidepressant, Wellbutrin (bupropion), has been associated with insomnia. However, studies that have examined electrical activity of the brain in patients taking bupropion indicate the drug actually increases REM sleep time.

It’s important to recognize whether the sleep problem you are having is a result of a side effect of a drug (or drugs) you are taking, or something completely independent of medication.

Antipsychotics are usually prescribed for schizophrenia and other psychotic disorders, though they are also prescribed for bipolar disorder and to supplement antidepressants in the treatment of depression. One of the most popular antipsychotics, Seroquel (quetiapine), has been associated with faster sleep onset and longer overall sleep time. A typical antipsychotic, Clozaril (clozapine) has also been associated with improving sleep onset and sleep time.

RLS (restless legs syndrome) can ruin a good night’s sleep and antipsychotics and antidepressants have been known to lead to cause it. The strong urge that RLS causes to uncontrollably move one’s legs can make it hard to sleep, lead to sleeplessness, irritability and depressed mood. Remeron (mirtazapine), an older, atypical antidepressant, is most likely to cause RLS. A case study found that RLS appeared to be provoked in patients on a low-dose of Seroquel. Interestingly, some evidence has shown that Wellbutrin may actually help to alleviate RLS.

Lifestyle Changes May Help Curb Sleep-Related Side Effects

However, you might find relief from RLS through lifestyle changes and/or taking certain vitamins. For example, going to the bed at the same time every night and getting up at the same time each morning can help. Also, there are some indications that a lack of some vitamins and minerals, such as iron, folic acid, magnesium, and vitamin B, can contribute to RLS.

Not surprisingly, insomnia and delayed sleep onset are associated with stimulants such as Adderall and Ritalin (methylphenidate), that are used in the treatment of ADHD. However, the effect of Ritalin on sleep may depend on the amount of time a child has been on the drug and when the medication is given. There have also been reports of children having difficulty falling asleep as they are being weaned off the medication.

Sleep is an important part of staying healthy and feeling good. Again, if you feel you are experiencing sleep issues as a result of medication, speak to your doctor without delay. Sleep-related side effects due to drugs impact relatively few patients. And if it ends up your sleep problems are not drug-related, the good news is there are steps you can take to rectify the situation. Changes in sleep hygiene and even in your bedroom environment can provide some of the most effective improvements, as can making sure you are getting enough sleep in the first place. As we are in the middle of Sleep Awareness Week, I recommend visiting the National Sleep Foundation’s website for more helpful tips.

This piece is based on an article, Adverse Effects of Psychotropic Medications on Sleep, published in the journal Psychiatric Clinics of North America in 2016.

New Studies Find No Link Between Antidepressant Use in Pregnancy and Autism, ADHD Risk

The offspring of pregnant women who take an antidepressant are not at increased risk of developing autism spectrum disorder or attention-deficit/hyperactivity disorder (ADHD), according to a pair of new studies.

Researchers in the first study examined data on nearly 36,000 live births. In pregnancies where the mother was taking an antidepressant – either a selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitor – 2% of the offspring developed autism. While this percentage was higher when compared to mothers who didn’t take an antidepressant, when confounding factors were considered, there was no statistically significant difference between the 2 groups, researchers reported in JAMA.

“Although a causal relationship cannot be ruled out, the previously observed association may be explained by other factors,” the authors wrote.

Another study, also published in JAMA, examined 1.5 million births in Sweden and maternal antidepressant use. While maternal antidepressant use during the first trimester of pregnancy, compared to women who didn’t use an antidepressant, was associated with a small increased risk of preterm birth, there was no increased risk for low birth weight, autism or ADHD.

“These results are consistent with the hypothesis that genetic factors, familial environmental factors, or both account for the population-wide associations between first-trimester antidepressant exposure and these outcomes,” the authors of the second study wrote.

Coping with the Side Effects of Antidepressants

Headaches, nausea, feeling on edge, being exhausted and a low sex drive. The irony of antidepressants is that in some cases, side effects can cause the similar symptoms as the depression they are supposed to treat. In fact, those side effects are a key reason that people stop taking the drugs.

There are many ways to cope with depression — therapy, exercise, nutrition and more — but some people will find they need the boost of an antidepressant. Be warned, however, that finding the right antidepressant medicine may take some time. It usually takes weeks for a therapeutic effect and sometimes the first antidepressant an individual is prescribed doesn’t work. And when you are ready to stop taking an antidepressant, you’ll have to be weaned off it because they cause dependence.

An estimated 6.7% of adults in the United States — that’s nearly 16 million people — experience at least 1 episode of depression each year, and approximately 11% of Americans aged 12 and older take a prescribed antidepressant medication. Many patients who take these drugs, however, experience adverse side effects that may influence whether or not they continue taking them. In fact, negative side effects are the top reason that people stop taking antidepressants.

“Side effects for antidepressant medications are not unusual,” said Keith Humphreys, MD, a professor of psychiatry and behavioral sciences at Stanford School of Medicine in California. “The 5 most common are getting headaches, feeling nauseous or even throwing up, feeling edgy or agitated, feeling excessively sleepy or low on energy, and experiencing reduced sexual desire or satisfaction.”

The older types of these medications, including tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), are typically associated with more severe side effects. As a result, they are not prescribed as much anymore. Some of examples of the TCAs include amitriptyline, amoxapine, desipramine and doxepin, while some of the MAOIs are isocarboxazid, phenelzine, selegiline and tranylcypromine.

Antidepressants are serious medicines that can significantly improve some people’s lives. However, the newer types such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) have also been linked with problems. A study published in 2008 in the journal Dialogues in Clinical Neuroscience, for example, found that 55% of people taking an SSRI reported that they had experienced at least one troublesome side effect as a result.

The sexual side effects are a top concern for both men and women taking antidepressants. In addition to issues with sexual interest and arousal, SSRIs can impede erection or ejaculation in men, and they may interfere with lubrication, genital blood flow or orgasm in women.

According to the results of a large survey conducted by Consumer Reports published in 2010, between 23 and 36% of people taking antidepressants reported having had related sexual problems, and some research findings suggest that rates of such side effects could actually be as high as 60%.

Trial and Error

“The side effects vary across the different types of antidepressants, and the precise mechanisms are not always understood, but in general, antidepressant medications alter the levels of chemicals in the brain that regulate many different functions,” explained Humphreys. “When they are effective, the result is reduced depressive symptoms and greater quality of life, but because medicine can’t perfectly adjust such a complex organ as the brain, unwanted effects also often occur.”

In addition, though the reasons are unclear, some individuals have a better response to some antidepressants over others, and one drug may work well for one person and poorly for another. Settling on the right one can sometimes take a bit of trial and error.

Your doctor should initially start you on the lowest effective dose of medication and then keep tabs on your response. Keep in mind that it can take up to 6 weeks before you notice any change as a result of the medication, and it is important to stay on it for about that long — unless you have severe side effects — in order to give it a chance to take effect.

Still, researchers have found that 30 to 40% of people do not improve with the first medication prescribed, in which case the doctor may need to increase the dosage or switch the medication to another one. “It’s not uncommon to try as many as 3 or even 4 antidepressants before you find one that works,” according to Consumer Reports.

Note that means it could be 3 to 4 months before you find an antidepressant that works for you. During this time period, you’ll need to take other steps to cope with your depression. Your doctor might suggest cognitive behavioral therapy (it’s the industry standard to partner antidepressants with therapy in any case). And many people find exercise, change of diet or other non-medical interventions to be helpful.

If you do experience bothersome side effects, other options should generally be considered if they do not fade after weeks or months, advises Humphreys. He points out that many side effects are often temporary, and those that linger should be checked out.

“The best advice is to talk to the prescribing doctor about alternative antidepressant medications,” he said. “Many patients who have unpleasant side effects with one medication will have a better experience on a different medication.” You may ultimately decide that the benefits of a particular medication outweigh any negative effects it may cause.

Know What to Expect

When people experience side effects — or in some cases, when they start feeling better — they may decide to suddenly quit taking their antidepressant. But don’t do it. You should not stop taking the medication without the guidance of your healthcare provider, who will help you taper off of it at a safe pace that will allow your body adequate time to adjust.

“People don’t get addicted (or “hooked”) on these medications, but stopping them abruptly may also cause withdrawal symptoms,” according to theNational Institute of Mental Health. Suddenly quitting these meds may also increase your risk of depression relapse.

Certain symptoms, however, could signal an emergency and require immediate action. You should call your doctor right away if any of the following occur while you are taking antidepressants, particularly if the symptoms are new, getting worse or causing you significant worry:

  • Suicidal thoughts or attempts
  • New or worsening depression or anxiety
  •  Feeling very agitated, irritable or restless
  • Panic attacks
  • Sleep problems such as insomnia
  • Acting aggressively, dangerously, impulsively and/or violently
  • A significant increase in activity and talking–symptoms of mania
  • Other unusual behavior or mood changes

According to researchers at Boston University and Massachusetts General Hospital/Harvard Medical School in Massachusetts, the “successful management of side effects begins with adequate communication and patient education prior to and throughout treatment with antidepressants.” Physicians should also help you sort out whether symptoms are truly side effects of treatment or symptoms of depression or other medical problems. Diminished sex drive, for instance, can be caused by antidepressant medication, but it can also be a symptom of the depression itself.

Ideally, your doctor will consider a wide range of options such as changes in the dosage or timing of medication, behavioral approaches, possibly a different medication altogether or additional pharmacological strategies. “Sound and resourceful management of side effects is an important component in achieving depressive remission and enhancing patient safety and quality of life,” they concluded.

Are Antidepressants Any Better Than a Placebo?

Most people take antidepressants with the idea the side effects associated with the drugs are worth it since they will help alleviate their depression. However, evidence is growing that antidepressants might not be all they are cracked up to be. In fact, they may be no better than a placebo.

The gap effect seen between medication and placebos is sharply narrowing, even for those with severe depression, according to a recent article by Christopher Davey, PhD, and Andrew Chanen, PhD, of Orygen, the National Centre of Excellence in Youth Mental Health, published in The Medical Journal of Australia.

Antidepressant use worldwide has been steadily rising. In the US, the CDC reported that between 2005 and 2008, antidepressants were the most frequently prescribed medications, with 11% of Americans over the age of 12 years taking them. And, as previously reported at MedShadow, “antidepressants are prescribed for conditions other than depression nearly 50% of the time.” The CDC notes that only 1/3 of individuals with severe depressive symptoms take antidepressants.

Research on Antidepressants vs. Placebos

While the overall effect of antidepressants is higher for severe depression, according to Davey and Chanen, “meta-analyses show a modest overall effect size of about 0.3.” Effect size for children and adolescents is even less.

With the response between medication and placebos sharply narrowing, what is becoming apparent is that patients are recovering from depressive symptoms over time, irrespective of treatment.

A brief review of recent literature shows that this conclusion is not limited to Davey and Chanen’s observations. A Cochrane review published this year found that antidepressants in dialysis patients showed no benefit on improved quality of life compared to placebos.

Another recent study, published in the Brazilian Journal of Medical and Biological Research, showed no difference in children and adolescents taking antidepressants compared to placebos.

There are several other studies that have shown similar outcomes. Considering the low effect size and overprescribing questions that are troubling with antidepressants, of particular concern is both the growing rate at which children and adolescents are being prescribed antidepressant medication and the associated adverse drug reactions and side effects.

Adverse Drug Reactions and Side Effects

There are a wide variety of antidepressant medications on the market, the best known varieties being SSRIs (selective serotonin reuptake inhibitors), SNRIs (serotonin and noradrenaline reuptake inhibitors) and TCAs (tricyclic antidepressants). Nearly all antidepressants are associated with side effects. However, there are also some adverse drug reactions to be aware of.

Adverse drug reactions are serious and potentially fatal reactions to medications that occur at normal therapeutic doses, while side effects are less serious secondary effects that occur outside the intended therapeutic action of the medication.

Serotonin syndrome is a more serious adverse reaction that can occur in all age groups from antidepressant usage and ranges in severity from mild to life-threatening. It is caused by overactivation of the central and peripheral serotonin receptors as a result of the medications. Symptoms include a change in mental status, hyperthermia, hyperreflexia, tremor, elevated creatine kinase, vomiting and diarrhea, among others.

Wellbutrin (bupropion), an atypical antidepressant known as a norepinephrine-dopamine reuptake inhibitor (NDRI), is also associated with more serious adverse reactions. Some of the more common observed in clinical trials were edema,  poor coordination, involuntary movements, mania/hypomania and increased libido.

The 2013 annual report of the American Association of Poison Control Centers’ National Poison Data System shows a total of 33,924 serious medical outcomes of moderate, major, or death associated with antidepressant use in 2013. Overall, antidepressants rank third on the list of top 25 substances related to more serious human exposures. And for substances associated with the largest number of overall fatalities, SSRIs rank 8th, miscellaneous antidepressants rank 10th, TCAs rank 12th, and SNRIs rank 23rd.

Additional Concerns for Children and Adolescents

Aside from the side effects mentioned above, all antidepressants can increase the risk of suicidal thoughts and behaviors in children and adolescents, particularly in adolescents, with the addition of possible mania or hypomania symptoms when first starting to take the medication.

One recent systematic review and meta-analysis, published in the British Medical Journal, assessed antidepressants duloxetine, fluoxetine, paroxetine, sertraline and venlafaxine in all populations. The data confirmed an increased risk of suicide in children and adolescents and found the risk of aggressive behavior doubled in this population as well.

While the logical conclusion appears to lean toward stopping antidepressants, Davey and Chanen emphasize that there is a modest effect, which is still considered clinically significant, particularly in patients with moderate to severe depression.

There are many alternatives to antidepressants, so before starting on a drug path, many researchers suggest trying exercise and diet changes, cognitive-behavioral therapy and interpersonal psychotherapy along with combination treatments such as psychotherapy with placebos for adults, children and adolescents.

SSRIs in Pregnancy Linked to Autism

Here is something destined to create fear and finger-pointing: JAMA Pediatrics has published research that finds a correlation between pregnant women’s use of SSRIs (selective serotonin reuptake inhibitors) — a common group of antidepressants — during the last 2 trimesters of pregnancy, and autism spectrum disorder (ASD). The researchers followed pregnant women and their babies/children in Quebec during a 12-year span. SNRIs (serotonin norepinephrine reuptake inhibitors) did not seem to have an impact.

Specifically, the average percent of children diagnosed with ASD during the study was about the same as the national average, under 1% (.07). Of those children whose mothers had taken SSRIs during the 2nd and 3rd trimesters of pregnancy, the autism rate jumped to 1.22%. Of those exposed only in the first trimester the slight increase was statistically insignificant.

But percentages are deceptive. A JAMA Pediatrics Editorial calculated that SSRI exposure led to “an additional 12 children with ASD (autism spectrum disorder) than otherwise would have been expected out the 2,532 children exposed in utero during the 2nd or 3rd trimester.”

The action of SSRIs might account for why ASD is linked to its use. According to the study:

  • SSRIs cross the placental barrier and are found in amniotic fluid
  • Serotonin can affect many prenatal and postnatal developments including cell division, neuronal migration (which brings cells into appropriate spatial relationships in the fetal brain), cell differentiation, and synaptogenesis (the formation of synapses in the nervous system).
  • SSRIs act by blocking the serotonin transporter, which promotes the accumulation of serotonin in extracellular space.
  • The capacity of the brain to synthesize serotonin develops atypically in children with ASD.
  • Serotonin receptor 2A binding is altered in the cerebral cortex of children with ASD.

The study did not take into account maternal lifestyles that have been linked to autism, such as smoking or body mass index. In addition, autism is a range. It’s possible SSRI exposure might have only increased what might have been mild autism that could have gone undiagnosed. Many potential triggers for autism are being studied, from genetics to environmental exposures. The answer to what causes ASD may never be fully understood. And even if we understood them, could we control all the variables?

However damning this report looks for SSRI use in late pregnancy, the reality is that the decision to stop SSRIs is not black and white. Depression is a life-threatening condition. For some pregnant women the risk of harm to mental health by stopping SSRIs will outweigh the increased risk of ASD. The decision as to whether to try to stop SSRI use in pregnancy will, as with all health decisions, have to be made by the pregnant woman herself in consultation with her obstetrician and psychiatrist.

Antidepressants at Normal Doses Linked to First-Time Seizures

During the assessment period of a study spanning from 1998 to 2012, investigators at the University of Basel, in Switzerland, found an increased risk for first-time seizures in patients being treated for depression. Out of the 8.7 million patients, 619 of the151,005 that were diagnosed with depression had a first-time seizure. Incidence rates of seizures tended to be higher in users of SSRIs, SNRIs, or other antidepressants than in users of tricyclic antidepressants (TCAs) or nonusers of antidepressants. Via Medscape. Posted April 6, 2015.

Anti-Anxiety Meds: Options, Side Effects & Alternatives

In 2006, as she was preparing for her wedding, panic attacks began to take over Kara Baskin’s life. “I worried constantly that I was on the edge of bankruptcy, or dying of cancer, or that my fiancé was about to be fired from his job,” she explains. “My fears and my panic kept me home from social events, caused me to fight with my fiancé, and led me to the emergency room with imagined heart attack.”

Things didn’t improve after the wedding. On her dream honeymoon to Hawaii, she spent most of the time not on the beach, but back in her room with her heart racing. She realized she needed help. Back home, she found a therapist and through a combination of medication and talk therapy was able to get her panic under control. Today she uses the medication only as needed.

Kara is one of an estimated 40 million adult Americans — 18.1 percent — who suffer from some form of anxiety disorder. While other therapies are available (see Therapy, Meditation, Sleep and Exercise Can Help Lessen Anxiety), many people with anxiety disorder will find their lives so disrupted that they will need the immediate relief that medication provides. While side effects of these are generally mild, there are precautions you need to take if you choose this route.

What is Anxiety Disorder?

The term “anxiety disorder” actually encompasses several different conditions: generalized anxiety disorder (GAD), panic attacks, social anxiety, specific phobias, and post-traumatic stress disorder.

Some anxiety is normal — even helpful. But for people with anxiety disorder, symptoms are so severe and frequent that they interfere with daily life. “For example, being a little anxious about an upcoming test can help you perform better,” says Katherine M. Moore, MD, Assistant Professor of Psychiatry at the Mayo Clinic in Rochester, MN. “A person with anxiety disorder may be so anxious that she can’t study productively or go to school on the day of the test.”

Symptoms of anxiety disorder can be mental (racing thoughts, constant worrying, restlessness and difficulty concentrating) and physical (heart palpitations, sweating, trembling, shortness of breath, chest pain, nausea, dizziness and chills or hot flashes). These symptoms can be so severe that they interfere with your relationships, keep you from being able to enjoy your life, or even make it difficult for you to leave your home.

Anti-Anxiety Meds and Their Side Effects

For patients who need to get these symptoms under control, the first choice of medication is usually either SSRIs (selective serotonin reuptake inhibitors, such as Celexa, Lexapro, Luvox, Paxil, Prozac and Zoloft) or SNRIs (serotonin-norepinephrine reuptake inhibitors, such as Efflexor and Cymbalta). Both these medication types increase the serotonin available in the brain. SNRIs also increase the availability of the neurotransmitter norepinephrine. Both serotonin and norepinephrine improve mood. These medications are effective for all anxiety disorders, and SNRIs are particularly helpful in the treatment of generalized anxiety disorder, according to the Anxiety and Depression Association of America (ADAA).

Side effects of these medications are generally mild and go away after the first few weeks of treatment. They can include insomnia, headache, sexual dysfunction, weight gain and nausea.

Even if you are pursuing other treatments, such as cognitive behavioral therapy, your doctor may recommend that you try one of these medications. “We often can do therapy without medication,” explains O. Joseph Bienvenu, MD, Phd, Associate Professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, in Baltimore. “But it requires a lot of work and courage on the part of the patient. Sometimes medication just gives people the courage to pursue other treatments.”

While taking these medications, it’s best to limit your consumption of alcohol, says Dr. Moore. “Because, like alcohol, these medications are metabolized through the liver, while you are taking them you will feel the effects of alcohol more quickly,” she explains. It’s also important to not stop these medications suddenly. If you decide to stop taking them, work with your doctor to taper off the medication gradually, she says.

Another class of medications, benzodiazepines (including Klonopin, Xanax and Ativan), is sometimes prescribed for short-term management of severe symptoms, “if somebody has social phobia or panic symptoms so severe that she can’t leave her house,” for example, Dr. Moore says. They can also be used occasionally. “For example, if somebody with a fear of flying travels a couple of times a year, a dose before a flight can be helpful,” she explains.

The main concern with the ongoing use of benzodiazepenes is dependence and addiction, Moore says. With prolonged use, you may find you need to increase the dosage to achieve the same effect, she explains. For this reason, it is best to limit use them only occasionally or, if daily, for no more than 3 to 4 months, she Tricyclic antidepressants, such as amitriptyline, imipramine, and nortriptyline can also help control symptoms. But doctors avoid prescribing them because of their side effects, including low blood pressure, constipation, urinary retention, dry mouth and blurry vision.

Special Concerns for Women

The dramatic hormonal changes of pregnancy and the post-partum period can make this “a time when women with pre-existing anxiety disorders may see worsening of symptoms, and a time when new symptoms can emerge,” says Samantha Meltzer-Brody, MD, MPH, Director of the Perinatal Psychiatry Program at UNC Center for Women’s Mood Disorders, in Chapel Hill, NC.

Changing levels of the stress hormone cortisol at this time also combine with the outside stresses of adjusting to parenthood to make new mothers more susceptible to developing anxiety, she says. While some anxiety at this time is normal, she says, “seek help if you feel the anxiety is making it difficult for you to manage or to enjoy your baby,” she says.

“Many anti-anxiety medications are considered safe in pregnancy and while breastfeeding, she says. It is hard to give an exact list of safe medications,” she says, “because it needs to be discussed on a case-by-case basis.” So much depends on other factors, including the severity of the symptoms, previous response to treatment, and the dose prescribed, she explains. It’s important to discuss your own situation with your doctor before taking these medications in pregnancy. At this time, it may be best to combine behavioral therapy, which teaches you skills to manage your anxiety, with interpersonal therapy, which helps you manage the complex relationships with your spouse, baby, and your child’s grandparents at this difficult time. A November 2000 study of 120 women published in the Archives of General Psychiatry found that interpersonal psychotherapy is an “effective alternative to medication in the post-partum period.”

A Winning Combination

Whatever your stage of life, many people, like Kara, find that medication is most helpful when combined with some type of therapy. “The medication put me in the frame of mind to take that next step and get the help I needed,” she says. “Therapy helped me to be more aware of my mind and my body, to feel more in control, and to be aware of what makes me anxious. Now that I know what my triggers are, I can prepare myself if I know I am going to be in a stressful situation.”

Ellen Wlody is a writer who specializes in health and parenting topics. She lives in upstate New York with her husband, children, and two dogs.