All about SSRI antidepressants (practically)
“I found out what happiness is only after taking sertraline”.
“Before starting paroxetine, I had panic attacks every single day, getting out of my house was a big no for me”.
“Escitalopram has made me improve till being able to participate actively in my psychoterapy”.
These sentences, and many others that we psychiatrists hear in the office quite often underline the value of the selective serotonin reuptake inhibitors (SSRI), the antidepressant medications most prescribed currently although, as we’ll discuss later, they are not only used for depression.
These are the SSRI, in order of development:
- Fluvoxamine (Luvox).
- Fluoxetine (Prozac).
- Citalopram (Celexa).
- Paroxetine (Paxil, Seroxat).
- Sertraline (Zoloft).
- Escitalopram (Lexapro).
And their approved indications:
- Depression.
- Generalized anxiety disorder.
- Social anxiety disorder.
- Panic disorder.
- Obsessive-compulsive disorder.
- Postraumatic stress disorder.
The first ones started to be used at the end of the 80s, fluoxetine particularly, and became so famous that a few years later we could read best-sellers whose title contained the word “Prozac”, brand name for fluoxetine: Prozac Nation: Young and Depressed in America (E. Wurtzel, 1994), Amor, curiosidad, Prozac y dudas (Love, curiosity, Prozac and doubts; L. Etxebarría, 1997), Plato, not Prozac! (L. Marinoff, 1999), or even El Prozac de Séneca (Seneca’s Prozac, C. Newman, 2014).
These medicines put in the public arena much needed conversations about mental health, and have contributed hugely to lessen the associated stigma: they brought along a great revolution in the treatment of various disorder and in closing the gap between Psychiatry and global society.
In order to understand why SSRI meant such a revolution we have to consider the psychopharmacology then present, used to treat depression and anxiety: the “old” antidepressants (monoamine oxidase inhibitors [MAOI], tricyclics) and barbiturate/benzodiazepines. Even though they are really effective, their side effects cause discomfort to say the least, most are sedating, may be lethal in overdose and their addiction potential is high. With SSRI, for the first time ever the psychiatrists have at hand a pharmacological armamentarium which is effective, well tolerated, easy to dose and not addictive.
The name betrays their mechanism of action: these drugs inhibit in brain synapses (sites of communication between neurons) the reuptake (return to the cell) of serotonin, a very important neurotransmitter; this leads to an increase of available serotonin in the synapsis, and gave rise to the «chemical imbalance» so widely purported for years as cause of the symptoms: both patients and doctors claimed that a “deficit of serotonin” lay at the root of the disorders. This excessively simplistic notion has been discarded (among other reasons, because the increase in serotonin in the synapses occurs immediately, while the antidepressant, antiobsessive or antianxiety action usually takes from days to weeks) and currently we consider that these medications act instead as “emotional regulators”, modifying emotional perceptions at unconscious level. It is clear that serotonin is just a piece in the big brain puzzle and mental disorders, but the fact that we ignore the exact mechanism of action for SSRI does not necessarily mean that we shouldn’t use them, as some claim. Suffice to say that we still don’t understand the mechanism of acetaminophen (paracetamol), one of the most used medications in the world, and we don’t let this stop us from making use of its great efficacy to treat the headache or fever caused by a cold, for instance.
What is it like to take antidepressants (SSRI)
And after this theorical discussion of their mechanism, here comes a more practical exposition. ISRS are extremely easy to take: once a day, with or without food. They are very safe (even in pregnancy!), have very few absolute contraindications and are mostly very well tolerated. Their most frequent side effects are upset stomach and nausea (up to 10%; they usually disappear after a few days of treatment), excessive sweating, nervousness (they may increase anxiety initially) and tremors. Other effects, much less frequent (1% maximum) include sexual issues (from decrease in libido to impotence and lack of orgasm), a feeling of excessive emotional indifference, suicidal ideation and bruising/bleeding tendency. We must remember that most patients do not suffer any effect, the vast majority of them tend to disappear as the treatment goes along and very often it’s possible to minimize them starting with low doses and increasing as suggested by the 2017 top song: des-pa-ci-to (slowly, just in case there’s still someone unable to translate).
It is always appropriate to remind that, as it is the case with every other medication in continuous use, they have to be recommended, prescribed, controlled and withdrawn by a doctor: let us help you here at SINEWS, with SSRI and a lot else!
About the author
Alicia Fraile is a psychiatrist at SINEWS with more than 20 years of experience in general clinical psychiatry. She has worked in brain damage, Mental Health Centers, occupational psychiatry, work accidents and their repercussion in psychiatry (post-traumatic stress disorder, adaptive disorders), patients with chronic health problems and of course with the most frequent pictures of our field: anxiety, depression, insomnia, obsessive-compulsive disorder.
Division of Medicine
Psychiatrist
Adults
Languages: English and Spanish
What is chronic pain and how can it be managed?
Even though I am a psychiatrist, the lines and paragraphs that follow aren’t devoted to moral or soul pain, that pain no Band-Aids will ever cure, but “organic” or physical pain, where painkillers are so efficient (aren’t they?).
What exactly is pain?
Pain is a defensive mechanism. So boldly stated, it might be viewed even as an insult to all those doomed to live in pain on a daily basis, but a little reflection is enough to realize why evolution has promoted its existence. Pain is the very first “red flag”, a signal that something is wrong and compels us to acknowledge it: either stop moving a painful limb, which may be fractured, or seek immediate help with the unbearable pain of a heart attack. The rare people who cannot feel pain due to a genetic deficit are witness to those benefits, as well as the ailments, much more frequent, that patients with diabetes suffer in their feet because the damage of the nerves that transmit the pain makes them unable to feel it, so a simple graze due to tight shoes may become a terrible ulcer as these people lack this warning system whose function is to alert us of potential dangers.
The International Association for the Study of Pain defines acute pain as an unpleasant sensory and emotional experience associated with, or resembling that associated with actual or potential tissue damage. This definition states something we all know, but it is so difficult to convey to other people, or even to acknowledge its severity. The best tool to quantify pain, the Visual Analogue Scale (VAS), asks us to score our pain from 0 to 10. This provides an easy way to assess the efficacy of a treatment for pain, calculating the percentage of decrease in VAS.
Which types of pain can we find?
The simplest classification is acute (defined above) and chronic:
- Chronic pain, as opposed to acute pain, is a persistent pain state not associated with the triggering event and exists beyond the normal healing; it lacks a protective role.
- Acute pain is usually a symptom of the underlying health problem, whereas chronic pain is a disease condition in itself, with symptoms of refractory pain, functional and psychological impairment, and disability.
Another important distinction is between nociceptive pain, due to the activation of pain receptors or nociceptors, and neuropathic, secondary to the disturbance of the very same nervous structures committed to the transmission and perception of pain. Nociceptive pain is what we feel with a hit, puncture, heat, inflammation, etc., while neuropathic pain is felt more as an intense “bolt”, an extremely unpleasant sensation difficult to describe: the best-known example is the shock we feel along the forearm when we hit the internal aspect or our elbow. It is also usually accompanied by changes such as dysesthesias (distorted sensations: burning, tingling), hyperesthesia (oversensitiveness) and allodynia (pain perceived with painless stimuli).
How is pain transmitted?
We have a good knowledge of pain transmission paths and the substances involved. Concisely and simply put, the sensation starts at the nociceptors, specialized nervous structures, and from these to sensitive nerves, spinal cord, thalamus and eventually several brain areas, ultimately responsible for the perception of pain.
This deep knowledge of structures and substances permits on the hand to understand how pain is the result of damage to the various levels (spinal cord injury, stroke) and, on the other, develop strategies to fight pain in every front (blocks of peripheral nerves, spinal stimulators).
How is acute pain managed?
It was several decades ago (1986) that the World Health Organization (WHO) released its “pain relief ladder”, initially proposed for cancer pain and adopted subsequently in other conditions. The pain is graded in mild, moderate and severe (according to the VAS score) and suggests various medications in each of the steps, from acetaminophen and nonsteroidal anti-inflammatory drugs (NSAID: ibuprofen, aspirin…) to the strongest opioids (morphine, fentanyl) in the last one.
Generally and even though there are obvious exceptions, the management of acute pain with medications (through several routes: oral, intravenous, regional, epidural…) obtains an effective relief. It is important to adjust carefully the doses and duration of the treatment to avoid complications and specially, addictions to opioids.
What is the way to chronic pain?
With repeated and ongoing exposure to painful stimuli, our central and peripheral nervous systems undergo a process known as sensitization, dependent upon neuronal plasticity: the final result is persistent pathological pain: enhanced and prolonged pain perception after minor nociceptive stimuli, or even in absence of these. Once peripheral and central sensitization are involved, the pain is usually more difficult to treat or even refractory to standard therapies.
It is now believed that this sensitization process is involved in a wide variety of chronic pain conditions, such as tension headache or carpal tunnel syndrome, also in those previously thought to be mainly nociceptive in nature (osteoarthritis, fibromyalgia).
What are the most common causes of chronic pain?
The most common causes span from primary pain disorders (fibromyalgia, chronic headache) to rheumatological (arthritis), endocrine (diabetes) and orthopedic (disk hernia) conditions: all of them are prevalent disorders in general population. Even though the various reports yield widely variable figures, the lowest estimate of prevalence for chronic pain in general population is around 25%.
How is chronic pain managed?
In chronic pain, which constitutes a disease entity by itself as we stated above, medications are just a small part of the management. The best outcomes come from a multimodal approach, consisting on the simultaneous, instead of sequential use of multiple treatment modalities for pain: medicines (not only painkillers, certain antidepressants and antiepileptics are first line treatments in several pain conditions), rehabilitation (physical therapy, occupational therapy), psychology (see below), interventional pain management (peripheral nerves block, epidural injections), implantable devices (spinal cord stimulators, intrathecal pumps), complementary and alternative medicine (acupuncture), nutritional counselling (losing weight), vocational counselling (return to work).
It is essential to identify and treat all the comorbid conditions if we aim to have good outcomes in chronic pain, including psychological/psychiatric disorders or even the lack of social support.
What is the role of psychology/psychiatry in chronic pain?
Many of the people who suffer chronic pain also have psychological/psychiatric disorders, mainly anxiety and depression; it is not pure chance that every Pain Unit is staffed with a psychologist/psychiatrist.
Just like those philosophical questions so difficult to answer, it remains a challenge to differentiate between cause and effect, whether anxiety and depression came before the pain or this is the root cause of the psychological issues. Anyway, it seems reasonable to assess and treat the actual condition, and worry later, almost at a mere academic level, about establishing which one arrived first.
Antidepressant drugs treat anxiety and depression, and one of their categories, the so-called “dual antidepressants”, which enhance both serotonin and noradrenaline, is the first-line choice for neuropathic pain.
There are multiples modalities of psychotherapy well described in pain: hypnosis and visualization, guided imagery, biofeedback, cognitive-behavioral therapy, group psychotherapy and family therapy. They use different techniques, but all of them have in common assisting the patient to cope with the condition and avoiding pain from becoming the absolute focus of their lives.
A message of hope: the advances in the understanding of paths and substances involved in pain, recent developments in its management, from new pharmacological strategies to outstanding interventionist procedures, together with the realization that psychological/psychiatric therapy constitutes an essential component of a comprehensive management of pain, have permitted and will further permit that many people won’t be doomed to live in pain anymore.
About the author
Alicia Fraile is a psychiatrist at SINEWS with more than 20 years of experience in general clinical psychiatry. She has worked in brain damage, Mental Health Centers, occupational psychiatry, work accidents and their repercussion in psychiatry (post-traumatic stress disorder, adaptive disorders), patients with chronic health problems and of course with the most frequent pictures of our field: anxiety, depression, insomnia, obsessive-compulsive disorder.
Division of Medicine
Psychiatrist
Adults
Languages: English and Spanish