While SSRIs can have an immediate effect, the full effect can take anywhere from weeks even longer sometimes depending on the person. They are generic and cheap. This is my style, and there is certainly nothing wrong with those who do prescriber newer meds which I also do on occasion. While they are overall fairly well tolerated and arguably with less side effects than older classes of antidepressants, some people may be more sensitive to side effects of this class e.
In this class, the risk of discontinuation syndrome aka SSRI withdrawal will be greatest with paroxetine. Most people do not have significant symptoms of this syndrome when they wean off slowly, but a small subset of people are quite sensitive to such and struggle to wean off.
This syndrome will be much greater with medicines with short half lives including paroxetine and the SNRIs discussed below, but can also occur with other SSRIs mentioned above but less so with the others.
Again, typically this is a mild or absent syndrome, but some are more sensitive than others to it. That being said: one mechanism of action of SSRIs may be boosting serotonin levels in the brain. Research also shows these meds may also enhance glial cell function these are brain cells that support, nourish, insulate and protect the brain neurons , and increase BDNF levels brain derived neurotrophic factor.
Many people presume the serotonin boost is the main mechanism, but this is not necessarily true. The other mechanisms I mentioned tend to peak in effect at months, and this actually correlates more with the timing of the peak therapeutic effect in some people.
These may be a good choice for those experiencing both anxiety and depression. However, sometimes higher doses can be overstimulating and contribute to anxiety.
This may be less likely with citalopram and escitalopram. Sometimes even low doses can trigger anxiety in certain people. I know it sounds paradoxical that the medicine being used to help anxiety can trigger it instead. This at least partially reflects many issues including the fact that while we have come a long way in psychiatry with psychotropic medicines, we still have a long way to go. The prescribing of anxiety meds is not an exact science at all.
While people can theoretically abuse any medication esp something sedating or stimulating, even things like over the counter Benadryl , SSRIs and all the other antidepresant classes mentioned below are generally not thought of as addictive.
Some research shows when treating OCD, you need higher doses, and it takes much longer to get peak effect. However, some clinicians question the validity of such research.
Paroxetine is not ideal for elderly patients. It may also have the most potential weight gain within this class of medications.
These include venlafaxine aka Effexor , duloxetine aka Cymbalta , desvenlafaxine aka Pristiq , levomilnacipran Fetzima , and milnacipran Savella. One difference is they also boost more noradrenaline in the brain, and not just serotonin but some SSRIs also boost noradrenaline.
In theory, any antidepressant could also treat pain. However, duloxetine does have an FDA approval to treat certain kinds of pain. Milnacipran Savella is actually only FDA approved for fibromyalgia, and not any specific anxiety or depressive condition but still might help latter.
These include but are not limited to alprazolam aka Xanax , lorazepam aka Ativan , clonazepam aka Klonopin , and diazepam aka Valium. These are quick acting. However, there can also be a cumulative effect over the 1st 2 weeks or potentially longer for some like diazepam because it has an extremely long half life of hours.
These can be highly addictive. These are dangerous and potentially fatal to mix with alcohol; some patients even report synergistic effects between alcohol and the other antidepressant classes mentioned, but that combination is still safer on average than mixing benzos with alcohol. Some recent research describes a possible association between long term benzo use and dementia.
This is not well understood or proven yet. However, benzos are somewhat similar to alcohol, and even used for detoxing from alcohol. Severe and chronic alcohol use is known to cause dementia. Thus, it would not surprise me if benzos were related to dementia. On the flip side, there are likely a subset of patients who do fine on small to moderate doses of benzos long term.
These can also be dangerous to mix with other addictive drugs like opiates. Any quick acting benzo is more likely to lead to rebound anxiety. This occurs when the medicine wears off. Then, the anxiety is higher than before the medicine was taken.
This can lead to use of higher and more frequent doses, fueling potential addiction. Because of this, I rarely ever start someone on alprazolam. I almost always use lorazepam instead. Quick acting ones will provide quicker relief but not last as long. Long acting ones will provide longer duration of effect, and thus one might need doses per day rather than Benzos are not good for the elderly especially the longer acting ones as they can cause sedation, falls and confusion; this class of meds is the 1 medication cause of falls in the elderly.
They work through potentiating GABA receptors. They can also act as muscle relaxants and antiseizure meds, so may be a good choice for those with these problems as well as anxiety. The minimum effective dosage should be prescribed for short-term therapy unless the patient will be using benzodiazepines long-term to prevent panic attacks.
Lower dosages may control generalized and anticipatory anxiety but, to prevent panic attacks, daily dosages in the range of 2 to 10 mg of alprazolam Xanax and 1 to 4 mg of clonazepam Klonopin , or the equivalent, 5 are required Table 1. Use of fast-acting, short half-life benzodiazepines such as alprazolam and lorazepam Ativan should be avoided.
While adequate comparative trials are lacking, some evidence 8 suggests that the slower onset and longer acting benzodiazepines like clonazepam are less likely to be abused, less habit-forming, and easier to discontinue. Beta blockers, once widely touted as effective antipanic medications, have proven disappointing as monotherapy in subsequent placebo-controlled trials.
When directly questioned by a physician, about 60 percent of patients who take SSRIs report experiencing sexual dysfunction, including delayed orgasm, anorgasmia, loss of libido, decreased lubrication, and erectile dysfunction 11 ; that number drops to 14 percent when patients spontaneously report the information.
In general, the sexual dysfunction is dose-related and responds to reductions in the total amount of antidepressant medication used. This strategy would presumably work best with short half-life agents such as paroxetine Paxil or sertraline Zoloft. Unfortunately, venlafaxine Effexor has an incidence of sexual dysfunction similar to that of conventional SSRIs. Other alternatives include adding the sedating antihistamine cyproheptadine Periactin to the treatment regimen 4 to 16 mg, one to two hours before engaging in sexual activity.
For example, using the sedating agents mirtazapine or nefazodone would be a good choice for patients with ongoing comorbid sleep difficulties, and sildenafil would be appropriate for the patient whose main problem is erectile dysfunction. Finally, switching to a different category of antipanic drug, such as tricyclic antidepressants, is another possibility. Nefazodone 15 and mirtazapine 16 are also likely to be useful in treating panic disorder; use of these agents has a low risk of sexual dysfunction.
CBT, a form of psychotherapy that is usually short-term and focused on symptom resolution through the observation and change of cognitive distortions and their subsequent behaviors, should be encouraged in patients with panic disorder. The basic premise of CBT is that internal cognitive distortions e. The gains made with CBT tend to be maintained after the treatment is discontinued, which is generally not the case for pharmacotherapy.
CBT is particularly effective for agoraphobic or avoidance symptoms, an area where medication alone has limited benefit. One barrier to adequate treatment of panic disorder is the potentially high cost of therapy Table 1.
Anecdotally, self-help groups like Agoraphobics in Motion, Crooks Rd. One reason for a patient to have a suboptimal response to therapy is an incomplete diagnosis. Unfortunately, most commonly used diagnostic and screening tools for mental health disorders in the primary care setting are not sufficiently comprehensive; the less familiar Mini-International Neuropsychiatric Interview M.
Finally, it is important to assess the risk of suicide in all patients who have panic disorder. Because panic disorder is a chronic condition that often manifests early in adult life, 25 comorbid mood disorders, substance use, and anxiety disorders can develop over time.
Accordingly, the development of panic that is refractory to treatment in a patient with previously well-controlled panic disorder should prompt rescreening for these disorders. With increasing age, patients may develop medical comorbidities that can interact with panic phenomenology to produce refractory panic symptoms. Selecting treatments for panic disorder in a rational sequence will presumably decrease the likelihood of a patient becoming refractory to treatment.
Several groups 2 , 17 , 27 have proposed guidelines for treatment selection but, except for a general preference to begin with an SSRI or CBT, the recommendations differ.
Unfortunately, there are no controlled trials to guide the next therapeutic selection. Algorithm for sequencing treatment for panic disorder. Information from references 2 , 18 , and Augmentation, the addition of another treatment to a partially effective maintenance drug program, has become popular in the treatment of panic disorder. Evidence of efficacy is limited to favorable case reports; especially appropriate for patients with comorbid generalized anxiety disorder or mild depression because of efficacy in treating these comorbidities.
Growing controlled evidence of efficacy; especially appropriate for patients with another benzodiazepineresponsive condition such as generalized anxiety disorder; check for potential drug interactions, which vary by agent.
Experience is limited to favorable clinical experience, particularly with patients who have prominent autonomic symptoms. Experience limited to favorable clinical experience; limited experience with use of this strategy in patients with depression; check for potential drug interactions.
See Table 1 ; watch for potential drug interactions, which can increase serum TCA levels. Evidence of efficacy is limited to small case-series; check for potential drug interactions. Evidence of efficacy is limited to case reports and small case-series; an obvious choice for patients with comorbid bipolar disorder.
Information from references 1 , 5 , 10 , and Common errors in treatment sequencing include sequential trials of multiple agents from the same therapeutic class usually SSRIs , failure to offer CBT early in the treatment course, initiating chronic benzodiazepine therapy before exhausting other treatment options and failing to consider comorbidities in treatment selection. The availability of safe, easy-to-use medications has proven to be a boon for primary care physicians who treat patients with mental health disorders.
Nevertheless, not all patients tolerate these medications, and intolerance or partial responses are all too common. The eight strategies described in this article can help primary care physicians optimize the care of these patients. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. MARK A. SSRIs usually need to be taken for 2 to 4 weeks before the benefit is felt. You may experience mild side effects early on, but it's important that you don't stop taking the medication.
These effects will usually wear off quickly. They may recommend increasing your dose or trying an alternative antidepressant. A course of treatment usually lasts for at least 6 months, although longer courses are sometimes recommended and some people with recurrent problems may be advised to take them indefinitely. SSRIs aren't suitable for everyone. They're not usually recommended if you're pregnant, breastfeeding or under 18, because there's an increased risk of serious side effects.
However, exceptions can be made if the benefits of treatment are thought to outweigh the risks. It may take several weeks for you to notice an improvement in your symptoms. However, there are several possible side effects. If you have great difficulty with side effects, your doctor may decide to prescribe a different SSRI. In general, lower initial doses that are gradually increased reduce the chance that you will have bad side effects.
The results of such a combination can be fatal. Although rare, it is possible during the initial phase of treatment for symptoms to worsen rather than improve. It is important to monitor symptoms during this time and report any negative changes to your doctor. In , the FDA released an advisory concerning SSRIs and risk of suicidal thoughts and behaviors, particularly in children and adolescents. In addition to the FDA advisory on suicidal thoughts, there has also been an advisory released regarding the use of triptans for migraine headaches in combination with SSRIs.
In combination, there is a risk of serotonin syndrome , a potentially life-threatening condition. In general, it is important to inform your doctor of all medications, both prescription and nonprescription, that you are already taking.
If you are having suicidal thoughts, contact the National Suicide Prevention Lifeline at for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call For more mental health resources, see our National Helpline Database. SSRIs should always be discontinued under the supervision of a medical professional.
Abruptly stopping these medications can result in a relapse of anxiety symptoms. You also can experience serotonin withdrawal symptoms, including trouble with coordination, tingly sensations, vivid dreams, flu-like symptoms, anxiety, and depressed mood.
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