SSRIs are medicines that boost serotonin and are used to help to improve mood in people who are feeling low or depression. Fluoxetine ("Prozac") may also be used to help treat the eating disorder "bulimia nervosa". In addition to this, the SSRIs are now widely used to help a variety of other symptoms. These include anxiety (where a lower starting dose often helps), social anxiety or social phobia, Obsessive Compulsive Disorder, PTSD (Post-Traumatic Stress Disorder), panic disorder, pre-menstrual syndrome and agoraphobia. Some drugs are "licensed" (ie officially approved) for some of these conditions (e.g. paroxetine for social anxiety or social phobia) but this does not necessarily mean the others do not help, just one manufacturer can prove it and has applied for a licence.

Trazodone ("Molipaxin") is not strictly a pure "SSRI" but has many of the same effects and so is included in this group for convenience.

The SSRIs are now the most commonly prescribed antidepressants but there are many other similar drugs. All these antidepressants seem to be equally effective for depression at the proper dose but have different side effects to each other. Apart from nausea, the SSRIs generally have less side effects than the older drugs. If one drug does not suit you, it may be possible to try another. Starting with a lower dose for a week or so may also help the drugs to be more tolerable or have less side effects.

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The brains has many naturally occurring chemical messengers. One of these are called serotonin (sometimes called 5-HT) and is important in the areas of the brain that control mood and thinking. It is known that this serotonin is not as effective or active as normal in the brain when someone is feeling depressed. The SSRI antidepressants (e.g. escitalopram, citalopram, fluoxetine, paroxetine, sertraline) increase the amount of this serotonin chemical messenger in the brain. This can help correct the lack of action of serotonin and help to improve mood.

An SSRI is a Selective Serotonin Reuptake Inhibitor and blocks the reuptake of serotonin. So, the next time an impulse comes along, there is more transmitter, a stronger message is passed, and activity in that part of the brain is increased. 

To help understand this better you may find it helpful to read the answers to the following questions:

• How do medicines work in the brain?
• What happens when transmitter activity is low?
• How do SSRIs work in detail?

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Tablets and capsules:
Tablets and capsules should be swallowed with at least half a glass of water whilst you are sitting or standing. This is to make sure that they reach the stomach and do not stick in your throat.
Trazodone modified release tablets ("Molipaxin CR") should be swallowed whole and not chewed. This is because they are made so that they release the drug over a longer period of time. This can help to reduce side-effects or reduce the number of times a day you need to take your medicine. Crushing or chewing these will cause the drug to be released too quickly.

Liquids:
Your pharmacist should give you a medicine spoon or oral syringe. Use it carefully to make sure you measure the correct amount. Ask your pharmacist for a medicine spoon if you do not have one.

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Take your medication as directed on the medicine label. Try to take it at regular times each day. If you are told to take your dose once a day this will usually be best in the morning, except with fluvoxamine, which is probably best in the evening. If you feel sick when you first start taking your SSRI, this should only last for a few days, but this can be helped by taking your medicine with or after food. Also, taking it at mealtimes may make it easier to remember as there is no problem about taking any SSRI with or after food. They are not sleeping tablets.

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It may take as long as two weeks or more before the SSRIs start to have any effect on your mood, and a further three or four weeks for this effect to be reaching its maximum. Unfortunately in some people the effect may take even longer to occur e.g. several months, especially if you are older.

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This should be discussed with your doctor, as people respond differently. To help you make a decision, it may be useful for you to know that research has shown that:

    * for a first episode of major depression, your chances of becoming depressed again are much lower if you keep taking the antidepressant for six months after you have recovered (longer if you have risk factors for becoming depressed again)
    * for a second episode, your chances of becoming depressed again are lower if you keep taking the antidepressant for one or two years after you have got better
    * for depression that keeps coming back, keeping taking an antidepressant has been shown to have a protective effect for at least five years.

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They are not addictive, but if you have taken them for eight weeks or more you may experience some mild "discontinuation" effects if you stop them suddenly. These do not mean that the antidepressant is addictive. For a drug to be addictive or produce dependence, then it must have a number of characteristics:

    * should produce craving for the drug when the last dose "wears off"
    * should produce tolerance ie you need more drug to get the same effect
    * there should be an inability to cut down or control use
    * should produce withdrawal symptoms
    * there should be continued use of the drug despite knowing of harmful consequences

Thus antidepressants, if stopped suddenly, may produce some "discontinuation" symptoms but these are more of an "adjustment" reaction from sudden removal of a drug rather than withdrawal.

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It is unwise to stop taking them suddenly, even if you feel better. Two things could happen. Firstly, your depression can return if treatment is stopped too early (see "How long will I need to keep taking them for?"). Secondly, you might also experience some mild "discontinuation" symptoms (see also above). At worst, these could include dizziness, vertigo/light-headedness, nausea fatigue, headache, "electric shocks in the head", insomnia, abdominal cramps, chills increased dreaming, agitation and anxiety. They can start shortly after stopping or reducing doses, are usually short lived, will go if the antidepressant is started again and can even occur with missed doses. These effects have been reported for all the SSRIs, but it seems that they occur more often with paroxetine than the others.

If you get these discontinuation symptoms, you have a number of options:

    * If they are not severe, you can wait for the symptoms to go - they usually only last for a few days or weeks
    * Ask for something to help your symptoms in the short-term e.g. a sedative or sleeping tablet
    * Start the medication again (the symptoms should go) and then try reducing the dose more slowly over a longer time e.g. reduce the dose by about a quarter (25%) every 4-6 weeks. Another system that works for some people is to use the syrup; everytime you take a dose, add some diluent (e.g. syrup or water) and then the syrup gradually (rather than suddenly) gets more and more dilute.
    * Switch to another antidepressant - this sometimes helps e.g. fluoxetine has a long "half-life" and is easier to stop than is e.g. paroxetine

When the time comes your doctor should withdraw the drug slowly e.g. by reducing the dose gradually every few weeks. You should discuss this with your doctor.

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Start again as soon as you remember unless it is almost time for your next dose, then go on as before. Do not try to catch up by taking two or more doses at once as you may get more side-effects. You should tell your doctor about this next time you meet.

If you have problems remembering your doses (as very many people do) ask you pharmacist, doctor or nurse about this. There are some special packs, boxes and devices which can be used to help you remember.

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Use the information in the table below to find out about side effects associated with Specific serotonin re-uptake inhibitors or SSRIs.

Side effect	What happens	What to do about it
COMMON
Nausea and vomiting	Feeling sick and being sick.	Take your medicine after food. If you are sick for more than a day, contact your doctor. This tends to wear off after a few days or a week or so.
Insomnia	Not being able to get to sleep at night.	Discuss with your doctor. He or she may change the time of your dose, or reduce the dose a little to start with.
Sexual dysfunction	Finding it hard to have an orgasm. No desire for sex.	Discuss with your doctor. See also a separate question in this section.
LESS COMMON
Drowsiness	Feeling sleepy or sluggish. It can last for a few hours after taking your dose.	Don't drive or use machinery. Ask your doctor if you can take your SSRI at a different time of day.
Headache	Your head is pounding and painful.	Try aspirin or paracetamol. Your pharmacist will be able to advise if these are safe to take with any other drugs you may be taking.
Loss of appetite	Not feeling hungry. You may lose weight.	If this is a problem, contact your doctor or chemist for advice.
Diarrhoea	Going to the toilet more than usual and passing loose, watery stools.	Drink plenty of water. Get advice from your pharmacist. If it lasts for more than a day, contact your doctor.
UNCOMMON
Restlessness or anxiety	Being more on edge. You may sweat a lot more.	Try and relax by taking deep breaths. Wear loose fitting clothes. This often happens early on in treatment and should gradually ease off over several weeks. A lower starting dose may help sometimes.
RARE
Rashes and pruritis	Rashes anywhere on the skin. These may be itchy.	Stop taking and contact your doctor now.
Dry mouth	Not much saliva or spit.	Suck sugar-free boiled sweets. If it is bad, your doctor may be able to give you a mouth spray.
Skin rashes	Blotches seen anywhere.	Stop taking and contact your doctor now. This is a particular problem with fluoxetine (Prozac)
Tremors and dystonias	Feeling shaky. You may get a twitch or feel stiff.	It is not dangerous. If it troubles you, contact your doctor.

Table adapted from UK Psychiatric Pharmacy Group leaflets, with kind permission www.ukppg.org.uk

Do not be worried by this list of side effects. You may get none at all. There are other rare side-effects. If you develop any unusual symptoms ask your doctor about them next time you meet.

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Fluoxetine ("Prozac") may cause you to lose weight. You tend to lose more the heavier you are so this "side effect" is not usually one which people complain about! The other drugs in this group tend to have less of an effect on body weight. If, however, you do start to have problems with your weight tell your doctor next time you meet as he or she can arrange for you to see a dietician for advice. It may be that in the long term (ie several years), there may be tendency to gain a little weight.

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Drugs can affect desire (libido), arousal (erection) and orgasmic ability. The SSRIs are know to affect all three stages in some people. Delayed orgasm is known to occur in many people. Indeed some of these drugs are now widely used to help treat premature ejaculation. If this does seem to have happened, you should discuss this with your doctor, as a change in dose, when you take the dose or drug may help reduce any problem.

With trazodone, a serious condition known as priapism has been reported very rarely. Priapism occurs in men and is defined as a persistent painful erection without sexual stimulation. It is no joke and should be treated as an emergency, as it can cause permanent damage. If this should happen, you should go to a hospital accident and emergency department as soon as possible, and certainly within a couple of hours.

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These drugs may make you feel drowsy, although this effect is less than with other antidepressants. You should not drive (see below) or operate machinery until you know how they affect you. You should be careful as they may affect your reaction times or reflexes. They are not, however, sleeping tablets, although if you take them at night they may help you get to sleep.

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Alcohol in moderation should be OK while taking an SSRI, although it might make you feel more sleepy. If this happens, you would need to take extra care if you need to drive or operate machinery and you must seek advice on this. Also, the effects of alcohol can be increased if it is taken while you are taking fluvoxamine ("Faverin").

^8.10

 

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You should have no problem with any foods or drinks, other than alcohol (see separate question). Taking an SSRI after food can help reduce the sickness some people get when they start taking an SSRI.

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The SSRIs have some interactions with other medicines:

• Fluoxetine or paroxetine can sometimes increase the effects of some beta-blockers (e.g. propranolol, atenolol), valproate or carbamazepine (possibly), warfarin, tricyclics (e.g. dosulepin, imipramine, lofepramine), clozapine, risperidone, paliperidone or atomoxetine
• The effects of fluoxetine and paroxetine can sometimes be increased by terbinafine
• Citalopram and sertraline have almost no interactions although both should be used carefully with clozapine
• Fluvoxamine can sometimes increase the effect of caffeine, ciclosporin, lansoprazole, theophylline, clozapine, warfarin, agomelatine, melatonin, quetiapine, mirtazapine or methadone.

In people over 80, SSRIs should be taken with care if you are also taking an NSAID (used for arthritis or pain, e.g. ibuprofen, naproxen, diclofenac, ketoprofen, mefenamic acid), as this can cause stomach bleeding in a few people.

All medicines that increase serotonin should only be used together with care as this can cause serotonin syndrome (which causes a 'flu-like set of symptoms) e.g. any combination of SSRIs, trazodone, tramadol, linezolid, venlafaxine, duloxetine, MAOIs (e.g. phenelzine, isocarboxazid, tranylcypromine), moclobemide, St. John’s wort, tryptophan or some triptans (e.g. sumatriptan, zolmitriptan, rizatriptan, almotriptan; used for migraine)

This does not necessarily mean that this will happen in everyone or that some of these medicines can not be used together. It just that you may need to follow your doctor’s instructions very carefully. There are many other possible drug interactions.

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You should have no problems with "The Pill" and the SSRIs. However, if you get diarrhoea ("the runs") or are sick this might reduce the amount of "The Pill" that goes into your body. This would make it less effective.

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It is important to consider that there will be a risk to you and your child from taking a medicine during pregnancy but also a possible risk from stopping the medicine e.g. getting ill again. Unfortunately, no decision is risk-free. It will be for you to decide which is the least risk. All we can do here is to help you understand some of the issues, so you can make an informed decision. For your information, major malformations occur "spontaneously" in about 2-4% of all pregnancies, even if no drugs are taken. The main problem with medicines is termed "teratogenicity" i.e. a medicine causing a malformation in the unborn child. A medicine causing teratogenicity is called a "teratogen". Since a baby has completed it's main development between days 17 and 60 of the pregnancy (the so-called "first trimester") these first 2-16 weeks are the main concern. After that, there may be other problems e.g. some medicines may cause slower growth. The infant may also be affected after birth e.g. withdrawal effects are possible with some drugs.

If possible, the best option is to plan in advance. If you think you could become pregnant, discuss this with your doctor and it may be possible to switch to medicines thought to carry least risk, and take other risk-reducing steps e.g. adjusting doses, taking vitamin supplements etc. If you have just discovered you are pregnant, don't panic, but seek advice from your GP within the next few days if possible. He or she may also want to refer you on to someone with more specialist knowledge of your medicine.

Very few medicines have been shown to be completely safe in pregnancy and so no manufacturer or advisor can ever say any medicine is safe. They will usually advise not to take a medicine during pregnancy, unless the benefit is much greater than the risk. In the UK, there is the NTIS (National Teratology Information Service) who offer individual risk assessments. However, their advice should always be used to help you and your doctor decide what is the risk to you and your baby. There is a risk from taking the medicine and a risk should you stop a medicine e.g. you might become ill again and need to go back on the medication again. The advice offered here is just that i.e. advice, but may give you some idea about the possible risks and what (at the time of writing) is known through the medical press.

It may be helpful to know that in the USA, the FDA (Food and Drug Administration) classifies medicines in pregnancy in five groups:
A = Studies show no risk, so harm to the unborn child appears only a remote possibility
B = Animal and human studies indicate a lack of risk but are not fully conclusive
C = Animal studies indicate a risk but there is no safety data in humans
D = a definite risk exists but the benefit may outweigh the risk in some people
X = the risk outweighs any possible benefit

The SSRIs are classified as "B", "C" or "C" (fluoxetine and sertraline are "B", citalopram and fluvoxamine are "C", paroxetine is "D"). The SSRIs are not thought to be teratogenic in animals, and most human safety data is for fluoxetine. No major abnormalities have been reported to date with paroxetine, but some "discontinuation" effects (such as increased breathing rate and jitteriness) have been seen in a few infants for a couple of days after birth, so it may be wise to reduce the dose a little before your due date. Also, there is some evidence that there may be a slight increase in heart defects in children born to mums who took paroxetine during the first 3 months of pregnancy (first trimester). If you discover you are pregnant while taking paroxetine, it is not recommended that you stop immediately, but rather go to see your doctor as soon as possible. Fluoxetine is the most widely studied SSRI in pregnancy. Information on over 2000 pregnancies indicates that the risk of "spontaneous abortion" may be slightly higher than normal but that the number of abnormalities is the same as the general population and so fluoxetine did not appear to be a major risk. A recent study has shown no evidence of any short or long-term effects on intelligence and language development, although there was a slight reduction in the length of pregnancy (by about 6 days). You should, however, still seek personal advice from your GP, who may then if necessary seek further specialist advice. Sertraline and citalopram seem to have no known problems.
Trazodone is classified as "C". There is no evidence of a teratogenic effect, and animal tests show a low risk of danger but you should seek personal advice from your GP, who may then if necessary seek further specialist advice.

Finally, there is a slight risk (1 in 100 chance) of PPHN (persistent pulmonary hypertension in the newborn) if an SSRI is taken after week 20 of pregnancy. You should talk to your doctor about this.

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You will not need a blood test to check on your SSRI. (1.7.09)

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You may feel a bit drowsy at first when taking any of the SSRIs. Until this wears off, or you know how your SSRI affects you, do not drive or operate machinery. You should be careful as it may affect your reaction times.

Under Section 4 of the Road Traffic Act 1988 anyone driving while unfit to drive, due to illness or any drug, can be prosecuted. Under UK law it does not matter if the drug is a prescribed medicine or an illegal drug. It’s the effect on your driving that is the main thing. If your ability to drive might be reduced due to illness or medicines, under UK law you must let your insurance company know. If you don’t, the insurance might say this is as 'withholding a material fact' (ie not telling them something they ought to know) and might mean that if you have an accident they might not pay up. Your doctor will be able to advise you.

Medical rules for all drivers:
For the full story click here (opens in new window) and go to "Medical standards". Here there is a pdf document (regularly updated) called "At a glance guide to the current medical standards of fitness to drive" that can be downloaded. It is aimed at medical practitioners (GPs).
For the "Customers guide" (ie a guide for the general public) click here (opens in new window) and download the 'Customer service guide for drivers with medical conditions'.

How to tell the UK DVLA:
If you need to tell the DVLA and you already have a license, you need to download the medical questionnaire from the DVLA website. Or you can call the DVLA to ask them to send it to you. You also need to fill out a form to give your consent for doctors from the DVLA doctors to contact your doctor or a specialist. You can either post, fax or email these forms back to:
Drivers Medical Group, DVLA, Swansea, SA99 1TU
Tel: 0870 600 0301
Fax: 0845 850 0095
Email: eftd@dvla.gsi.gov.uk
Web www.direct.gov.uk/motoring (opens in new window)

You should always allow DVLA to contact your doctor, as what your doctor says will help the DVLA decide if you can keep your license. Rarely, the DVLA may ask you to have a (free) medical examination, which will be free. This is called a medical enquiry.

What happens next
If you give the DVLA all the information they need, they can usually sort things out within 15 days. If they need more information from you, your doctor or other sources, they will try to sort it out within 90 days. What they decide will also depend on what you’re doing e.g. driving a bus is different to driving down to the shops. What can happen includes:

• You may be able to keep your license or be issued with a new one.
• If the DVLA’s doctor thinks your fitness to drive needs to be reviewed again, you may be given a license valid for 1, 2 or 3 years.
• Your license may be taken from you (revoked) or your application refused. This will only happen if you do not meet the standards of fitness to drive at the moment. If this happens, you would be told the reasons for the decision. You would also be told when you can apply again.

Driving safely
If you want to carry on driving, you must take sensible steps to reduce any risk:

• Avoid driving when you are tired or ill
• Do not drive after having any alcohol as this can make an drowsiness worse (a third of all fatal road traffic incidents involve alcohol-dependent drivers)
• Avoid driving at night, dusk or in bad weather
• Avoid motorways, dual carriageways and the rush hour
• Give yourself plenty of time. Don’t rush
• Be extra careful if you have not slept well the previous night

As some medicines can affect your driving, be extra careful:

• If starting a new medicine
• After a change in dose (especially an increase)
• If you are on a high dose or seem very sensitive to side effects
• If you are taking any medicines for other symptoms e.g. antihistamines for hay fever or allergies
• If your medicine causes you blurred vision, drowsiness, poor co-ordination, poor attention

If you are driving less than 2000 miles a year, once you consider insurance, tax, MoT, repairs, maintenance and petrol, you may actually find it is cheaper to get taxis and busses, and walk the short journeys.

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