Less Sad, Less Hard

SSRIs can help, but if sex gets harder or you feel flat, bring it up. And work out stopping before you decide you’re done.

SSRIs can help depression and several anxiety disorders. The goal isn’t to turn you into the guy who’s thrilled about everything. It’s to get enough of your day back that getting out of bed doesn’t require negotiations with the ceiling. That’s a useful change.^[1]

These can actually help

A 2018 review put together 522 trials involving 116,477 adults with major depression. All 21 antidepressants studied beat placebo for treatment response, including the SSRIs in that review. There are real reasons to use these medicines. That still doesn’t promise the first one you try will be the one that helps.^[2]

Those weren’t 522 SSRI trials. Other drug classes were included, the search stopped in January 2016 and the studies were about acute treatment. Certainty ranged from moderate to very low. After all that research, we still can’t use it to tell you which drug will work for you over the next several years.^[2]

The diagnosis still matters

Sertraline is sold as Zoloft, and escitalopram as Lexapro. Sertraline has approvals for depression, OCD, panic disorder, PTSD and social anxiety, among other uses. Escitalopram has approvals for depression and generalized anxiety. Check which drug is actually approved for your problem and age. Saying ‘it’s an SSRI‘ doesn’t answer that.^[3][4]

SSRIs slow serotonin reuptake between nerve cells. That doesn’t establish that your depression happened because you were missing one chemical. Even the escitalopram label describes its antidepressant mechanism as presumed to be linked to that serotonin activity. It can help even though that simple serotonin explanation doesn’t tell us everything.^[4]

Every rough stretch doesn’t automatically need a prescription. NICE’s adult depression guideline says not to routinely make antidepressants the first treatment for less severe depression, unless that’s the person’s informed preference. Therapy and other suitable treatments belong in the conversation. You should have a choice based on what’s actually going on.^[5]

Feeling better includes your sex life

Lower desire, trouble getting hard and delayed or absent ejaculation can happen. Depression can interfere with sex too, so get specific about what changed and when. If your mood’s improved but your dick has quit, tell your doctor. A better depression score doesn’t make that less worth bringing up.^[3]

Feeling emotionally flat needs attention too. A survey of 669 people taking antidepressants found reports of blunting, but those reports also went along with depression severity. It couldn’t cleanly separate a drug effect from remaining depression or reliably rank the drugs. ‘I don’t care about anything’ deserves more than somebody deciding the cause before you’ve finished the sentence.^[6]

Don’t disappear until the next refill

Benefit usually takes weeks. Stomach upset, headaches and sexual problems can show up while you’re waiting. That doesn’t mean you’ve agreed to tolerate every lousy change until the calendar gives you permission to mention it.^[1]

Don’t wait until you need a refill to mention what’s happening. Set the first check in early. NICE usually says within two weeks, or one week if you’re aged 18 to 25 or there are particular suicide concerns. Talk about what the medicine is helping and what it’s making worse. Some unwanted effects persist, so taking every tablet doesn’t tell us the plan’s working.^[5]

Tell your doctor about mornings, work, sleep, answering messages and doing things you used to enjoy. Say what got worse too. You don’t need to act happy for fifteen minutes to prove you’re cooperating. Give them the information they’ll need to make a useful decision.

Some changes need help now

Antidepressants carry a warning about increased suicidal thoughts and behavior through age 24. Monitoring still matters at every age. New suicidal thoughts or dangerous behavior need urgent help. Fever, confusion and stiff or twitching muscles can mean serotonin syndrome and need emergency care. Don’t file that under ‘probably just adjusting.’^[1]

Tell your doctor about past mania, seizures, heart or eye problems, low sodium, pregnancy and other medicines. SSRIs can trigger mania, increase bleeding and cause dangerously low sodium. Aspirin, anti inflammatory pain medicines, blood thinners and other serotonin acting drugs need an interaction check. Discuss alcohol and impaired driving too. Leaving something off the list doesn’t make the interaction go away.^[3][4]

Stopping needs a plan too

Withdrawal can mean dizziness, electric shock sensations, anxiety and changes in sleep. It can be severe or last weeks or months, although not everybody gets it. Plan stopping with your doctor rather than quitting abruptly. Returning depression needs attention too; one bad week doesn’t tell you which of those is happening.^[5]

Keep track of the changes you wanted and the ones you didn’t. If you’re less depressed but can’t enjoy what you’ve got back, say that at the next review. Don’t leave it out to make the prescription look successful.

Sources

1. NIMH: Mental Health Medications. Selected antidepressant and treatment planning sections. General education, not a complete prescribing guide.
2. Cipriani and colleagues, 2018: antidepressants for acute major depression. Complete abstract and listed funding on the authors’ institutional archive. Not the full review or all 522 trial papers.
3. Viatris: Zoloft prescribing information and Medication Guide. Selected indications, warnings and counseling. Displayed revision August 2023, not a latest FDA review.
4. Lexapro prescribing information. Selected indications, mechanism and safety context. Displayed update October 2023, not the whole label or all SSRI labels.
5. NICE NG222: Depression in adults. Selected treatment choice, monitoring and withdrawal recommendations. Not the whole guideline or evidence reviews.
6. Goodwin and colleagues, 2017: emotional blunting survey. Complete PubMed abstract, not the full paper or proof of drug causation.