When do you start SSRIs?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

vanfanal

Full Member
10+ Year Member
Joined
Jun 26, 2012
Messages
223
Reaction score
160
I know it’s a weird question, but let me explain. I trained in a dynamically oriented programme and I remain dynamically inclined. I feel like I conceptualise depression differently from most colleagues. But out of training now, the pressures and demands of daily practice are different. I see low mood and anxiety every day, but rarely what I would conceptualise as “pathological”.

Generally the evidence shows that for mild or moderate depression, lifestyle change and various forms of cognitive and behavioural therapy are preferred and first line, and medications have an equivocal role. Only for sever depression or significant neurovevegetative symptoms do medications seem to have a significant effect. I really like the way it’s put in the latest NICE guidelines.

When I see patients I look for changes in function and impairment, *new* onset changes in sleep, appetite and energy, and lack of mood reactivity. But most just have low mood that goes up and down with normal life or chronically dysthymic (depressive personality). Still, most of my colleagues will start and SSRI if the patient wants, and what gets me, is that some indeed do feel better. Now this can be placebo, and I think it’s one of those things where the med works until the next stress hits and then it “stopped working”. And then of course one can end up in a trap of trying endless med combos for something that may never improve with medications.

My practice is to say, look, I think meds are less likely to give you the effects you’re looking for, try psychotherapy first, but of course most aren’t committed or don’t have access.

So just surveying the group, what’s your threshold to start meds for depression rather than just low mood?

Apologies if this comes across as a niive questions. But I find it hard to reconcile if I’m being more nuanced, psychodynamically and philosophically.

Appreciate input.

Members don't see this ad.
 
Last edited:
  • Like
Reactions: 3 users
I factor in whether they're actually going to be able to get to therapy. With waitlists the way they are, this is in no way a given. If therapy is preferred but meds are what I can offer, then so be it, at least for things where the med can be said to be indicated and is fairly low risk.

If a patient has done well for a while and comes in newly down with major life stuff going on, unless they've become functionally impaired, I try and discourage med changes and see how thing are once the acute event blows over. Hoping to avoid the idea that meds fix the normal ups and downs of life.

I also will talk to my pts about the limits of meds if they are frequent users of alcohol and/or marijuana. If I think the most important thing for them to do is cut down on those substances I will also minimize med changes until they do. Essentially getting rid of those things *is* a med trial, and if it's the thing I think is most likely to help them, I'm not going to keep making med changes I don't think matter. They can keep coming back to me for appts and brief therapy in the visits if they want to, and they often do. More often then they want to stop drinking, but, oh well.

These are just my brief and rambly thoughts. I do think adding and increasing meds just to feel like doing something is a plague of modern medicine. Seeing and talking to the patient is doing something. Every visit doesn't require a med change.
 
  • Like
Reactions: 4 users
I do start SSRI`s irrespective of whether patient has neurovegetative symptoms or not. My threshold is the functional impairment due to dysphoric mood. I am very well aware that most of these patients do not have major depressive disorder. However, at this point in time, we do not have better and safer medications than SSRi`s. If it works, great! I would say it works great for %25-30 of patients based on my experience in the community. The benefit for the rest of the patients is debatable.

For cognitive behavioral therapy and lifestyle changes to work, patient needs to be ''willing'' to put in the effort. This is the first and the most difficult obstacle to tackle. Also there is no guarantee that just putting in the effort will be enough.
 
  • Like
Reactions: 2 users
Members don't see this ad :)
My general rule is severe depression, you get medicated. Moderate depression (obvious functional impairment), I recommend meds but will work with alternative options if the patient doesn't want meds. Mild depression, we talk about multiple options and I start a med if the patient wants to. Adjustment disorder, I'll sometimes prescribe depending on the patient, but typically inform them the med is unnecessary or will likely provide minimal benefit.

I always recommend therapy and discuss adjunct options if patients want or I feel the effect would be significant (diet, exercise, other lifestyle mods, etc). I don't like to medicate feelings and agree that we often pull the trigger to medicate too easily. I'd also say that I don't really care if the benefit is placebo or not, the long-term side effect profile is good enough that I'll take those benefits for depression over risk of side effects.

I'd also clarify that I strongly disagree with the concept that once an adjustment disorder meets criteria for a MDE that it should be diagnosed as MDD and that our most basic levels of diagnosing depression are grossly oversimplified.
 
  • Like
Reactions: 4 users
After 2 years of analysis? lol

On a serious note, what's the issue with doing both therapy and medication? Most research seems to support the superiority of both vs one alone.

My approach is generally very patient-driven; even if they have rather mild adjustment dx sx, if they are convinced that medication will be helpful; I am very willing to rx it. It is very likely to help, even if due to placebo effect. On the other hand, even is someone is severely depressed but keeps having side effects/not wanting to take meds, I am not going to keep pushing the issue. You can approach this dynamically and there is literature on dynamic prescribing..

Personally, I believe that if someone's depression is largely biologically based (e.g. someone has a seemingly great life but is severely depressed), then I truly believe they are likely to see benefit from medication.

Also, I am assuming by SSRIs you also would consider SNRIs or Wellbutrin
 
  • Like
Reactions: 1 user
After 2 years of analysis? lol

On a serious note, what's the issue with doing both therapy and medication? Most research seems to support the superiority of both vs one alone.

My approach is generally very patient-driven; even if they have rather mild adjustment dx sx, if they are convinced that medication will be helpful; I am very willing to rx it. It is very likely to help, even if due to placebo effect. On the other hand, even is someone is severely depressed but keeps having side effects/not wanting to take meds, I am not going to keep pushing the issue. You can approach this dynamically and there is literature on dynamic prescribing..

Personally, I believe that if someone's depression is largely biologically based (e.g. someone has a seemingly great life but is severely depressed), then I truly believe they are likely to see benefit from medication.

Also, I am assuming by SSRIs you also would consider SNRIs or Wellbutrin

Yes, in my mind I've lumped them all into SSRIs.
Haha, I love it. Meds only if treatment resistant analysis. jks.
Hands down if I see it as biologically driven, I'll recommend meds and even ECT (which I do and have access to).
It's the cases where "I'm struggling financially, my landlord isn't fixing my broken place, I have no motivation to do anything but I still go to work because I have to, no SI but sometimes I think what's is the point, I've never really slept well"...

I guess it's time to reconsider some of my notions around meds. First year is always lots of unlearning what you learned in training. haha.
 
  • Like
Reactions: 1 user
I do think adding and increasing meds just to feel like doing something is a plague of modern medicine. Seeing and talking to the patient is doing something. Every visit doesn't require a med change.

^nicely put. Very much agree with everything you said. Nice to have some interaction with like-minded peers.
 
  • Like
Reactions: 1 user
I know it’s a weird question, but let me explain. I trained in a dynamically oriented programme and I remain dynamically inclined. I feel like I conceptualise depression differently from most colleagues. But out of training now, the pressures and demands of daily practice are different. I see low mood and anxiety every day, but rarely what I would conceptualise as “pathological”.

Generally the evidence shows that for mild or moderate depression, lifestyle change and various forms of cognitive and behavioural therapy are preferred and first line, and medications have an equivocal role. Only for sever depression or significant neurovevegetative symptoms do medications seem to have a significant effect. I really like the way it’s put in the latest NICE guidelines.

When I see patients I look for changes in function and impairment, *new* onset changes in sleep, appetite and energy, and lack of mood reactivity. But most just have low mood that goes up and down with normal life or chronically dysthymic (depressive personality). Still, most of my colleagues will start and SSRI if the patient wants, and what gets me, is that some indeed do feel better. Now this can be placebo, and I think it’s one of those things where the med works until the next stress hits and then it “stopped working”. And then of course one can end up in a trap of trying endless med combos for something that may never improve with medications.

My practice is to say, look, I think meds are less likely to give you the effects you’re looking for, try psychotherapy first, but of course most aren’t committed or don’t have access.

So just surveying the group, what’s your threshold to start meds for depression rather than just low mood?

Apologies if this comes across as a niive questions. But I find it hard to reconcile if I’m being more nuanced, psychodynamically and philosophically.

Appreciate input.
I am similarly inclined to you in my natural way of thinking about and wanting to help patients dynamically. What I have had to accept, which has been difficult for me, is the limitations of the system that we are in and of the situations that patients are living in.

Of course psychotherapy for the vast majority of depression, anxiety, and trauma patients would be ideally incorporated and regularly received. This is far from realistic though. It has been a painful disillusionment for me.

I am rather direct with my patients about what I recommend, and this doesn’t change, regardless of the reality of the system and the patient’s circumstances. If they are adequately maintaining function but struggling to do so, and/or they are experiencing distress or impaired quality of life in any way that can be attributed to psychiatric symptoms, I don’t have difficulty offering the patient medication to address the symptoms as indicated. While I often offer medication, for these cases that are rather higher functioning and not severely distressed and suffering, I inform the patient of what is potentially realistic to expect. I am frankly direct about the psychosocial issues (e.g., problems with relationships, occupation, finances, housing stability, related to ACEs, etc.), substance abuse problems, medical problems, cognitive/behavioral problems, and even the characterologically driven maladaptive patterns of behavior that would NOT be changed by medication and that contribute to the patient’s current dissatisfaction or whatever brought them to the psychiatric encounter.

When it comes to something like your run-of-the-mill anti-depressants, basically the SSRIs/SNRIs, I am extremely comfortable offering patients trials on these, one, two, or three trials maximum if the patient reports continued symptoms in the way that they originally presented, depending on the patient, before returning to the original conversation I had with them about realistic expectations and the importance of psychotherapy. This is entirely assuming that the diagnosis has been correctly made and that they aren’t the patient with Bipolar 2 Disorder, for example, who most of the time goes misdiagnosed or undiagnosed in today’s psychiatric practice. I would refuse to go on a wild goose chase across the psychopharmacological spectrum, trialing medication after medication. I would refuse to augment treatment beyond the addition of something common, as long as it was indicated, like Wellbutrin, Trazodone, Buspirone. I wouldn’t even trial any of the more recent generation of anti-depressants, like the serotonin modulators. I would respectfully and compassionately return to the root of the problem being something requiring a non-pharmacological intervention, reiterating it for as long as the patient kept coming back to me, and providing them referrals and guidance regarding how to try and achieve the necessary intervention (e.g., finding a therapist, going to ___ anonymous meetings, etc.).

The anti-depressants most commonly used nowadays are remarkably safe for the vast vast majority of people, and it would be unlikely to have anyone that had a frank contraindication. The risk is very small with these aforementioned agents, and the benefit could be much bigger than I anticipate in a particular case—though usually I am reasonably accurate about what is realistically possible but have been pleasantly surprised a few times and have learned the importance of not being stubborn or overly conservative about prescribing these to patients that have put in the effort to seek care and be present with me for the assessment.

Prescribing of these low-risk anti-depressant medications doesn’t need to follow a strict black and white protocol, and as long as there are symptoms present that are reasonable indications for the medication and you have had the nuanced conversation with the patient about what you recommend in order of their importance for the patient’s treatment and why, and they express understanding and still wishing to trial medication for what they perceive to be problematic in their lives, then there is nothing wrong with good faith trials of lower-risk medications.
 
  • Like
Reactions: 1 users
Threshold is some level of impairment in daily functioning.
 
If naive to treatments, or new onset episode not on meds I have 2 thresholds
1. do they want treatment
2. if so, what is actually feasible

If therapy is not feasible, then meds are fine with me so long as they actually have depression. If therapy is feasible, I usually recommend both since mild depression cases are not seen by me in my current settings.
 
  • Like
Reactions: 1 users
If you'll let me do a thorough assessment, discuss the expected low benefits and low risks, discuss the many other things I expect you to do to take care of yourself including psychotherapy, and there's no contraindications,

Then if you want an SSRI I will give you one.
 
Heck I'll give you 3 (sequentially) ! STAR D says we'll have to do that to get past 50% remission anyways.
 
  • Haha
Reactions: 1 user
Fascinating question, interesting to see the range of opinions here.

There is literature suggesting that trait neuroticism actually responds more to SSRIs than core depressive sx do. So I think an emphasis on whether or not someone should be diagnosed with MDD or not is necessarily the most helpful lens.

My schtick is: "Look, these medications can definitely be helpful, but they work because they change how you react to and perceive the world. This makes it easier for you to make different choices and interact differently with others, which will change how the world interacts with you. But, if you don't make any changes to what you choose to do or how you live your life, they are probably going to do absolutely nothing. They facilitate you getting better. They will not make you better by themselves."

It's the cases where "I'm struggling financially, my landlord isn't fixing my broken place, I have no motivation to do anything but I still go to work because I have to, no SI but sometimes I think what's is the point, I've never really slept well"...

The question I ask in these situations is always something like "so, how happy do you think you ought to be in this situation?" The answer always gives useful grist for the mill, almost irrespective of the particulars.
 
  • Like
Reactions: 11 users
The question I ask in these situations is always something like "so, how happy do you think you ought to be in this situation?" The answer always gives useful grist for the mill, almost irrespective of the particulars.
I love this perspective building. Immeasurably helpful to get stuff like this. Going to steal
 
  • Like
Reactions: 1 users
If you don’t prescribe the SSRI for the patient who is struggling, they‘ll see the NP down the street who will prescribe stimulants for just about any impairment in functioning. Just a little frustrated because I have a couple right now who have been led down that road and had a session yesterday with one who was speeding hard, almost manic in their rate of speech and tangentiality, and thinks they need an increase in the dose. Sadly, they are “improving“ their functioning, but in the long run…. I for one would much rather have placebo effect at play while I help them learn how to improve their functioning through developing healthy strategies. Heck, maximizing placebo effects is half of what I do anyway.
 
  • Like
Reactions: 8 users
Heck, maximizing placebo effects is half of what I do anyway.

This is what I tell people anyway. The placebo effect IS AN EFFECT. It's just probably not FROM the medicine but rather may be associated with taking a medicine at all. So if my intervention is helpful and doesn't seem to be harmful, is there too much of a point of getting hung up on whether something is a "placebo effect" or not?

I also emphasize to people that just because we start an SSRI doesn't mean that they need to be on one forever and we should re-evaluate down the line if we feel it's still helpful or not or we could consider discontinuing it. A lot of patient just end up discontinuing it themselves anyway at some point....
 
  • Like
Reactions: 7 users
Top