Antidepressant Insights

Listen in as our expert panel discusses practical considerations for starting and optimizing antidepressants for treating depression and anxiety.  You’ll listen to panelists cover various aspects of antidepressant use, such as serotonin syndrome, QT prolongation, and weight gain concerns.

Special guests:

• Tammie Lee Demler, BS, PharmD, MBA, BCGP, BCPP 
  • Director of Pharmacy and Residency Programs, New York State Office of Mental Health 
  • State University of New York at Buffalo School of Pharmacy and Pharmaceutical Sciences 
• Sarah E. Grady, PharmD, BCPS, BCPP
  • Professor, Drake University College of Pharmacy and Health Sciences
  • Clinical Pharmacist, Inpatient Behavioral Health Unit, Broadlawns Medical Center

You’ll also hear practical advice from TRC’s Editorial Advisory Board member:

• Craig D. Williams, PharmD, FNLA, BCPS
  • Clinical Professor of Pharmacy Practice
  • Oregon Health and Science University

None of the speakers have anything to disclose. 

This podcast is an excerpt from one of TRC’s monthly live CE webinars, the full webinar originally aired in May 2025.

TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter,or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

Claim Credit

The clinical resources related to this podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights.

• Clinical Resources: 
  • Choosing Antidepressants
  • Switching Antidepressants
  • Combining and Augmenting Antidepressants
  • Pharmacotherapy of Anxiety Disorders in Adults

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The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

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Transcript

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Introduction

DISCLAIMER 0:00

This transcript is automatically generated.

Tammie Lee Demler 0:00

The discontinuation process is different for everybody. I think that those paresthesias, that electric shock sensation that you described, Sarah, has gotten kind of a bad rap in that people have been describing that to each other as being addicted to your antidepressant. And that provides a disincentive for many people to start it because they don't want to be addicted to a medication. So to be able to describe that as being just a physiologic response to discontinuing something that affects your neurochemistry. So I think in terms of educating our patients, we need to also provide that information that you're not addicted to your antidepressant, but discontinuation too quickly can cause these physiologic side effects that would

Narrator 0:57

Welcome to Medication Talk, an official podcast of TRC Healthcare, home of pharmacist letter, prescriber insights, and the most trusted clinical resources. Proud to be celebrating 40 years of unbiased evidence and recommendations. On today's episode, listen in as our expert panel discusses practical considerations for starting and optimizing antidepressants for treating depression and anxiety. You'll listen to panelists cover various aspects of antidepressant use, such as serotonin syndrome, QT prolongation, and weight gain concerns. Our guests today are Dr. Tammy Lee Demler from the New York State Office of Mental Health and SUNY at Buffalo School of Pharmacy and Pharmaceutical Sciences. and Dr. Sarah E. Grady from the Drake University College of Pharmacy and Health Sciences. You'll also hear practical advice from TRC's editorial advisory board member, Dr. Craig Williams from the Oregon Health and Science University. This podcast is an excerpt from one of TRC's monthly live CE webinars. Each month, experts and frontline providers discuss and debate challenges in practice, evidence-based practice recommendations, and other topics relevant to our subscribers.

CE Information

CE Narrator 2:07

And now, the CE information.

Narrator 2:11

This podcast offers continuing education credit for pharmacists, pharmacy technicians, physicians, and nurses. Please log into your pharmacist's letter, pharmacy technician's letter, or prescriber insights account and look for the title of this podcast in the list of available CE courses. None of the speakers have anything to disclose. Now, let's join TRC editor, Dr. Sarah Clockers, and start our

Evaluating Antidepressant Options

Sara Klockars 2:38

For today's discussion, we'll spend most of our focus on the use of antidepressants for the treatment of depression or anxiety, where they're one of the initial treatment options, along with talk therapy or cognitive behavioral therapy. And the antidepressant choice will be tailored to the individual patient. And so, Tammy, I was hoping you'd get us started and share some factors you consider in your approach when evaluating antidepressant options.

Tammie Lee Demler 3:06

Sure. I would like to say it's all about shared decision-making first. But I have to go right to FDA approvals because that's where my pharmacist cap comes on. And I look at what medications have FDA approval and rigor in evidence for their use. So it's surprising that not all antidepressants have every indication as every other one for either anxiety or different types of depression. So I go with FDA approvals first and then work with our patients to sort of look at pharmacodynamic characteristics, what the side effects or adverse effects could potentially be And I'll just add quickly that not all adverse effects are bad. Whereas, you know, some of them may cause sedation or sleepiness. Some people may want that for a sleep time improvement for their particular condition. Others may need a more energy boosting medication. So I think tailoring the side effects, and I say that as a term I don't like to use very loosely. I prefer adverse reaction or adverse experience. We look at those as trying to optimize what the person-centered approach then would later be after we kind of cover all those checkboxes. Excellent. Sarah,

Sarah E. Grady 4:18

did you have anything to add? I agree with everything that Tammy said. I just want to make emphasis on the shared decision-making. If a patient really wants to take a certain medication and it has FDA approval and they're comfortable with the side effect profile, then we definitely take a look at that. We also take a look at if they have a family history of a certain antidepressant that worked for their depression or anxiety condition of that family member, then we also consider it in the differential.

Craig Williams 4:53

I'll just add too, sir, a brief in expectations that if, you know, we're talking second generation antidepressants, we do kind of moderate expectations a bit. So if patients don't know what to expect, we tell them don't necessarily expect to feel a lot different tomorrow. So stay with us for a bit on this and we'll talk at your follow-up appointment how you're feeling. So especially if you tried other agents that might have more acute effects.

Sara Klockars 5:15

Which leads me to

Starting an Antidepressant

Sara Klockars 5:17

just sharing a conversation you have with a patient when they're starting on an antidepressant. How do you expand on some of those expectations. Like you mentioned, Craig, you're not going to see benefit overnight. How do you have that discussion, Sarah?

Sarah E. Grady 5:33

Yeah, so really no different from anybody that is starting on a medicine for diabetes or hypertension or COPD. Just having a conversation. Do let people know, as Craig mentioned already, that these medications do not work instantly. They take weeks. Sometimes months. So that's one thing. The other thing is, is that if somebody is using it for depression, a lot of times the physical symptoms of someone's depression will start to improve before the emotional symptoms of depression. The physical symptoms of depression being poor sleep, poor appetite, low energy, those things may start to improve before mood improves, anhedonia decreases, suicidal thoughts reduce. So I think making that differentiation is very important. The other thing I make mention of is depending on which antidepressant it is, I may talk about common side effects and how to work with those. And as far as duration, a lot of times people will ask me, how long do I need to take this? That is really an individualized decision between the patient and their provider. However, if it's the first episode and they're getting relief from the medication, we treat for a minimum of six months to a year. And we may need to treat I would

Tammie Lee Demler 7:04

add that also I like to share with the patients that you're going to maybe feel a little nauseous or you might have some GI symptoms that will go away with continued use. I've had so many patients who've not been told that and they just stop it because they feel so yucky for the first few days.

Sara Klockars 7:19

Excellent points. So I wanted to dig into some of the side effects, interactions, risks with these meds. How would you recommend starting a conversation with a patient at the counter to just help evaluate how they're doing on their antidepressant? Or perhaps a pharmacist doing an MTM review and a patient, you know, says they're on these. How would you advise a pharmacist to talk to the patient about this?

Sarah E. Grady 7:48

Yeah, absolutely. Human to human, heart to heart. I tend not to push people. People aren't ready to talk. They're not ready to talk, but I always let them know that I'm here to assist, to help them. Okay, so just kind of watching if they're in the pharmacy, watching the nonverbals. And if they're not in the pharmacy and you're on the phone with them, sometimes you can kind of tell by the tone of their voice. So again, just slowly, carefully, again, human to human, heart to heart. And let's say someone is willing to talk. You know, you just explain your purpose. You know, my role here is to help answer your questions, help you get the most effectiveness and safety from your medication. And then I usually start by really going over those education points that we discussed. Because like Tammy had mentioned, a lot of times people aren't either informed or we do tell them, But because they have depression or anxiety or both, they are not able to process what we actually told them about the medication. So we may need some repetition. I don't know how many times people have said, okay, I started this Sertraline a week ago and I feel no different. And I said, that's what I would expect. And I'm like, oh, here's some good news because some of the side effects we would have seen by now. So again, repetition about key education points with regards to time course, maybe assessing about side effects that Tammy had mentioned correctly. So that a lot of times people feel worse before they feel better. Because the therapeutic benefits of the medications have not started to kick in yet and the side effects show up. So maybe starting there. How have you been feeling? Usually that's where I start. What have you noticed since you've been taking this medication? A lot of times they'll say nothing if it's been a couple days. Or they'll say, my stomach hurts. And I say, oh, okay, you're on an SSRI. That's to be expected. Are you taking it with food? Are you taking it with milk? So really just starting somewhere. Get them talking. Get them reporting. You can also ask about symptoms. If they have depression, have you seen any changes in your sleep? Have you seen changes in your appetite? in your energy, in your concentration, in your mood, in your focus, in your anxiety levels. And then just reminders and reminders that these meds don't work overnight, but they can work and they improve symptoms. And the other thing, the last thing I'll add, have somebody that's talking and particularly someone that says, I don't think this is working. I've been taking it for three weeks. I haven't noticed anything. You know, depending on how well I know someone, I'll ask them, has anyone close to you comment it to you on how you look or things along those natures. Or sometimes patients will just offer it. They're like, yeah, I've been told that I look better or I seem brighter or something. And so I just remind people that with antidepressants, most of them, the changes that people feel are so slow and subtle that oftentimes people don't even notice it, but other people close to them might. So those are just some things, some places to start. Let's be honest. It's not an easy conversation to have. Sure, it's easy for me because I work on an inpatient behavioral health unit and people are pretty open about starting conversations. And because I've been in this field so long, depression and hypertension look the same to me. No big deal. Both are treatable. But I've been in this business for a long time and not everybody else has. And so there may be some discomfort. And I think that's why we just need to recognize that. Watch the nonverbals. Watch the tone of voice. And let's not push people. Just say, hey, you know, If you'd like to talk at another time when you're feeling a little bit better, here's my name, here's my number. I would like to chat with you.

Sara Klockars 11:42

Very helpful tips. I'd

Serotonin Syndrome

Sara Klockars 11:45

like to move along to another question that we often get and see in practice, and that is, Serotonin syndrome. Can you just briefly describe what it is and your thoughts about when we should worry about this with some of our SSRIs and SNRIs?

Sarah E. Grady 12:06

Yeah, this is a great question. The whole topic of serotonin syndrome has honestly been confusing me for decades. You can look in the literature, and all of us have, as to how common or uncommon it is. It appears to be uncommon, but why is it uncommon? Is it because it's really the symptoms are very nonspecific and they can look like many other things? Times when it's been diagnosed by one physician, the next physician will come in the next day and say it's not serotonin syndrome, it's neuroleptic malignant syndrome. So I'm not really sure how often I have seen it over the course of my career. I have had a few patients tell me that they have been diagnosed with serotonin syndrome. And I asked them what medications they were were prescribed at that time. And it's always multiple serotonergic medications, particularly those that have serotonin reuptake inhibition seem to be some of the more problematic ones. But yes, I couldn't tell you how common it is just because the symptoms, signs and symptoms tend to be very nonspecific. And what do those look like? Again, nonspecific symptoms, GI upset, muscle rigidity, fever, seizures, agitation, restlessness, insomnia, confusion, hypertension, sweating. So really the best way we can map this is to look at when did they start certain medications? When did these symptoms develop? The few cases where we were pretty sure it was serotonin syndrome, All these cases, people were on multiple serotonergic medications, again, including a couple that had serotonin reuptake inhibition specifically. Okay, so multiple serotonergic medications, no surprise there because serotonin syndrome is too much serotonin in the brain, the periphery. Our body doesn't like that. Our body reacts in various ways as, you know, the not fun symptoms that I mentioned. But yes, serotonin syndrome, I won't lie, has been confusing me my whole career. So maybe someday I'll have a clear-cut answer for everybody.

Craig Williams 14:18

It is a confusing topic. For a while, it seemed to be in vogue to be combining second-generation antidepressants and SSRIs with SNRIs and multiple SSRIs. Fortunately, it's kind of fallen out of favor. The efficacy literature didn't support that too well, but... The case reports to severe serotonin syndrome almost always involve multiple agents. So I rarely think about this for starting a patient on a SSRI or an SNRI. But I will add that, you know, spending a lot of time in the hospital setting last 15 years, we get an awful lot of patients in the ED who on multiple agents who just are confused and they're just off enough and we hold everything for three days and suddenly they're magically better. And so curious myself, there's milder serotonin that maybe has been unrecognized for a while, but yes, do be careful combining multiple serotonin acting medications in practice.

Tammie Lee Demler 15:15

To your point, as far as combinations, we have never seen, I don't think, any case of one single agent contributing to any adverse drug reaction that we've seen relative to serotonin syndrome. What we have started to see, though, is with the popularity of augmentation with antipsychotics that have serotonin influence and perhaps a splash of something that they get at the ED, a tramadol prescription, for example, that nobody really thinks about. You know, we've seen subtle malaise, GI upset, that a strategic deprescribing has settled. We just sort of assumed that that might have been a beginning of a precursor to serotonin syndrome, and we just do some strategic deprescribing that would avoid that combination. But it's the stuff that kind of sneaks up on you. And

Craig Williams 16:03

Sarah made a nice point, too, about there often is a temporal association. So the lurch doesn't happen anytime, but it does seem to be more likely closer to a second agent being started. So yeah, I do always look for something new, acipation, but I mean, dexamethorphan is a classic over-the-counter agent, but lithium valproate are on the list, certainly trazodone. So, but yeah, I'm often looking for a temporal association medication number two, if someone's been stable on an SSRI or an SNRI for years in my refill pharmacy system, so.

Sara Klockars 16:38

Thank you.

QT Prolongation

Sara Klockars 16:39

I want to transition over now to cardiovascular risks with antidepressants. Here we get into our EKG changes and a recent abstract about increasing sudden cardiac death and QT prolongation. So how do we balance this, especially for our cardiac patients who need an antidepressant? So are there certain antidepressants that are riskier and ones that are safer that we should be considering in this population. Can you comment on some of these risks, Tammy? I

Tammie Lee Demler 17:17

would love to comment on QTC because we've really struggled with this over the course of the last 10 years. When your question is, are there any riskier medications, I would say that Of course, we're looking at tricyclics off the table because they have their own cardiac issues. The SSRI, citalopram is the only current medication that the FDA has put a cap on specifically for QTC risk in older adults, I believe as people over 60 on a limited lower dose. As a talopram, they are looking at possibly a dose reduction, but the FDA hasn't specifically made a dose suggestion for that that I know of. But as far as QTC risks, there are a lot of medications that are on the list. If people listening are wondering where our list could be We look to Credible Meds. I don't know if you all go into CredibleMeds.org. That's a free platform that is... robustly kept up to date. And there's a tool inside of that that does a score for you. So if you wanted to do, for example, a burden of all the meds a person's on, you can put them into this platform and it'll give you a score. And I'll just quickly say that we had this hypothetical paper score of risk strategy that we didn't know if it was really philosophical or really a legit score. You could do some clinical recommendations using. And we did actually a study looking at QTC and EKG. And the QTC score we calculated was very statistically significantly correlated to this EKG score that was done. So the QT prolongation factor was very much in line with the score you were able to calculate. So I would encourage people to consider that. I

Craig Williams 19:06

agree, Tammy. Credible Meds is the place to go. It is a great And you can sort drugs by class and by risk. So citalopram and escitalopram are the I think the two to be kind of aware of among these drugs. But otherwise, the FDA is not saying don't use any if the FDA didn't like the drug enough, they take it off the market. And it's just kind of a time for us to pause and say, okay. Do I really feel the benefits of this drug outweigh the risk? And this is one of the small risks. But for an otherwise healthy, let's say 25, 30-year-old, the risk is under 1 in 100,000 if we try to put a number to the risk of an actual cardiac event. So we have it in the back of our mind. On the inpatient side, we think about it a bit more because electroid abnormalities can be playing to the risk in severe dehydration and illness. But on the outpatient side, it is a difficult thing, I think, to operationalize. But I often find myself reassuring providers that if you feel like And SSRI and SRI is the right drug to use here. I would not be dissuaded by the EMR telling you there's this tiny risk because when you quantify it, it really is quite small.

Sara Klockars 20:06

Thank you.

Hyponatremia / Low Sodium

Sara Klockars 20:10

Question about hyponatremia or the low sodium levels with antidepressants. When should we check a sodium for patients on SSRIs?

Sarah E. Grady 20:22

Yes, so I think we should be checking sodium regularly. in our patients that are older adults. Older adults, I think, is the best time to check that. And this can be an issue with not just SSRIs, but numerous other antidepressants as well. I feel like psychiatrists ask me which antidepressant is least likely to lower the sodium level. And again, think about the question I'm being asked, least likely. And usually I recommend bupropion, but not everybody is a candidate for bupropion for a number of different reasons. But yes, mainly older adults is probably when we want to check sodium levels.

Sara Klockars 21:06

Thank you. Tammy, I have a question for you.

Seizure Risk / Bupropion

Sara Klockars 21:09

Are eating disorders really a contraindication due to bupropion use or can they sometimes be used?

Tammie Lee Demler 21:18

So the real concern about eating disorders and bupropion would be the seizure lowering threshold, that issue of just that pharmacodynamic phenomenon that can happen. And I always go with contraindication. There's very few reasons to push through a contraindication when there are other medications like fluoxetine, which is really ideal for people who have eating disorders for a number of reasons. But I'll just add, since we're talking about it, it doesn't have as much of an appetite stimulant to it. So people who have anorexia, for example, are more willing to take it because it's less likely to cause them to gain weight. So I would really adhere to that. We don't want somebody being in a situation where they would have a risk of seizure. Can you do bupropion with a mood-stabilizing anti-epileptic drug? Yes, I've seen it, but I prefer just to stay away from it. I don't push through chondroindication. We explore other options.

Sara Klockars 22:10

Great point and a good

Weight Gain

Sara Klockars 22:12

transition. We had some questions about some side effects. And how do you help patients reporting weight gain on antidepressants?

Tammie Lee Demler 22:22

I think when it comes to weight gain, I like to ask people questions. What was their baseline weight before they had the episode of whatever it is that they're experiencing? Did they gain weight because they were depressed? Some people lose weight. So it's not always a weight gain phenomenon. Some people do lose weight when they have depression. So depending on that circumstance is where I kind of go with my recommendations as well. I'll just say a pitch for mirtazapine for older adults who are losing weight. They're finding that they can't keep weight on. They either have a chronic illness like cancer that It's just preventing them from gaining weight. Mirtazapine has been really a godsend for us in that regard. So I look at this in a little different way in some cases. It's not looking at preventing weight gain. I'm sometimes looking for something that can cause sedation and weight gain. But for other people who are afraid of weight gain, they should really be looking at perhaps what they're eating, what their intake is. Are they able to exercise? Because exercise makes us all feel better, even in the smallest little bit. Nobody likes the E word, but really when we think about it, it does make us feel better. So I don't know if my colleagues have anything else. I'll just add two confounding effects of pain, for example. Some people have pain and depression and they're unable to move as they would like to. So knowing what the contributing confounders are is also important.

Sarah E. Grady 23:44

Yeah, I want to echo Tammy's sentiments about mirtazapine. Individuals that can't sleep, can't eat, has been really helpful. And then also on my unit, we don't use the E word, exercise. We just call it moving. Are you able to move? Can we move? Moving seems to go over better than exercise.

Craig Williams 24:07

I'll just add, I mean, like the bookends here, I think for everyone to recognize mirtazapine and proxine at one end and bupropion at the other end, I think is a very useful, practical take home for listeners.

Sara Klockars 24:20

Excellent.

Optimizing Treatment

Sara Klockars 24:22

Let's move along and discuss optimizing treatment and answer a few more subscriber questions. Sarah, so how long do you treat with a specific agent before you consider a treatment failure and change agents? And then when do you consider switching a med versus combining meds?

Sarah E. Grady 24:41

Yeah, excellent question from the subscriber. So a couple of things that we as pharmacists want to investigate before there's any talk of transitioning medications or adding medications on, a couple of very important questions. Number one, is the patient able to take the medication every day as prescribed? That's question number one. Are we taking it? Number two, is our dose high enough? So say, for instance, if somebody is prescribed venlafaxine and they're three weeks into it and they're still on 37.5 or 75 milligrams, that's not a target dose for most people. So are they taking it? Is the dose high enough? Is the duration long enough? Looking at duration, if you look at the trials, most of those were six to eight weeks long. And that was someone taking the medication every day. The dose is high enough. Okay, the duration needs to be long enough. And the other thing that we need to think about and we can use this as a counseling point, but we have to do it so that we're not coming off judgmental, is that gentle reminder that alcohol is a depressant. Okay, so if people are drinking a lot of alcohol, of using street drugs, these things interfere with the effectiveness of the antidepressants. So looking at all those scenarios is really important. But let's say your patient, they're taking the med, they're on a decent dose of the med, they've been on it six to eight weeks. Then we look at if it's not working at all, if they're not even getting a partial response, then we probably look at switching meds. If they are getting a partial response, then we can look at maybe augmentation. The guidelines aren't really clear as to what to do. The guidelines tell you you can do one of three things. You can increase the dose, make sure they're maxed out on the dose. You can switch or you can combine. It's not really clear which way to go. So involving the patient, do they feel comfortable adding another medication on board? Some people do, some people don't. Every time we add another medication on board we run the risk of drug interactions and additional side effects etc so every outcome every possibility has risks and benefits

Craig Williams 26:56

I'll just add, sir, briefly that it's the FDA's classic news, eight to 12 week studies to make determinants of this drug is effective or not compared to a placebo. So I think as a single number, eight weeks is what I tend to use and teach our learners. If the patient's really convinced nothing has changed and we're convinced they're taking it, that eight weeks is a sufficient duration. And then, yeah, I'll share that we're really not big fans of combining antidepressants. So especially if it's of a first failure, it's virtually always going to be a switch of an agent after a first try for us.

Tammie Lee Demler 27:28

I would just add, too, that patients are very... I would say susceptible, sensitive, and rightly so, direct-to-consumer advertising is very effective. And so if they're seeing something like an augmentation antipsychotic of whatever the genre it is, I don't want to bring one out for specific purposes, but adding an antipsychotic augmentation, perhaps after trying something else like a switch instead, can put a person at metabolic risk, adds the complications of drug interactions that may be unnecessary. So I think encouraging a patient to try Exclusive monotherapy first that's really effective might just be a better way to go than adding stuff on and increasing the burden of medications. Even though that's an option, I hesitate to add something if I can do good monotherapy, if that's an option. That's a

Sara Klockars 28:18

great point.

Sarah E. Grady 28:20

One thing I just want to add before I forget about it is some of the guidelines talk about augmenting with psychotherapy. So if the patient, say, is getting a partial response with their antidepressant and they want to go up on the dose for whatever reason, they don't want to switch, they don't want to add anything, if they are not already in psychotherapy, if they are able to add in psychotherapy as an augmentation strategy.

Craig Williams 28:48

Yeah, I'll say I don't have a particular app to recommend, but we're getting more and more patients saying they're using various online things that the friends have used, some referred. And yeah, it seems to Sarah's point, talk therapy can be very effective. There's lots of ways to get it these days. So again, I don't have one I can recommend and not want to refer patients to, but that's historically, we should not be just relying on pharmacotherapy here, obviously, especially if someone's saying I've given this drug an eight week try, I really don't feel any different. This is not working for me. So.

Sara Klockars 29:19

Good point. Other non-drug measures. We mentioned moving. We have talk therapy, different apps. Are there any other things that you guys encourage or recommend for your patients on antidepressants?

Craig Williams 29:33

I'll just say outside of a closed psychiatric ward, I do still call it exercise and recommend exercise for ambulatory patients. I know it does mean different things to different folks. And we often do have to kind of back up and say, this does not mean you're going out for a 5K run tomorrow. It means you're walking around the block or just getting outside even. Coming up with exercise and other euphemistic ways to refer to as exercise, moving is a great way to start. But yeah, little bits go a long ways there.

Tammie Lee Demler 30:02

I would also advocate, you know, somebody looking at their diet, if they're not specifically diet centered or able to really look at the nutrition they're consuming, having an essential protein intake to help with those amino acids and the neurochemicals. A high carb diet that really brings you no value calorically and just adds on the pounds can be counterintuitive. So we like to have nutrition consults just to take a look at what they're eating, because it may just be empty calories that aren't being considered and not really helping drive the production of those neurochemicals.

Sara Klockars 30:36

Thank you. And then

Duration of Treatment

Sara Klockars 30:38

just wanted to speak briefly about the recommended length of treatment. How long are patients on antidepressants for anxiety and depression? If someone does want to stop, what's the best way to stop? Sarah, would you mind tackling some of that? Sure.

Sarah E. Grady 30:58

Sure. Absolutely. Yes. This is a common question that I get from my patients and I'm sure many people in the community, a common question that they have as well. And I think it's justified. I think it's important to inform people, just remind them that this is a very individualized decision that typically after the first episode of depression or anxiety occurs, If people have a good response with a particular antidepressant, it is recommended that they stay on the medication for a minimum of six to 12 months. Once you get out to about a year, then you can have a conversation with your provider. I encourage people not to come off of antidepressants without provider instruction and direction. If people just stop antidepressants, they can have antidepressant discontinuation syndrome. Anti-discontinuation syndrome can be very bothersome. People can have a very bad mood or irritability, anxiety, insomnia, GI upset, shakes, tremors. They can have what people have described to me as electrical shocks, brain zaps. So once somebody has been taking an antidepressant for a while, one of the reasons why we want them to be under the provider's care is that we need to taper them off of the antidepressants. We don't just want a cold turkey off of six months or a year. It's a very strategic step-down process while symptoms are being monitored. Full disclaimer, I've not really read this in the literature. It's just something I've heard many of the psychiatrists I work with tell patients is that when someone is in the middle of a stressful life event, whether it's good stress or bad stress, that's not a good time to start calming down off of antidepressants. I had a research student work with me, had been feeling okay with her antidepressant. She was at about the year mark and she's like, yeah, I think I want to start coming off my antidepressant. And I said, you know, it's middle of the semester of a very stressful graduate school program. Now that there's ever a time in life where we are a hundred percent stress-free, but there's definitely times in our life where there might be You know, we're not in graduate school. We're not getting married. We're not getting divorced. We're not having kids. You know, just looking at those major life events that can be stressful, both in a good way, potentially in a bad way too. Maybe that's not the best time to start implementing a tapering process. So lots of factors go into it too. Strong family history. We might want to stay on antidepressants longer than the six months to a year mark too. So everyone's going to have a different prescriptive treatment plan, which makes sense.

Tammie Lee Demler 33:46

I agree with Sarah. And the one thing I would add to that is, you know, the discontinuation process is different for everybody. You know, some people need a slower, more gradual discontinuation. Other people are a little bit more apt to accept a maybe more traditional taper, but it really is dependent on the person. There's not anything that says it has to be done a certain way. I think that those paresthesias, that electric shock sensation that you described, Sarah, has gotten kind of a bad rap in that people have been describing that to each other as being addicted to your antidepressant. and that provides a disincentive for many people to start it because they don't want to be addicted to a medication. So to be able to describe that as being just a physiologic response to discontinuing something that affects your neurochemistry, very similar to abruptly stopping perhaps a blood pressure medicine when your body will rebound and have that be kind of an opposite reaction. So I think in terms of educating our patients, we need to also provide that information that you're not addicted to your antidepressant, but discontinuation too quickly can cause these physiologic side effects that would be absolutely expected.

Sara Klockars 34:59

Thank you for addressing that.

PRN Antidepressants

Sara Klockars 35:03

And I have one other subscriber question that came in a couple of times. One comment was, I often see SSRIs and SNRIs prescribed to PRN for anxiety. Does this provide any benefit or is it risky? And then another question was, can you use antidepressants, PRN, for any indication? So curious if, Tammy, if you want to comment on that.

Tammie Lee Demler 35:27

My initial thought when you asked the question was that PRN antidepressants are not the traditionally prescribed antidepressant for depression or anxiety. Those need to be scheduled and taken on a regular basis. Optimal dose, optimal duration, traditional way. But with the use of some of the medications for premenstrual dysphoric disorder, PMDD, the intermittent dosing is recommended for those particular conditions. Now you can take them continuously for people who have that indication, or you can choose to do it during these luteal phases or a specifically prescribed intermittency. So even that is an individualized approach to treatment. So with the agreement of the prescriber and the patient-centered treatment, a regimen is discovered and derived and then prescribed.

Sarah E. Grady 36:15

Yes, Tammy, I agree with everything that you said. To my knowledge, There's not good evidence-based literature on using antidepressants as needed. Again, there's decent evidence with the luteal phase dosing with PMDD, which we do a little bit here. I would say more of what we see here is that we usually have the women on the SSRI the whole month, say if it's sertraline, They may be at 100 milligrams or 150 milligrams. And then the week before their menstrual cycle, we may increase the dose. We have done that. But yes, antidepressants as needed. Based on what I know and what I've seen, I don't recommend that at this time until we've got better literature supporting that practice.

Conclusion

Narrator 37:10

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