r/Drugs FAQ series: SNRIs and SSRIs

Follow up to my last post. If you have a question about an SSRI or SNRI, post it here! I would love help in answering questions; in fact, I've never taken a true SNRI so I can't really help there. I'm sure many of you have had experiences and would like to chime in. However, if you make a claim, try to back it up with a source rather than using anecdotal evidence (I/my friend/my dog took these and went crazy). Together we can clarify our knowledge about these drugs and minimize misinformation.

• The drugs: many chemicals and brand names worldwide. Common SSRIs are fluoxetine (Prozac), paroxetine (Paxil, Seroxat), fluvoxamine, citalopram/escitalopram (Celexa/Lexapro), and sertraline (Zoloft). Common SNRIs are venlafaxine (Effexor) and duloxetine (Cymbalta). They are all prescription drugs but do not have abuse potential and so are not scheduled.

• History: the first SSRIs were discovered during an intentional search into antihistamine relatives in the 1970s. Prozac was the first commercially available SSRI in the US in 1987 after 10 years of trials. Many have followed since then, each with different half-lives, potency, and secondary binding profile. SNRIs emerged later on, with the recognition that SSRIs did not help a significant number of depressed people.

• Action: all SSRIs share one thing in common: SERT inhibition. SNRIs combine SERT inhibition with NET inhibition. Each compound binds less potently to a few other receptors (except citalopram, the only true selective SSRI). You can compare some of the binding profiles for specific drugs here: http://www.preskorn.com/books/ssri_s3.html

• Uses: originally, major depressive disorder, OCD, and GAD. Today used for a wide array of anxiety, mood, stress, pain, and energy disorders - and even male premature ejaculation!

• Experience: The #1 rule with SSRI/SNRI drugs: YMMV (your mileage may vary). People are sometimes idiosyncratic in their responses to other drugs, but with these drugs it is the rule. They do not affect two people the same way. If you have a seriously bad physical or emotional reaction right off the bat, STOP taking the drug!

Taking any SSRI/SNRI for one or a few days will not generally have any positive effect. The side effects (insomnia, headache, anorgasmia) may be more prominent during the first few weeks and then lessen as the body adjusts. During chronic administration, if things go well, negative emotions become less intense, and the depressed person feels a peace of mind and renewed interest in relationships and work. SSRIs can be very effective in weakening or dissolving obsessions, neurotic habits, and social anxieties. If you have been depressed for a long time or your whole life, it can almost feel like being born again, but this feeling tends to fade fairly quickly.

• More common side effects (SSRIs): reduced sexual interest, difficulty achieving orgasm, jaw clenching, insomnia, dizziness

• More common side effects (SNRIs): the above, with presumably more insomnia and anxiety. Anyone care to add?

• Less common side effect (but very serious): SSRIs can trigger mania in bipolar people and may make your bipolar worse in the long run http://www.psycheducation.org/bipolar/controversy.htm Again, ymmv. If bipolar disorder runs in your family, you might think twice about taking any of these drugs. If you find yourself feeling really good after taking these drugs - like you're on cocaine or ecstasy all day, and you have no social inhibitions, and you're spending tons of money - this is not a good sign!

• Interactions with other drugs. Bluelight has a decent page on this http://wiki.bluelight.ru/index.php/Anti-Depressants_and_Recreational_Drugs

Again, ymmv. Your mileage may really vary, but in general:

• marijuana seems unaffected, or at least, highly idiosyncratic
• alcohol hits a bit harder and is more of a sedative. Hangovers may be substantially worse. A minority of people (including myself) become basically alcohol intolerant
• traditional psychedelics work but may be less intense or require higher dosing
• MDXX drugs don't work well and may, occasionally, contribute to serotonin syndrome
• MAOIs should definitely be avoided. No ayahuasca for you.
• DXM should probably be avoided, especially the recreational/psychedelic dosage levels

• Withdrawal

First, why do I choose the term withdrawal rather than discontinuation? Not because SSRIs are addictive in the same way that opiates are, but because discontinuation was a drug company fiction designed to hide a quite painful reality.

The concept of addiction is so inadequate and inflexible. Most people have no urge to take more than the recommended dose (if you do, you're most likely bipolar). I've never seen a person take obvious joy or pleasure in taking any SSRI. In fact, many people downright dislike them but like the cumulative effect. Binging, taking massive doses, and more intense ROAs are basically unheard of (though search around on Erowid and who knows...).

On the other hand, some people do need to up their dose over time. And here's the real nasty: the withdrawal, especially from higher doses, can be absolutely dreadful. For some, perhaps most people, it's not. But if you're unlucky, you might get very sick and very angry at these drugs even if they had helped you previously.

The good doctor says this all better than I can: http://www.benzo.org.uk/healy.htm

SSRI withdrawal symptoms

• extreme dizziness, dissociation, changes in spatial perspective & balance. http://www.ncbi.nlm.nih.gov/pubmed/20144124
• brain shocks! There's not even medical terminology for it besides the general paraesthesia basically a weird feeling hehe. It feels like being psychically electrocuted from head to foot, or like the world's framerate is glitching. No evidence that they are dangerous, but can be very disoncerting
• migraine-like headaches, or actual migraines if you get them. Do not attempt SSRI withdrawal if your migraines are not under control, because they will get worse and can become quite scary.
• general flu-like feelings: chills, foggy head, fatigue
• wild mood swings, ranging from elation to severe depression. It's important to remember that this is temporary and due to chemical withdrawal. If you actually become depressed again, it will not happen until a few months after you go off SSRIs.

SNRI Withdrawal

• SSRI withdrawal symptoms plus some additional features (help me out here)
• venlafaxine/Effexor withdrawal is widely reputed to be the worst of these drugs to withdraw from. This is probably due to its high potency for both serotonin and NE and its very short half-life. If you can't get off Effexor you might seriously consider asking/demanding to be tapered onto fluoxetine during withdrawal.

I've written enough for this morning. There are many reputed cures and aids for going through withdrawal - feel free to discuss them. It's hugely unfortunately that there has been essentially no published research in this area. My favorites are kratom and fish-oils, but I'm not a doctor, so don't take that as a recommendation. Feel free to PM me if you want. I'm withdrawing from Lexapro and pretty bored anyways.

Sources:

• Crazymeds.us
• Dr. David Healy, Dependance on Antidepressants & Halting SSRIs
• Healy, The Antidepressant Era
• http://www.preskorn.com/books/ssri_s3.html
• bluelight Mega thread and wiki on AD interactions
• pubmed.gov