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SSRIs are widely prescribed for anxiety and depression and are reported to be beneficial. However research is inconsistent and the true extent of the risk of harm associated with these medications may not as yet be fully known and acknowledged.

We all experience stress and some symptoms of anxiety during our lives and this is perfectly normal; even adaptable. Anxiety is an emotion and so can be experienced in varying degrees of intensity by different people. At one end of the spectrum it is normal and helps us to function; at another it can be extremely maladaptive and result in considerable distress for the sufferer.

It is duration, intensity, and frequency that separate normal, functional anxiety from abnormal, pathological anxiety. Abnormal anxiety is where it has become disproportionate to the scenario that led to the feelings of anxiety; it is regarded as pathological anxiety or an anxiety disorder when the intensity, duration, and/or frequency of anxiety are such that it has a significant impact on a person's daily functioning.

Anxiety disorders may be treated in different ways. Treatment is recommended on the basis of individual diagnoses: that is, the number, severity, and duration of symptoms alongside the extent of distress and impact on daily life. Recommended treatment will also be based on the individual's circumstances such as any physical health complaints, environmental stressors, pre-existing/co-morbid mental health or substance use issues and previous responses to treatment.

The most commonly prescribed medication for anxiety are antidepressants and selective serotonin reuptake inhibitors (SSRIs) specifically are the antidepressants most often prescribed. While they are antidepressants, they can also relieve anxiety symptoms.

Selective Serotonin Reuptake Inhibitors (SSRIs)

These were introduced in the 1980's and heralded a new approach to the treatment of depression and anxiety. This class of drugs offered a different chemical structure than the traditional tricyclic antidepressants and so had different effects on the brain and brought different side effects. Primarily they are thought to work by enabling the brain to maintain a sufficient supply of the neurotransmitter serotonin by blocking its reabsorption, or reuptake, by specific nerve cells. This is believed to have a positive effect on mood, emotions and sleep.

The hypothesis that depression and related mental health conditions are caused by low serotonin levels was first proposed in the 1960's but contemporary research has been unable to confirm any serotonergic deficit in any mental disorder, and has actually provided significant evidence to the contrary. There is no scientifically established ideal “chemical balance” of serotonin, let alone an identifiable imbalance in the condition. However, an increase in serotonin levels via these medications seem to have a positive impact on symptoms and render people more receptive to other treatments, such as psychological therapies.

For example, several reviews report that 50 to 75 percent of patients with anxiety disorders report experiencing a significant benefit after taking an SSRI. There may be many mechanisms at work to explain why a medication works – most of which are likely to be more psychological in origin. For example, the belief for an individual that they are being acknowledged and treated is a significant component in symptom relief. However, the psychoactive nature of these drugs is perhaps underestimated and it may be that the mechanism of action is not so different to self-medication with substances of one sort or another. The drug lifts mood but in the same way an illicit substance would, rather than it fixing some underlying imbalance.

The following SSRI medications may be used in the following ways:

  • Fluoxetine for OCD, depression, panic, social anxiety, PTSD, generalized anxiety
  • Fluvoxamine for OCD, social anxiety, panic, PTSD, and generalized anxiety
  • Sertraline for OCD, social anxiety, panic, PTSD, and generalized anxiety
  • Paroxetine for OCD, social anxiety, panic, PTSD, and generalized anxiety
  • Escitalopram oxalate for OCD, social anxiety, panic, PTSD, and generalized anxiety
  • Citalopram for OCD, panic, PTSD, generalized anxiety

SSRIs: Side effects and risks

These medications can cause:

  • Nausea and other stomach complaints
  • Feelings of restlessness
  • Visual disturbances
  • Headaches
  • A dry mouth
  • Loss of appetite
  • Difficulty sleeping
  • Sexual dysfunction
  • Feeling agitated or anxious
 Although their side effects are reported to be less intense compared to the older-style anti-depressants such as the tricyclic antidepressants and monoamine oxidase inhibitors, that means that SSRIs are far from free of side effects. Several investigators have reported rarer but more serious effects, including electrolyte imbalance, movement disorders, weight gain and increased bleeding.

SSRIs can also cause withdrawal reactions such as anxiety, stomach issues, fatigue, feeling wobbly/unstable, headaches, nausea and vomiting, tremors, paresthesia (burning or prickling in the limbs) and visual disturbances, can occur if the medication is stopped abruptly.

SSRIs are reported to take longer to work in cases of obsessive compulsive disorder, compared with other anxiety disorders. Those suffering from panic disorder and post traumatic stress disorder are often reported to be more sensitive to the effects of SSRIs and so lower doses are needed initially to enable people to adjust.

Studies report that SSRIs decrease the frequency of panic attacks and in some cases completely eliminates them, they can lessen anticipatory anxiety, and even reduce phobic symptoms. In post traumatic stress disorder, some symptoms are reported to be more responsive to SSRI therapy than psychological approaches involving re-experiencing of the trauma. Generalized anxiety disorder and social anxiety disorder are also reported to receive a clear benefits from SSRIs —  compared to benzodiazepines which reduce physical symptoms, antidepressants are reported to be more effective for psychic symptoms, such as worries.

However as stated earlier, research is inconsistent. A recent study analyzed all clinical trials looking at the benefit of the SSRI paroxetine in comparison to placebos for treating generalized anxiety disorder or panic disorder and found that they had little benefit over placebo. The individuals given placebos experienced a similar benefit that was nearly 80 percent as effective and so much of their effect is not likely to be due to the drug's specific ingredients.

Interestingly, they also found that the drug's benefit was lower in unpublished trials, which indicated that studies that were published were the ones that overestimated the drug's effectiveness. The authors of this study argue that the risks may outweigh the benefits, given the side effects, withdrawal syndrome; and rare (but more severe risks) which include increased suicidal ideation in children and young adults and serotonin syndrome, which is a life-threatening negative reaction to the drug.

A recent study found that pharmaceutical companies were not being transparent regarding all of the results of drug trials. When documents from 70 different double-blind, placebo-controlled trials of selective serotonin reuptake inhibitors (SSRI) (and serotonin and norepinephrine reuptake inhibitors (SNRI)) were examined, it was found that the extent of serious harm in clinical study reports largely went unreported. For example, the reports showed that the risk of suicide and violence were four to five times more common, as was the risk of experiencing a psychotic event. Yet this is not declared as a risk for most people when being prescribed antidepressants.

In summary, SSRIs may be helpful in treating anxiety, but the extent to which this is due to the actual constituents of the drug or other factors is unclear; as is the cost-benefit analysis when it comes to risk of serious harm. What is important is that people have access to the information so that a truly informed decision can be made.

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