What are selective serotonin reuptake inhibitors?

Selective serotonin reuptake inhibitors (SSRIs) are medications used to treat both depression and anxiety. They work by increasing the levels of serotonin within the brain. Serotonin is a neurotransmitter that carries "feel good" messages between brain cells and help promote a sense of well-being, calm, good mood, as well as, improve appetite and sleep. SSRIs help increase the available serotonin levels within the brain by preventing the reabsorption of serotonin by the nerve cells.  This allows more serotonin to be available to help transmit "feel good" messages more effectively. They are called selective because they do not interfere with the reuptake of other neurotransmitters.  

The following are the most common SSRIs utilized in children and adolescents:

Which SSRI is considered a good fit?

Like all medications, a good fit would be one that provides the most benefit with the least amount of side effects. Both fluoxetine (Prozac) and sertraline (Zoloft) are considered more "activating" or energizing while escitalopram (Lexapro) can be more calming. The type of depression and/or anxiety symptoms experienced by the patient can help determine which medication may be a better fit. Generally, if one SSRI is ineffective or not well tolerated, a trial of another one is recommended. Please note that SSRIs are most effective when combined with psychotherapy and good self-care. 

What are the possible side effects? 

All SSRIs work in similar ways and can cause similar side effects although not everyone will experience the same side effects.  Side effects are not common, and if they do occur, typically are mild and transient.  If a patient experiences side effects with one SSRI, they may still be able to tolerate another SSRI as everyone’s bodies differ in how receptive it is to each medication and how quickly it breaks it down.

Possible side effects include:

• Nausea, vomiting, diarrhea
• Headache
• Sleep disturbance (drowsiness > insomnia)
• Dry mouth
• Dizziness
• Sexual problems (ex. Reduced sexual desire, difficulty reaching an orgasm, erectile dysfunction)
• Appetite disturbance (increase or decrease)
• Mania or hypomania (euphoria, impulsivity/hyperactivity, disinhibition, irritability) 
• Agitation/akathisia (restlessness, inability to sit still)

What are additional safety issues? 

SSRIs are safe for most children and adolescents. Rare potential safety issues include the following:

Drug Interactions

It’s important to let the patient’s doctor know of any other medications that the patient is taking on a regular basis as some may interact with SSRIs.   Most over-the-counter medications, asthma inhalers, birth control pills, and acne medications can be taken concurrently with SSRIs, but it is always advisable to inform the provider if taking these or any other medications. 

Serotonin syndrome

Rarely, SSRIs can lead to excessive accumulation of serotonin levels in the body and cause symptoms that can be uncomfortable. This is more likely to happen if a patient is taking 2 or more medications that increase serotonin levels. Signs and symptoms of serotonin syndrome include agitation/anxiety, high fever, sweating, confusion, tremors, poor coordination, changes in blood pressure, and increased heart rate. Patients should seek immediate medical attention if these symptoms occur.

Increased suicide risk

The FDA requires that all SSRIs carry warnings which are placed on medications with potentially dangerous side effects. In rare cases, children and teenagers taking SSRIs may develop or observe increased suicidal thoughts or behavior. If this occurs, it is more likely during the first few weeks of starting an SSRI or when increasing doses. Given this, patients taking SSRIs need to be monitored carefully. Parents should ask children about such thoughts/behaviors and if present, notify their doctor. These thoughts are reversible upon discontinuation of the medication. It is also important to remember that in the long run, SSRIs can decrease overall suicidal thoughts and behavior by improving mood and decreasing anxiety.

Are SSRIs addictive?

SSRIs are NOT addictive and that is the main reason for using them as first-line treatment in children and adolescents. However, stopping or decreasing the medication abruptly can lead to unpleasant withdrawal-like symptoms. It is best to work with the patient’s doctor to gradually and safely decrease the dose.

How long do SSRIs need to be taken?

Duration of medication treatment will vary depending on individual patients and the severity of their depression and/or anxiety disorder. It should be discussed on an individual basis with the patient’s clinician. The average duration of therapy for depression is 6-12 months and the average duration of treatment for anxiety tends to be longer, around 12 months. Some patients may require longer courses while others may need to restart medications after a break if symptoms of depression and/or anxiety recur or worsen.