Selective Serotonin Reuptake Inhibitors (SSRIs)

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:

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.

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)

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.

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.

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.

Refill requests can be made in a couple of different ways - either by calling the prescribing clinician’s office or more easily through the patient’s MyChart account with 5 easy clicks!  Go to Medications on top and click on Request Refills (right side).  Choose the medication you are requesting a refill for and click Next.  Confirm the desired pharmacy and click Next.  Review your request and Submit.  

Please allow 3-5 business days for your refill request to be processed.  It is your responsibility to monitor when a refill is due - putting a reminder on your phone is a good way to not lose track of time!  Last minute requests may not be fulfilled nor is it guaranteed that your pharmacy will have the medication in stock so it is important to give yourself those 3-5 days of buffer to avoid unnecessary delays in your medication refills.

It is also our group’s policy to ensure that patients have recommended follow up visits scheduled prior to receiving their refills.  You can still receive the refills needed until your next visit, but it is important to schedule the follow up visit as soon as possible to avoid delays in your medication refills.  

It is our group’s policy that patients who are changing medications or medication doses follow up with the prescribing clinician at least once every 4 weeks although some may recommend more frequent check ins.  The follow up visit can either be an in-person or telehealth visit depending on the clinician’s recommendation and availability.  Keep in mind that weight, height, blood pressure, and heart rate measurements are needed at least once every 6 months but these can be obtained at other in-office visits you come in for, even if the specifically related to anxiety and/or depression.

Once a stable medication and dose has been reached, the follow up visits can be stretched out to every 3 months.  One of these follow up visits can be combined with a well child check if the prescribing clinician is also your primary care provider.  

Failure to follow up as recommended can result in delays in receiving your  medication refills.  Repeated failures to keep appointments can also result in discontinuation of the medication by the prescribing clinician.

The easiest way to make a follow up appointment is to make one at the end of your current visit - either at the front desk on your way out if you just had an in-office visit or by your prescribing clinician if you had a telehealth visit.  You can also quickly make the appointment through MyChart - just click Schedule an Appointment on the top and an Behavioral Health Follow Up Visit scheduling ticket should be available under .  If no such scheduling ticket is available, please contact the prescribing clinician’s office to schedule the visit.