Sometimes clients ask what I think about a particular selective serotonin reuptake inhibitor (SSRI) medication that you're considering taking for anxiety or OCD. More often, you tell me you want to come off your SSRI. Clients who say this have usually been taking SSRIs for 10 years or longer and frequently share that "It helped me at the start but it's not helping anymore."
As a nutritionist, I can't tell you to take or not take medication because this is out of my scope of practice. I can tell you that you may benefit from taking specific supplements alongside your SSRI, *and* that research shows when you come off an SSRI, you need to do so very, very slowly. I'll share more on this below.
Because I've seen some questionable claims and culture around SSRI medications on social media recently, I'm going to share some facts and thoughts for you to consider.
1. In cases of extreme life stress, a traumatic event or series of events, or impaired daily functioning because of a mental health problem, I believe SSRIs can be helpful for some people in that they help you 'keep your head above water'.
Ideally, I think they should always be taken alongside seeing a therapist. The more tools you have in your mental health toolbox, the more resilient you can be. And when things are that bad, I don't think humans were designed to simply rely on medication to get us through. We are wired for connection with each other. When times are tough or more than tough, we need supportive people around us. A good therapist experienced in the area you need support with can be invaluable during such times, and help you learn tools that will serve you for life.
2. According to the National Centre for Health Statistics in the United States of America, 25% of people taking SSRIs have been on them for ten years or longer. However, according to award-winning Wall Street health journalist Andrea Petersen, even the best studies on the safety and efficacy of SSRI use have followed the study participants for only a few years. No long-term research on SSRI effects has been done.
3. If you are considering taking SSRIs for the first time or changing your current medication, perhaps ask yourself if you see taking medication as a short-term (months) or long-term (years) tool? Additionally, consider what your support options will be if you don't find SSRIs helpful, they stop being helpful, and when you decide to come off them. Keep in mind that your doctor may have good experience in prescribing but less experience in supporting patients through tapering and withdrawal.
4. If you experience a worsening of your mental health when you come off an SSRI, this may actually be withdrawal symptoms and not a recurrence of your original condition. In other words, don't take it as proof you will need to take medication for life but consider that you might need to taper much more slowly to minimize the withdrawal effects. Again, be aware that your doctor may not have a lot of experience in supporting patients through withdrawal, and may not recognize withdrawal symptoms. See the study linked below, The 'patient voice'.
5. A 2019 study published in The Lancet Psychiatry recommended SSRI withdrawal be done over months or even years, rather than the standard four weeks, to greatly minimize distressing withdrawal effects such as insomnia, 'brain zaps', and anxiety.
6. When deciding to take an SSRI, your doctor or psychiatrist should make you aware of all the common side effects, less common side effects, and rare side effects of the medication you are being prescribed. This is necessary for your informed consent and part of the health professional's duty of care. If you are told to simply "read the insert", I would find a new doctor or psychiatrist.
7. Since 2004, most SSRIs come with a black box warning stating they are known to cause increased risk of suicidal feeling, thinking, and behaviour in young people, especially teenagers. A black box warning is the most stringent warning the FDA can put on a medication. Despite this, they continue to be prescribed to adolescents.
8. In 2015, an extensive analysis published in the British Medical Journal found some birth defects appear to occur 2 to 3.5 times more often for women taking Prozac and Paxil (fluoxetine and paroxetine) during the month before conceiving and their first trimester. I had never before been told, heard or read about this potential risk until I began looking at research while writing this article.
9. If you're an avid social media user, be mindful of the narratives around mental health and the possibility of recovery that you expose yourself to. I have noticed a small number of health professionals who regularly publish their enthusiastic views on medication. This raises questions.
Is the health professional's repeated personal disclosure about their own ongoing SSRI use truly for the benefit of their followers?
Is it responsible to continually promote SSRIs, particularly to younger audiences (see point 7), without ever discussing their side effects, withdrawal effects, and the possibility of trying other tools to support your mental health. Or acknowledging that you are not actually qualified to prescribe them?
Are some health professionals who repeatedly promote SSRI use subconsciously seeking validation from their followers?
To me, repeated posts along these lines feel exhibitionistic, and not in keeping with the ethics of personal disclosure. If you follow health professionals on social media who are avid endorsers of SSRIs, I encourage you to notice if they allow others to have and express different experiences and choices, or do they (or their fans) exclude, belittle or even attack those with a different view on medication or anyone who comments that nutrition is known to be important for mental health?
If you come across these types of posts on social media, I remind you that their choices and beliefs don't have to be your choice or reality.
Don't let others sway your personal power or your belief in recovery. And don't let anyone convince you they are informed about nutrition when they have likely done minimal to no study in this area. Different health professionals receive very different training. Hold on to the truths that you know of YOUR experiences with medication, nutrition, and any other tools you have used to support your mental health.
10. I have seen and heard the following comparison in a number of circles.
"You wouldn't shame a diabetic for taking meds, and it's the same with SSRIs...our brains are wired differently".
This is such a poor comparison and thus argument. With type 1 diabetes, we know for certain the pancreatic beta cells simply aren't producing the needed insulin.
With depression, anxiety, OCD, panic disorder, and other mental health conditions? The contributing causes are far more varied and include social (e.g., your childhood, stress, trauma), biochemical, and genetic influences. The causes of mental health problems are nowhere near as clear cut as a condition like type 1 diabetes. Hence, this poor comparison makes for a poor argument for SSRIs.
11. Informing people about the known problems associated with taking and ceasing taking SSRIs is not shaming people for taking them or telling them not to, or suggesting that anyone who takes SSRIs is 'weak'. It is supporting people in making a more informed choice for themselves and their families (e.g., see points 7 and 8).
Most developed countries consider thorough and well explained healthcare information to be a health consumer's right and have legislation around this. Just like when you have surgery, and the surgeon (ideally) tells you about all the possible risks and outcomes, good and bad.
Additionally, given how easy SSRIs are to obtain from a GP, given SSRI use has been on the rise for the past 20 years in many countries (in some developed countries, around 10% of the population take them), I don't see it can believably be argued that we need to be concerned people who need SSRIs are being put off taking them or finding them hard to access. I think we do need to amplify voices calling for a more wholistic approach to mental health care. Because when root causes are addressed, change tends to be long lasting.
12. There is some evidence that SSRIs deplete important nutrients, such as calcium and folate (vitamin B9). Additionally, there is growing research showing that taking supplements such as omega 3, SAM-e, folate, and vitamin D alongside an SSRI tends to lead to reduced depressive symptoms. It's great to watch the growing body of evidence for nutrition for mental health, and yet begs a question: how have we come to a situation where so many people readily take pharmaceuticals for their mental health, but question whether the very nourishment that grows and fuels our bodies can help their mental health?
13. The best health professionals to seek advice from on nutrition for mental health, are those who have completed thousands of hours study of nutrition and human health. This is registered nutritionists and registered naturopaths. Registered dietitians may also have a lot to offer here but I don't know a lot about how they are currently trained.
14. It bears repeating - withdrawal from SSRIs should always be done s l o w l y.
If you'd like to learn more about how nutrition can support your mental health, you can follow me on Instagram. You can also purchase my ebook, Nutrition for Your OCD Recovery (and read a sample chapter at the link).
New Concerns Emerge About Long-Term Antidepressant Use.pdf (adaa.org)
The 'patient voice': patients who experience antidepressant withdrawal symptoms are often dismissed, or misdiagnosed with relapse, or a new medical condition - PubMed (nih.gov)
How to Quit Antidepressants: Very Slowly, Doctors Say - The New York Times (nytimes.com)
Tapering of SSRI treatment to mitigate withdrawal symptoms - The Lancet Psychiatry
Specific SSRIs and birth defects: bayesian analysis to interpret new data in the context of previous reports | The BMJ
Antidepressants: global trends | Health | The Guardian
Are Antidepressants Stealing Your Nutrients? (designsforhealth.com)
AJP15091228 575..587 (psychiatryonline.org)