SSRIs: Onset of Effect, Safe Discontinuation, Serotonin Syndrome, and Suicide Risk

Who needs this teaching

Clients who start a selective serotonin reuptake inhibitor (SSRI), such as sertraline, fluoxetine, escitalopram, citalopram, or paroxetine, for depression or an anxiety disorder, and the family. SSRIs block serotonin reuptake at the synapse. The FDA boxed warning describes an increased risk of suicidal thoughts and behavior in children, adolescents, and young adults under 25 years.

The priority teaching points

1. Onset of effect. Sleep, appetite, and energy improve first. Mood improves over 2 to 6 weeks. Take the SSRI every day, including before benefit appears. Continue it after symptoms resolve; the provider sets the length of treatment.
2. No abrupt discontinuation. Abrupt discontinuation causes discontinuation syndrome: dizziness, nausea, irritability, anxiety, insomnia, flu-like symptoms, and electric-shock sensations. Paroxetine causes the most severe symptoms. The provider tapers the dose gradually. Keep refills current.
3. Common adverse effects. Nausea, headache, and insomnia or drowsiness are common in the first 1 to 2 weeks and decrease over time. Take the dose with food to reduce nausea. Sexual dysfunction (decreased libido, delayed orgasm, erectile dysfunction) frequently persists. The client reports it instead of stopping the drug.
4. Alcohol and bleeding. Avoid alcohol. Alcohol worsens depression and adds sedation. SSRIs increase bleeding risk with NSAIDs, aspirin, and anticoagulants. Ask before these drugs and report bruising or black stools.
5. Serotonin syndrome. Combined serotonergic drugs cause serotonin syndrome. These drugs include MAOIs, tramadol, triptans, linezolid, other antidepressants, and St. John's wort. Allow at least 14 days between an MAOI and an SSRI, and 5 weeks after stopping fluoxetine before an MAOI. Signs are agitation, confusion, hyperthermia, diaphoresis, tremor, muscle twitching, tachycardia, and diarrhea, usually within 24 hours of a new drug or dose increase. Call 911.
6. Suicide risk. Clients under 25 years have an increased risk of new or worsening suicidal thoughts, especially in the first weeks and after a dose change. Energy returns before mood improves, so the client has the energy to act on suicidal thoughts. Monitor clients of all ages for worsening depression, agitation, akathisia, insomnia, and behavior changes. Ask the family to secure firearms and large medication supplies.
7. Crisis plan and mania. Call or text 988 (the Suicide and Crisis Lifeline in the US) or the local crisis line. Call 911 for immediate danger. Report decreased need for sleep, racing thoughts, or unusually high energy; these indicate mania.

Red flags the client reports

Teach-back questions

• "How long will it take before you feel the full benefit?"
• "What will you do if you want to stop this medicine?"
• "Which medicines and herbal products will you check first?"
• "Which signs of too much serotonin mean you call 911?"
• "Who will you call if thoughts of suicide start?"

Teaching tips

• Ask directly about suicidal thoughts at each contact.
• Write 988 and the provider's number on the handout.
• Include a family member in teaching about mood and behavior changes.
• Review all prescriptions, nonprescription products, and supplements for serotonergic drugs.

Read more on NCLEXPace

• Psychiatric Medications: The Four Emergencies
• Suicide Risk: What the NCLEX Expects You to Do
• Delirium vs Dementia vs Depression: The 3-D Table

Sources

• Sertraline Hydrochloride Tablets: FDA prescribing information, including boxed warning, and Medication Guide (DailyMed).
• Paroxetine Tablets: FDA prescribing information, including boxed warning (DailyMed).
• American Psychiatric Association. Practice Guideline for the Treatment of Patients With Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010.
• Boyer EW, Shannon M. The Serotonin Syndrome. N Engl J Med. 2005;352(11):1112-1120.