This article is a transcribed edited summary of a video Bob and Brad recorded in January of 2021. For the original video go to https://www.youtube.com/watch?v=gwjKG_QTpAs&t=642s
Bob: So today's topic is going to be anxiety medications. We're going to talk about the SSRIs,
and we'll explain to you what that is. You know, what do you do? How do you choose one? We're going to go through all that. And Chris has a plethora of knowledge on this. So, you want to start by talking about what the SSRIs are?
Chris: Yeah, basically what an SSRI is, it stands for selective serotonin re-uptake inhibitors. So it's kind of a mouthful.
Bob: That’s what I thought.
Chris: It’s definitely kind of hard to process, but there's several drugs in that category.
I mean, you can go with, Celexa which would be citalopram. There's Lexapro, which is escitalopram. There's Zoloft, which is sertraline. There's Prozac, which is fluoxetine, and Paxil is paroxetine. So those are the main ones that are in that family.
Bob: The big question I have is, what is it exactly doing? It's improving your serotonin levels?
Chris: Yeah, so basically what happens is, to understand when we're treating anxiety,
basically, when we put people on these types of medications, is its communication between two nerve cells. And so what serotonin does is it kind of carries signal A to signal B. And when we have anxiety, some of those nerves are hyper polarized and you're not getting really good transmission. And serotonin is kind of looked at as kind of a feel good or a relaxing type of neurotransmitter. When that message is interrupted, or maybe just not sent properly, it's going off into the other areas of the brain and bloodstream, what have you, you're finding that these cells are hyper charged and you're getting things known as anxiety. When we take medications, like the aforementioned SSRIs, what it does, it doesn't have your body make more, but what it does, it blocks the uptake of it. So it's a selective serotonin re-uptake inhibitor. So inhibit- think of it as blocking. And so it's going to allow more serotonins to kind of bathe that cell gap, so that it transmits more of that information to hopefully help you to feel a little bit more calm.
Bob: So when you go off the medication, eventually, is that going to affect your body's ability to produce the serotonin, or, do you know what I mean?
Chris: Yeah, that’s an interesting question. And it's debatable. So basically, we know for a fact that anxiety is a biochemical driven condition. Is it brought on by life circumstance? Is it bought on by something else? There's a lot of mitigating factors that lead to it.
Bob: Sure.
Chris: And there's different forms of anxiety within that group as well. You and your doctor are part of this team to determine when it's ready for you to go off of these types of medications, you have that discussion and you'll want to taper off, because if you go off of these medications abruptly, you're going to have some very serious problems. It’s not so much that you're physically addicted to the medication, but you can have, kind of this, withdrawal syndrome kind of thing, where you go off the medication and you feel yucky, you get rebound anxiety…
Bob: Can't you get like electrical shocks?
Chris: Yeah, basically the term that kind of floats around in my circle is brains zaps.
Bob: Yeah, that's it.
Chris: And so, basically people feel like just little electrical stimulation kind of going through the brain, they can't stay focused, they feel agitated. They don't sleep well. They can be short with their tempers, feel achy. I mean, it's actually, it's a multitude of side effects that are associated with that. And even just one of the things that's very important in my arena, as well as adherence to the drug. Meaning you have to take it consistently. Drugs don't work if you don't use them consistently. In these it's paramount that you take them on a daily basis as your doctor directs.
Bob: So, let's bring up this question. What if you miss a dose?
Chris: Well, that's a very good question, actually, Bob. What we do when you miss a dose, we try and tell the patient, it kind of depends on the time of the day that you recognize it. We use the kind of half a day so if it's within 12 hours, take it for sure right away when you remember it. If you're getting to let's say it's the next morning, and you're like, "Oh my gosh, I forgot my dose yesterday. No wonder, I felt horrible." We don't want you to double up. You just take your normal scheduled dose, and get back on track.
Bob: And you'll obviously feel maybe a little bit of the effects of that.
Chris: Yeah. You're going to notice that. With the exception of the drug fluoxetine or Prozac, that's the only one that people can kind of get away with skipping. All the other ones have shorter half-life’s and you know it when you skip a dose. All of a sudden, let's say you just take your normal dose at six in the morning every morning after you have breakfast. All of a sudden it's noon, and you're like, "I just don't feel right. I can't focus. I'm kind of ornery." And you're like, "Oh, I forgot my medication." So, and then at that point it's like, man.
Bob: That probably creates some anxiety in itself.
Chris: Sure, and it can, so, I mean at that point we'd instruct you, if it's possible, I mean, if you're in the middle of your work day I don’t know if you can just leave work and go back home and take your medication, or somebody can bring it to you. We want to try and come up with some sort of solution because it will definitely affect the remainder of your day.
Bob: Sure, now you talked about, a lot of people out there are questioning whether or not they should be on drugs. They don't want to be, because people don't like to take drugs if they don't have to. I mean, you know, when we talk about the stigma...And you talked about the three things that are important.
Chris: With anxiety, I mean to understand it, the mainstays of therapy are really, it's going to either be medicine, or chemical, and then also there is therapy, cognitive behavioral therapy. Those are really the big two, and you're a big proponent of that. And across the board, when doctors are choosing what's best for the patient, the patient is driving the bus in this case, because if somebody is not saying, "Oh gosh, I don't know that I feel comfortable going to counseling. You know, I just, I don't have the time I can't leave work."
Bob: Imagine the stigma.
Chris: There sometimes can be considered a stigma, which is the absolute wrong thing. We have to smash that stigma, because it's not a stigma.
Bob: Right.
Chris: I mean, you're talking about 50 million people, one in five.
Bob: You also mentioned when we were talking about this at one point that you said that you've seen more this year, then ever.
Chris: Yeah, you know. It's been stressful year, 2020, thank goodness this is the last day of the year.
know, it's one of these things where, it has been rough. As a pharmacist, when I dispensed the medications that doctors are prescribing I've seen a tremendous increase in both the SSRIs, and other drugs used for anxiety as well. So it's definitely there. It's definitely prevalent, and again it's so important to just kind of circle back that the patient kind of drives the bus for the treatment. You know, if you think, "Well, I can take a tablet every day and it's going to work for me." And you're going to make it work. I think it's important that that's probably your choice. And your doctor will go through a series of questions that are going to determine maybe what's the best choice for you, and ask would you be amenable to considering counseling, you know cognitive behavioral therapies.
Bob: So yeah, you had mentioned the five drugs and these are the main five? Correct? And some of them have been around a lot longer than others. And so they have a long history of them and how they affect people. So they can feel comfortable with what you can propose the side effects are.
Chris: Absolutely, and actually all of these drugs now are old. I mean, I've been a pharmacist for over 25 years. These drugs are all older medications.
Bob: So you probably don't need to make a choice based upon that.
Chris: No, but from a scientific standpoint, it's kind of interesting that with brain imaging we're seeing that these drugs, they work. And if you think of a stream, actually when we take the SSRI drugs as a class, there's a lot of things going on upstream probably that are much more significant as far as what we're seeing with brain chemistry. And then using the medication certainly helps, but it's kind of more downstream meaning the things that are probably to come with medicinal science are probably going to be much improved therapies as they learn which systems to trigger or what trigger points that we need to hit. So there's other things going on above stream. So I think, I don't want to say it's crude or rudimentary, because they're excellent medications that safely help people to manage anxiety conditions every day. But I think there's things that we can do better. And I think that's the wonderful thing about science is we're always pushing that envelope. We're always trying to learn; we're always trying to go forward.
Bob: It's a miracle what they're able to do now, even, if you ask me.
Chris: Yeah. Oh, the doctors are very, very adept at helping patients these days. I mean, and it's not even always drugs, like I said. Therapy for some people is a wonderful opportunity.
Bob: Now, the side effects, you had mentioned that they are fairly similar, among the five.
Chris: Yeah, they really are. It’s kind of interesting that all of the drugs have a different chemical structure but they act on the same area, which is the serotonin re-uptake. And they're just really in that synapse. So from that standpoint, it kind of comes down to the clinician's ability to select something for your needs, you know, maybe your body type, and they might even ask some questions about family members. Because you know, genetics play a big part in all of the things that we drive and they do kind of drive the bus. So let's say, you know, your mother your father, aunt, uncle, brother, sister took something like, hey, that drug worked well. Well, you know what, why don't we try, maybe sertraline is going to be the best choice for you or maybe fluoxetine is the best choice for him. Or maybe paroxetine is the best choice for me. It just kind of depends on what your clinician decides. And keeping in mind, these drugs do take time to work. So it's not quick. It's a four to six-week endeavor to start to get relief, which is frustrating.
Bob: That's the thing, right. Because if you have anxiety that seems like for a lifetime.
Chris: Yeah, I mean, it is, it is a lifetime.
Bob: You're counting off the days. So we understand that. If this is something you're considering, you probably want to get it started.
Chris: You want to get started. You know, just even the definition of anxiety is kind of interesting, but you know they want you to, most days of the week you should have a thought that's just not sitting well with you for six months. I mean, that's kind of DSM five guidelines.
Bob: To put up with for six months.
Chris: If you have anxiety, you want it gone yesterday.
Bob: Yes.
Chris: It is an awful feeling. It's an overwhelming sense of dread, and it's just something that we really don't want to delve into because it's just such an awful uncomfortable feeling. And until you've been in those shoes, it's really hard to understand that perspective. And again, it's just like, well I don't know why he feels that way. He seemed just fine yesterday. It doesn't work like that at all.
Bob: They can't understand it.
Chris: And that's the other thing, as a pharmacist and I'm sure as a doctor, if we had one sitting here, too, and you tell a patient, “it's going to take about four to six weeks before this is going to help you feel better.” I mean, you're like what?
Bob: What, yeah, exactly.
Chris: And I mean, it just, it's somewhat deflating but, the thing is, is that we get your body used to it. We minimize the side effects. We keep you on track.
Bob: You ramp up slowly.
Chris: We do ramp up slowly because if I give you too much too fast, in all likelihood, you're going to feel yucky. You can feel yucky. You can have an upset stomach. You can be nauseated. Your appetite can be shot. You don't sleep well.
Bob: That’s going to compound this.
Chris: So we start basically baby steps and the appropriate dose based on body type, weight, again, genetic factors what have you, other medications that you take. So your clinician is going to look at a lot of different things that go into the prescribing of the choice that they provide.
Bob: Are the doses fairly similar for the five?
Chris: No, I mean, you look, let's see, we'll pick on citalopram, you've got a 10 and 20 and 40 milligram tablets, sertraline got a 25 to 50, a hundred milligram tablet. Fluoxetine is a 20 milligram and also a 40 milligram dose. So paroxetine, it's got the 10 and the 20 and the 40.
Bob: So the typical where they end up at, those tend to be different?
Chris: They do, but it's interesting. I mean, these drugs are also used for depression, but for anxiety, you'll see a little bit different dosing level for each of them. Sometimes it's a little bit higher.
Bob: For anxiety?
Chris: Yeah, it can be. So yeah, it's kind of funny how that works. And even within the classes themselves, Paroxetine tends to have a little bit higher dose for OCD, obsessive compulsive disorder, and things like that, or other types of anxiety. So, and then whether you're using it for social phobia or agoraphobia, I mean there's other anxiety conditions under that big umbrella too. So it just kind of depends. Your doctor is going to drive the bus on that. And really what they do is like we were talking about, you start slow and you gradually build up. They're going to ask you; you're going to come back for an appointment about four weeks. And then there's either going to be a phone call or another appointment after that discussing how well you're tolerating it.
Bob: That brings up the point. So you have five drugs here. What can you see as a difference between, let's say the best performing one and the worst performing one for you? Could you have one that this does nothing for you?
Chris: Well, well you can, and that's why these other choices exist. I mean, way back when Prozac came out on the market, and then all of a sudden Zoloft was number two. I think the drug industry itself, they see something, and Prozac at the time when it came out, I mean, there was a book Prozac nation. There's a lot of things out there that came out when these drugs were first available and they all, I guess the fondest form of flattery is imitation, right? So they come up with drugs, you know and they think, well, hey, as the manufacturer of Zoloft I'm going to one up, you know, the manufacturer of another brand. Then that's not necessarily true, but they come up with a way to get into that market, and they do want to constantly improve. I mean, when you look at the molecules, they all look functionally different. And so let's say we started you on something that didn't work well, we have other options available for you.
Bob: How soon would you know that?
Chris: You're going to know...
Bob: In a couple of weeks?
Chris: I would say you're going to have a solid answer probably within four weeks. And that's why that first appointment back to the doctor is so critically important. And they are going to ask you those questions. How are you doing today? You know, Bill or Bob or Gene.
Bob: So is that common, that you might not have any help from it?
Chris: I wouldn't call it common, but it can certainly happen. And so that's why it's important to keep that next appointment with your provider, because they have to gauge how well you're performing. If we're giving you a drug that doesn't work or you're not buying into the fact that you have to take it every day, we've got some serious issues that, as a pharmacist, we want to make sure that you stay adherent on the medication and that you're tolerating it well, and you're not experiencing the side effects that could create problems for you. And so, we always say, please give us a call. We'll try and help you out any way we can. Oftentimes I spend a lot of phone conversations with patients just saying, well, and we actually the other thing that we do with the company that I worked for is we make what we call adherence calls. So we'll call you in about five or six days, to make sure that you're actually doing well and comfortable on the medication.
Bob: See, that's what I was wondering because doctors have a feedback loop. They're seeing the patient and they come back. And I wasn't sure if that you had that. So apparently you do. You have a good sense of what all of these drugs work and what side effects.
Chris: Yeah, we do. Exactly, and it really does make a difference. And I think patients really like to hear from us too.
Bob: Oh, absolutely.
Chris: It's like, "Oh really, thanks for calling." And to me, it's very gratifying. It's worthwhile. And if, heck, if I can even just help somebody an inkling I feel like it's definitely made a difference, and I'm hoping we can keep things going forward so that they can continue to get the help that they need.
Bob: You know, when you're ramping somebody up, now let's say they end up being at 100 milligrams or something like that. They're not going to feel the full effect of that until they're at the hundred and for another four weeks after that, right?
Chris: It can be because there is a change. So you got the first four weeks where I guess honeymoon period is probably the wrong word.
Bob: You're at 25 to 50 maybe.
Chris: Yeah, if we pick on sertraline for instance, you know, a lot of times we'll recommend start at 25 milligrams because of the side effects, GI are most common. So it can cause nausea or it can cause, loose stool, pain. So, I mean, we want to try and avoid that. So to say a little food first.
Bob: Those will go away?
Chris: Those will go away. And usually within about five to seven days, they're gone. And then at that point, depending on your clinician's wishes, that might be the point where we jump you up a little bit. And then we kind of have you sit there until that four-week appointment. Then we see how you are doing, and your doctor will determine how you're tolerating it. And if it's beginning to see the benefits. So, in this case since we're talking about anxiety, to say are you feeling a little bit more calm a little bit more relaxed? Are you sleeping a little bit better? Are things a little bit better through your day-to-day? And hopefully the answer will be, yes. I think things are getting better. And then at that point, or if it's, you know if the answer is no, they're not doing well, I still feel like garbage. Well, do you feel like you've gained some benefit? Yeah. Well then maybe we are going to ramp you up to the next level dose. So on sertraline let's say we were at 50 milligrams for four weeks. Maybe we're going to try at 75 or even a hundred milligrams to see. And then we're going to re-engage in about a month to see how you're doing at that point.
Bob: How long does someone typically stay on the drug? And if they have the idea they'd like to get off.
Chris: Yeah, and that's an interesting question, Bob. There's not a simple answer. When these drugs all first came out they were thought you just needed to take them for six months and everything was all was well. We've found that over the years, that is not the case. I mean, there are people that have been taking it for years. You get to a point, too, where sometimes the drug just kind of runs its course and it doesn't seem to be as effective as it used to be. Or you just feel like, I'm in a really good place. I think it's time for me to have an engaging conversation with my physician and see if it's time for me to taper off.
Bob: Would that be six months minimum?
Chris: Well, I would tell you it's probably going to be longer. The problem is when we come off of these medications too quickly you get kind of almost a rebound effect. So you have to taper off of them very slowly. And even if we come up too soon, oftentimes you end up back on them three, four months after you're off of it because you've rebounded back to the same situation. So, when you look at it, at least in prescribing circles, pharmacy circles, we kind of look at, people are on these things for the long haul. And I would say a year plus, and maybe even longer yet, depending upon your tolerance.
Bob: I imagine it might even be the time of year.
Chris: It can be.
Bob: Like, you'd probably rather go off in Spring in Minnesota or Wisconsin, you know what I mean?
Chris: There are people that do benefit from short courses like that. So there's seasonal effective disorder. It depends. There are lots of other ways that you can treat with that. You know, the holidays can be tough for people. COVID has not made it easy for people. So we're going back earlier. I mean, I'm just seeing a lot more of these drugs being prescribed for anxiety than ever before.
Bob: All right. How are these drugs stored? Are they stored any differently?
Chris: A cool dry place in the house. So basically the worst two places storing any medication would be, if you're keeping score at home, guys. Don't keep them in the kitchen. Don't keep them in the bathroom. Moisture destabilizes these medications rather quickly. And so, you're spending good money on these medications. We want to make sure that they work for you. So, a bedroom, a drawer away from, out of reach of children, obviously, you want to use your safety caps if you have small kids or pets around the house. So keep it high, like on a shelf or just somewhere where kids can't reach, or maybe even out of eye sight, but where you know you're going to remember to be able to get at it every day.
Bob: Can you become dependent on these drugs?
Chris: Not physically dependent.
Bob: You've talked about tapering off.
Chris: Yeah, you taper off, but it's not like an addiction per se, that you're going to be like you're shooting heroin and you need to get your next fix. It’s nothing like that. But if you skip a dose, your body, like we talked about a little bit earlier, your body lets you know so there is a bit of a physical dependency just because your body is used to, and I always liken it when patients go, why does that happen? It's kind of like if you were standing on a rug, Bob and I just pulled the rug out from underneath your feet and you fell, that's an awful feeling. And it's much the same thing clinically. We accidentally skip a dose, your body lets you know, it's a bad time. It's a bad day and you definitely don't feel like it's effective and things are going sideways on ya.
Bob: Do you want to just talk about, we'll finish up with this. Maybe, do you want to talk about some of the side-effects that are common that you see? They list a lot of common side effects.
Chris: Yeah. If any consumer were to look at what I read on a daily basis or what a physician reads on a daily basis most people would probably be less inclined to take some medications that they do. And a lot of the studies that are done and I guess, to compare like with the vaccines out in warp speed, I mean we've done some really quick research. The research that went into these drugs is always ever evolving. Doctors are constantly publishing studies about what is safe, you know, is it okay to use during pregnancies, is it okay to use in pediatric patients? Is it okay long-term, short term, with certain different medications? So we'll come back to, we'll circle back to side effects. And so it's like what's best tolerated? Across the board, these drugs all have kind of the same side effect profile. And so it can be usually it's GI's the first thing most people discover. So we want you to take it with food.
Bob: Short term. I mean you should take it with food all the time.
Chris: Sometimes it's just kind of, a lot of the serotonin is in your gut. So it stimulates those receptors first. And so as a result, you get tummy side effects. So food, then drug helps to eliminate that. So that's the primary one that I always discuss with patients. Kind of an odd one that happens is in about 10% of the patients almost across the board with these drugs particularly, is some people can actually get tired. So there's one in 10 that's just like, man, I am just dragging tail. And so you feel like, man I need five cups of coffee just to get through my morning. Then all of a sudden I took five cups of coffee and now I'm more anxious than ever. Well, that's not the way we want to go. So that one in 10, we actually want you to take it at bedtime. Because you'll sleep through that side effect. Then by morning, everything's right. You kind of get your dose patterns established and it seems to work a little bit better. But for some people, you know that 90% of us that take these medications, you can get kind of an activating effect. It's not so much like you had a cup of coffee, but it's just got a little bit of a spark to kind of get you moving. And so it's something that obviously could interrupt sleep. And one of the side effects is of course insomnia. So we don't want to be promoting something that's going to keep you up all night when sleep is so paramount with actually treating anxiety. And that's again, we could probably almost do another video on all non-drug things to use, to treat anxiety.
Bob: Well, I think we'll cut off there since we're at a quite a long time here and we'll pick up this topic with another video where we're actually going to tell you a drug you can take to kind of help you make it through that four to six-week period.
Chris: Yeah, there's a couple out there that definitely work in addition to this and again, up to the doctor but I think there's a lot of good things that we can do to help people with anxiety.
Bob: Thanks.
Chris: Have a great day.
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