In a new article published in Psychological Medicine, Sebastian Camino and colleagues examine participants’ subjective experiences of taking different antidepressants. While many studies have examined the efficacy and safety of antidepressants, few have compared how different antidepressants (AD) might affect the subjective experience of service users. The present study seeks to fill this gap in the academic literature.
The authors examined 450 posts from the website www.askapatient.com, 50 posts each relating to the nine most used ADs: sertraline, citalopram, paroxetine, escitalopram, fluoxetine, venlafaxine, duloxetine, mirtazapine, and bupropion. Overall, satisfaction with antidepressant medication was inversely correlated with adverse side effects. Bupropion, citalopram, and venlafaxine showed the highest satisfaction ratings, with sertraline, paroxetine, and fluoxetine showing the most complaints of “emotional blunting.”
The authors write:
“This research points out that the subjective experience of patients under treatment should be taken into consideration when selecting an AD as differences between agents were evident. In contrast to the more frequent treatment decisions, users might prefer receiving a non-serotoninergic agent over a serotonergic one due to their lower propensity to produce emotional blunting.”
Although ADs are commonly prescribed to treat depression, many researchers have criticized their use based on their numerous side effects and dubious efficacy. In addition, the usefulness of ADs is likely overestimated in the academic literature due to corrupt publication practices. The minimal benefits paired with the risks of using these drugs have led some researchers to call for an end to professionals recommending ADs to treat depression.
ADs are commonly prescribed for diagnoses other than depression as well. Although the evidence of usefulness is scant, more than a quarter of Americans with chronic low back pain are prescribed an AD. Although there is little evidence for its efficacy, ADs are also prescribed for many other chronic pain diagnoses such as arthritis, migraines, and fibromyalgia.
ADs have been linked to increased suicide risk and increased instances of violence. One study found that ADs worsen long-term outcomes overall, with people that received no treatment faring better than those that received AD medication.
With prominent psychiatrists declaring that ADs are likely over-prescribed and the numerous negative side effects service users experience from these drugs, many AD users are seeking strategies for discontinuing AD use. Even when advised by medical professionals to discontinue AD use, many service users are afraid to quit the drugs due to biomedical understandings of their condition and the lingering side effects of withdrawing from ADs. Research has found that many popular websites incorrectly promote this biomedical view while systematically overestimating the benefits and underestimating the risks of ADs.
The present study explains that although several different ADs with unique treatment mechanisms exist, there are no biomarkers to indicate which AD may be most beneficial for each service user. In the absence of biological data to predict which drug best treats depression, the authors argue that a suitable alternative method would be to use service user opinion and experience data to decide which drug to prescribe.
The authors used www.askapatient.com, a website dedicated to cataloging service user experiences of different medications, to collect data on opinions around different ADs. The authors randomly selected 1000 posts that reported on one of nine commonly used ADs: sertraline, citalopram, paroxetine, escitalopram, fluoxetine, venlafaxine, duloxetine, mirtazapine, and bupropion. They further pruned these 1000 posts using the following inclusion criteria: the AD was used in an appropriate dosage range, the AD was used for at least four weeks, the indication for the AD had to be reported, and fewer than 50 posts about that AD had already been extracted. The final data set consisted of 450 posts, 50 for each of the nine most used ADs.
Sexual disturbances were most frequently reported with SSRI and SNRI drugs (sertraline, citalopram, paroxetine, escitalopram, fluoxetine, venlafaxine, and duloxetine). Few users of the dopaminergic drugs (mirtazapine and bupropion) experienced sexual disturbances as a side effect of AD use. Sedation was most reported by participants using mirtazapine and fluoxetine. Insomnia was most reported by participants using bupropion.
42% (189 participants) reported adverse emotional effects from AD use. Emotional blunting was reported by 18% of participants, emotional hyperactivity by 14.7%, and withdrawal by 14.7%. Emotional blunting was most common in participants using SSRIs (paroxetine, sertraline, and fluoxetine) and least common in those using bupropion and mirtazapine.
Bupropion had the highest satisfaction rating, with citalopram and venlafaxine a close second. Participants with anxiety disorders and more prolonged treatment durations generally reported more satisfaction with their ADs. The adverse effect most associated with low satisfaction ratings were suicidality, irritability, emotional blunting, cognitive disturbances, and withdrawal symptoms.
The authors acknowledge several limitations to the current research. The data came from a website on which people spontaneously post about their experiences. This means the participants are self-selected and may not represent a proper random sample. The data is self-reported, meaning the participants could be lying or exaggerating. There is also no way to know if the adverse effects reported came from the ADs or other confounding factors present in the participant’s experience. Lastly, the emotional blunting reported by many participants could also be a symptom of the underlying depression rather than an effect of the ADs. The authors conclude:
“The results of the present work show that inquiring about users’ experiences could contribute to opening new pathways in order to achieve a better approach for AD selection. These users have shown a preference for non-serotoninergic agents, in part due to their lower propensity to produce emotional blunting, predilection that goes in the opposite direction to the most frequent clinical behavior in which in more than 70% of the choices of a first antidepressant fall on an SSRI.”
Camino S, Strejilevich SA, Godoy A, Smith J, Szmulewicz A (2022). Are all antidepressants the same? The consumer has a point. Psychological Medicine 1–8. https:// doi.org/10.1017/S0033291722000678 (Link)