SSRIs, or selective serotonin reuptake inhibitors, include GlaxoSmithKline Plc's Paxil, Eli Lilly and Co's Prozac, Pfizer Inc's Zoloft and Symbyax, Forest Laboratories Inc's Celexa and Lexapro, and Solvay Pharmaceutical's Luvox, which is also sold generically as fluvoxamine. Many people have benefited from the use of SSRI drugs. However these medications do have side effects and doctors have to balance the benefit and risks of these antidepressant drugs.
   Those who wish to explore natural antidepressant options may visit this depression page. Natural antidepressants are a good option for those with mild or moderate depression. There are several to consider including 5-HTP, Tryptophan, SAM-E, St-Johns-Wort, and Mind Power Rx. Discuss with your health care provider before initiating treatment with natural antidepressants. Use low dosages at first until you find out how they influence your body and mind. Use one supplement at a time until you learn how it affects you. If you combine several supplements, you will not know which one is helping, and there could be side effects. Combining natural supplements with SSRIs carries a risk for side effects since many herbs and nutrients are quite potent.
 

Types of SSRI drugs
Celexa is the product name for citalopram
Lexapro also known as Cipralex - escitalopram
Luvox - fluvoxamine

Paxil - paroxetine
Prozac - fluoxetine - also known by the brand name Sarafem
Zoloft - sertraline
 

How Effective are SSRI Antidepressants?
Antidepressants, whether SSRIs or other types, fail to cure the symptoms of major depression in half of all patients with the disease even if they receive the best possible care, according to a definitive government study published in March 2006. Significant numbers of patients continue to experience symptoms such as sadness, low energy and hopelessness after intensive treatment, even as about an equal number report an end to such problems.

SSRIs and sexual side effects
It is quite well known that SSRIs increase serotonin levels and serotonin has an inhibitory effect on sexuality. Sometimes the sexual side effects can last several weeks or months after the SSRI is stopped.

SSRI danger

SSRIs or certain SNRIs in combination with migraine drugs known as triptans could result in a life-threatening condition called serotonin syndrome. Persistent pulmonary hypertension can occur in newborns if the mothers took SSRIs during pregnancy..Pregnant women and those who plan to become pregnant should avoid taking SSRI antidepressants because of the risk of birth defects.

NSAID and SSRI side effects
Selective serotonin reuptake inhibitors (SSRIs) and nonsteroidal anti-inflammatory drugs (NSAIDs), when combined, can interact to increase the risk of upper gastrointestinal bleeding.

Meta-analysis: Gastrointestinal bleeding due to interaction between selective serotonin uptake inhibitors and non-steroidal anti-inflammatory drugs.
Aliment Pharmacol Ther. 2007 Oct 5; Loke YK, Trivedi AN, Singh S. School of Medicine, Health Policy and Practice, University of East Anglia, Norwich UK.
SSRIs have been associated with upper gastrointestinal hemorrhage but the magnitude and characteristics of this reaction and possible interaction with concurrent Non-Steroidal Anti-Inflammatory Drug (NSAID) therapy are unknown. We searched PubMED, Science Citation Index, and trial registries for data on SSRIs, NSAIDs and UGIH. We evaluated spontaneous case reports from pharmacovigilance databases. SSRI use, alone and in combination with NSAIDs, substantially increases the risk of upper gastrointestinal hemorrhage. Clinicians should consider this when managing patients at risk of, or presenting with upper gastrointestinal hemorrhage.

SNRIs
SNRIs are selective serotonin / norepinephrine reuptake inhibitors. These include Lilly's drug Cymbalta and Wyeth's Effexor.

SSRI and Suicide
In a letter to doctors in May, 2006, GlaxoSmithKline and the Food and Drug Administration warned the SSRI Paxil may raise the risk of suicidal behavior in young adults. The warning letter was accompanied by changes to the labeling of both Paxil and Paxil CR, a controlled-release version of the SSRI drug, also called paroxetine. A review of clinical trial data on 15,000 patients treated with both SSRI Paxil and dummy pills showed a higher frequency of suicidal behavior in young adults treated with the SSRI drug. The FDA reported that there were 11 suicide attempts — none resulting in death — among the patients given the SSRI drug in the trials. Just one of the placebo pill patients attempted suicide.

SSRI and Irritable Bowel Syndrome

The results of a small, controlled crossover study suggest that treatment with SSRI antidepressants can reduce abdominal symptoms and promote overall well being in patients with irritable bowel syndrome (IBS), independent of their effects on depression. These findings confirm that serotonin has an important role in gastrointestinal tract activity. Whether small amounts of 5-HTP would be helpful is something to consider.

SSRI drugs increase fractures in older adults
The chronic use of SSRI antidepressant drugs doubles the risk of fractures in adults 50 years of age or older. These agents apparently decrease bone mineral density and raise the risk of falls, both of which are known to increase the fracture risk, Dr. David Goltzman, from Royal Victoria Hospital in Montreal bases his findings from a population-based study of 5008 community-dwelling adults who were at least 50 years of age. SSRI use, BMD, and history of falls were determined for each subject who were followed for over 5 years. The most common site of fracture, seen in 40% of cases, was the forearm, followed by ankle and foot in 21% of cases. "Animal studies have shown that SSRIs can decrease bone mineral density," which primarily involves a reduction in the amount of bone," adds Dr. David Goltzman. Arch Intern Med 2007;167:188-194.

SSRI and Pregnancy
Use of SSRIs during the second half of pregnancy may be associated with a condition called persistent pulmonary hypertension of the newborn. Newborns with this rare but life-threatening condition do not receive enough oxygen in the blood and require intensive-care treatment to survive. Babies born with this condition are several times more likely than healthy babies to have been exposed to SSRIs. Numerous reports in Canada and abroad have already indicated that some children exposed to SSRIs and other newer antidepressants during pregnancy may develop serious complications at birth. An increase in the overall risk of major birth defects has also been associated with SSRI use. Health Canada is advising women who are taking antidepressants known as Selective Serotonin Re-uptake Inhibitors (SSRI) and who are pregnant or intend to become pregnant to discuss the situation with their doctor due to potential risks to the baby. Generally, SSRI treatment should only be continued if the benefits to the individual patient are thought to outweigh the risks to the unborn child, while also considering the benefits and risks of switching to another treatment option or stopping treatment altogether.

   SSRI medication exposure in the womb may not linked to depression - Children who were exposed to SSRi medications in utero do not appear to be at increased risk for internalizing behaviors such as depression, anxiety, and withdrawal. Impaired maternal mood, by contrast, did increase the risk of internalizing behaviors. The findings are based on an assessment of internalizing behaviors in 4-year-old children born to 22 mothers who used SSRIs during pregnancy or 14 mothers who did not. The results appear in the American Journal of Psychiatry for June 2006.
   Babies born to women who take SSRIs during pregnancy appear to be at increased risk of having a low birth weight and to develop respiratory distress. The use SSRI antidepressant drugs early in pregnancy seems to moderately raise the risk of congenital malformations in offspring.

SSRI Failure
When patients with major depression fail to respond to a course of the SSRI Celexa (citalopram) or cannot tolerate its side effects, approximately one third of those whose treatment is augmented with either bupropion (Wellbutrin) or Buspar (buspirone) will experience a remission of their depression. If they are instead switched to Wellbutrin, Zoloft (sertraline), or Effexor (venlafaxine), about one out of four will remit.

Weaning off SSRI drugs

It has been more than two decades since Prozac — the first of the antidepressants known as SSRIs, or selective serotonin reuptake inhibitors — hit the market. Since then, many patients have reported extreme reactions to discontinuing the SSRI drugs. Two of the best-selling antidepressants — Effexor and Paxil — have prompted so many complaints that many doctors avoid prescribing them altogether. Patients report experiencing all sorts of symptoms, sometimes within hours, but most often within days, of stopping their SSRI medication. They can suffer from flu-like nausea, muscle aches, uncontrollable crying, dizziness and diarrhea. Many patients suffer “brain zaps,” bizarre and briefly overwhelming electrical sensations that propagate from the back of the head. There are case reports of people who have just quit SSRI antidepressants showing up in hospital emergency rooms, thinking they are suffering from seizures.
  The brain chemical affected by most of the SSRI antidepressants on the market today, serotonin, does a lot more than regulate mood. It is also involved in sleep, balance, impulse control, relaxation, digestion and other physiological processes. So when you throw the brain’s serotonin system out of whack, which is essentially what you’re doing by either starting or discontinuing an antidepressant, virtually the whole body can be affected.
  Generally the SSRI drugs that are metabolized most quickly cause more severe symptoms. Effexor, with a half-life of just a few hours, is one of the worst SRIs in that regard; Prozac, which has a half-life of about a week, is considered the best. Some doctors have been able to minimize withdrawal symptoms in patients who are quitting Effexor or Paxil by gradually switching them over to Prozac, then tapering them off the more easily discontinued drug.
  Would taking 5-HTP or St. John's wort reduce the symptoms of SSRI withdrawal? Perhaps they may help, but research is lacking.
 

Email from a Researcher
I just wanted to inform you about a paper I published recently describing permanent sexual side effects in former users of SSRI antidepressants. These three cases are just the tip of the iceberg, and it appears to be very common. A good reason to stick to herbal remedies as much as possible....
Yours sincerely,
Antonei Csoka, Ph.D. Assistant professor Dept. of OB-GYN and RS University of Pittsburgh http://www.pdc.magee.edu/faculty/csoka.html
 

SSRI questions
Q. I have been taking a SSRI anti depressant for 10 months which has been very helpful for panic disorder. It has also flattened out my emotions so although the anxiety has gone I don't feel a sense of wellbeing or happiness. I have consulted my doctor as you suggested about combining SAM-e and Citalopram but she doesn't know anything about SAM-e. I understand that you can't give personal advice and that there haven't been many studies on SSRI's and SAM-e. Do you know of any other way I can find out about personal experiences of combing the two?
   A. SAM-e is very potent and we are not aware of studies, you could do a google search to find personal experiences using various key words, for instance SAM-e Citalpram or SAM-e SSRI or SAM-e Prozac, etc.
 

Q. I am currently taken 200 mg per day of SSRI zoloft. Is tryptophan safe to take with SSRI zoloft, or is it counter productive since Zoloft tries to block serotonin levels between the various brain cells. What about 5-HTP.
   A. Tryptophan increases serotonin levels just like the SSRI Zoloft, therefore caution is advised. If your doctor approves, you could take half or a third of the Zoloft dose and only a third of a tryptophan dose to see how you do and then monitor based on this. The answer for 5-HT P would be similar to that of tryptophan since their actions are similar in some ways.

Q. Is tryptophan as good as a SSRI for depression?
   A. It's difficult to compare, although they both influence serotonin levels, their mechanism of action is different. I have not seen head to head studies involving an SSRI and tryptophan to know how similar or dissimilar they would be in terms of clinical improvement in depression.

Q. I've been on a SSRI for three years and am in the process of weaning off the medication in the hopes of switching to a natural alternative with fewer side effects. I've read that the withdrawal effects of stopping SSRI medications can be incapacitating. In your experience, are there nutritional supplements that can mitigate the effect of withdrawal from SSRIs (or SNRIs?) If so, would you have your patients begin these supplements during the weaning process, or only after the weaning is complete and the patient has stopped the medication entirely? (I know I'll have to do this under the supervision of my doctor, but I was hoping I could use your SSRI weaning philosophy as a point of comparison.)
   A. Each patient is different depending how long they have been on the SSRIs, which SSRI medication they are using, the SSRI dosage, how their body reacts, their current mood and disposition, their dietary habits and exercise program, their sleep patterns, etc. etc. Plus, each person responds differently to natural supplements, and the dosages and timing can make a huge difference. Each case is unique and hence we can't even give general guidelines.

Q. I would like to get your opinion on this. I see it was conducted in the year 2000 but I can't seem to find any follow up on it. Specifically how does this relate to the massive prescribing of SSRI and what chances individuals who are taking these types of medications are doing harm. Also if serotonin is the culprit, would it make a difference if it was a natural mood booster or pharmaceutical if they both delivered the same effect? Getting a straight answer on this one isn't easy. http://www.antidepressantsfacts.com/Thomas-Jefferson-University-Hospital.htm
   "Researchers from Jefferson Medical College in Philadelphia have found changes in brain cells in rats treated with large doses of several anti-depressant or anti-obesity drugs. In some cases, the cells shriveled or took on abnormal corkscrew shapes. While the clinical significance of the findings isn’t known, the scientists say, they may raise new concerns about the prolonged use of such commonly prescribed drugs as fluoxetine (Prozac) and sertraline (Zoloft). The work also highlights the need for similar studies on other classes of drugs that act on the central nervous system."
   A. It is difficult to compare the effect of massive doses of a drug or nutrient - in this case SSRI drugs - in rodents to what would happen when reasonable amounts are used in humans. I am not comfortable with people taking SSRI drugs for long periods due to potential SSRI side effects. Whether the doses of SSRIs used in treating depression in humans cause neural damage is not fully clear to me at this time but could be of concern. It's possible that high doses of certain nutrients such as 5-HTP could do the same damage, but I have not seen any postmortem evidence of such. In low doses 5-HTP is actually considered an antioxidant. SSRIs may influence neurons in a different way than 5-HTP. I realize people want clearer answers, but until more research is done this is the most one can say. Bottom line: use a SSRI medicine in as low a dose as possible, and take breaks from use.

Q. I read that Mind Power Rx should not be taken with an SSRI. Yet Mind Power Rx has so many good things for brain function and I am interested in getting some for my aged father who is showing some dementia, but he is on the SSRI Lexapro. What are  the reasons not to take the two together?
   A. Unexpected reactions occur when herbs and supplements are taken with SSRI drugs, and it is difficult to predict what those could be. Some potential side effects could be rapid heart beat, insomnia, restlessness, etc although some people may find no side effects when combining SSRI drugs and herbs. We prefer to be on the cautious side and not use them the same day.

Q. I really just want to take some time to say thank you to Ray Sahelian, M.D. for creating Passion Rx. I mean it from the bottom of my heart. I have been on antidepressant medications SSRIs for seven years now, and didn't realize what I was missing. I am a 25-year-old male. I did notice that I had virtually no attraction to anyone, and this was causing a depression all on its own. I know that Physician Formulas says not to take Passion Rx with SSRI antidepressants, but I can tell you that in my case with SSRIs it has not a problem. I take the pills as suggested: one once a day for two days, then two days off. I owe so much to you! I feel like a human being again. Thanks a million!
   A. Wow, we truly appreciate your report. Can you fill me in on a couple of things. Which SSRI are you taking and in what dosage for how long. Which Passion Rx were you taking, with or without yohimbe?And did you take a full capsule or part of a capsule, with breakfast or before breakfast. Did you notice the benefit the first day or did it take several days? We are so glad that Passion Rx helped you. This is the first feedback we have had by someone on SSRIs.
      Q. I have been taking the SSRI Lexapro 20 mg/day for six months. I take a whole capsule of Passion Rx with yohimbe in the morning, at least a half hour before eating anything. It took till the second day to notice a change in orgasm, and by the third day my libido, sexual thoughts, harder erection, more stamina, increased sensation, and more powerful orgasm all ensued. This has remained almost everyday. I cannot thank you enough. I actually forgot how pleasureful sex can be. I should let you know that I've been taking Passion Rx for about a month. | have recommended Passion Rx to both my sisters, thier partners, and my parents.
         A. Very interesting. We would suggest using the Passion Rx less frequently now. Once people notice the effects, they can take it less often and we also suggest at least a full week off each month.

Q. I am 34 year old female taking a SSRI medication called Celexa for anxiety and a side effect of the medication is low sex drive and difficulty achieving an orgasm, is it ok to take the Passion Rx formula or would it interfere with the SSRI medication? I also wanted to know if it's ok to take Mind Power Rx herbal supplement together with Celexa?
   A. It is difficult to predict the reaction to the combination of Passion Rx with a SSRI antidepressant medication such as Celexa. Celexa is known to cause loss of sex drive. Passion Rx can enhance sex drive but it may be more difficult since there is always the inhibition going on from the SSRI drug. If your doctor approves, you could try half a capsule of Passion Rx every other day, or two days on, one day off. And be patient for 2 weeks to one month. If you find you are having trouble sleeping, reduce the frequency of use of Passion Rx. Mind Power Rx may be taken at one capsule during the days when Passion Rx is not being used. If you notice any side effects with the combination, stop the herbs and resume at a lower dosage after two days. Your doctor may also advise you to reduce the SSRI dosage by half on the days that you take Passion Rx or Mind Power Rx.

Q. I am a 35 year old married man . I have been taking Passion Rx for the last 5 days now. I have had a low libido due to depression and also because i am on SSRI medication for 3 years now . Although there was major improvements in my depression / mental health and it did save my career and marriage . It took a toll on my sexual health (although the depression itself did reduce my libido) , the SSRI has had a negative effect too. Previously, Viagra has not helped much , except for erections and moreover my doctor stopped me that because of the side effects. I am taking Lexapro 10 mg, and my doctor agreed to try Passion Rx. I have had no interactions when taking Lexapro with many herbs with my doctor supervising me. My doctor started me on 1/2 a capsule of passion Rx for the first 2 days. Did not notice anything on the first 2 days. There was only a small effect on the 3rd day. As i had good tolerance for the first 3 days , The 3rd day my doctor told me to take 1 capsule. But so far i have noticed only minor improvements. i did not find any moderate to major improvements in my libido. I thought most of your customers respond on the 3rd day. nfortunately for me only minor changes, even on the 5th day. Does it have to do anything due to depression and also the Lexapro i am taking for the last 3 years. I am not sure if it will take much more time for major improvements. My doctor Insists me to continue, since i did not have side effects or interactions with Lexapro i am taking, and that its difficult to predict because each persons body chemistry is different. Any opinion and Suggestions from your Side ? Does it take some your customers a longer duration to see the effects . And sometimes how long can it take , so i can know if there is a chance it can work for me.
   A. Most users of Passion Rx who are not taking SSRI drugs notice the benefits in about 3 days to a week. The response is sometimes quicker with Passion Rx with Yohimbe. SSRI drugs enhance serotonin which is a potent inhibitor of sexuality and libido. Hence, the Passion Rx has to counter the continuous effect from the Lexapro. Therefore it may take 2 to 4 weeks for the full benefits to come about. We do suggest not taking it more than 2 days in a row. One option is to use it every other day, or take 2 days on, one or two days off.