Posted: 26.02.2025 | Author: Mr Mark Simpson
Long term use of Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs are the most commonly used antidepressants in the UK. They are used to treat mood disorders such as depression, anxiety, OCD and PTSD. They work by increasing the amount of the neurotransmitter serotonin in the brain. The most commonly prescribed SSRIs are sertraline, fluoxetine, escitalopram and citalopram.
Current recommendations are for patients to continue to take their SSRI for at least 6 months after recovery. For patients who have recurrent mood disorders, a period of two years is recommended.
Many patients choose to stay on these medicines for many years. As with many medicines, although short term side effects are well known, there can be some uncertainty regarding the long term effects and risks.
The purpose of this leaflet is to help doctors and patients when making decisions regarding longer term use.
The short term side effects of these medicines are well known and include:
· indigestion and stomach aches
· not sleeping well (insomnia), or feeling very sleepy
· headaches
· bleeding in the stomach
· Low libido and sexual dysfunction
Some of these can be transient but others can persist causing long term debility.
Compared to short term side effects, the longer term risks of any medicine can be difficult to establish. This is particularly true for SSRIs. Many people assume that there are no risks or harms. A study published in September 22 [1] aimed to investigate this. They used observational data from over 200,000 patient records to quantify these risks, adjusting for possible confounding factors.
They found that those using SSRIs long term had
An increased risk of strokes and TIAs(↑34%), death from heart problems (↑87%) and death from any cause(↑73%)
Interestingly they also found a reduced risk of high blood pressure (↓23% ) and diabetes (↓ 32%).
Previous studies in older people have found increased risks of falls, low sodium and overall mortality. [2] There have also been concerns that SSRIs reduce bone density and increase fracture risk [3]
These studies are observational and can’t say for sure that SSRIs have caused the effects seen. Indeed some evidence can be contradictory. It is important just to consider that these medicines may not be completely harmless in the long term.
When SSRIs are stopped suddenly many people will experience withdrawal effects such as anxiety, insomnia, low mood, lack of interest and electric shocks. Many patients attribute this to an unmasking of their ongoing mood disorder and promptly restart their SSRI. It is important to recognise that many symptoms like these will be transient and can be minimised by a gradual reduction in dosing. In general, you should aim to reduce your dose in step wise manner, leaving 2–4 weeks between reductions, or longer if you have been on the medicine for a number of years.
The royal college of psychiatrists have some very detailed and helpful information on antidepressant withdrawal here.
There is always a risk of relapse when you stop antidepressants and this needs to be weighed up when making a decision to stop. It’s important to recognise that relapse can occur even if you continue to take your antidepressant. A study in 2021 randomised patients in remission on long term antidepressants to either stop or continue their treatment. After one year 56% of those who stopped had a relapse, but so did 39% of the group who continued their treatment [3].
Many people have been prescribed antidepressants to successfully treat a mood disorder. After a period of remission it’s helpful to consider stopping your medication. These medicines have side effects and withdrawal can be more difficult as time goes on. As well as this there may be risks to cardiovascular health. If you do decide to reduce you should do so slowly to minimise withdrawal symptoms.
1. Bansal N, Hudda M, Payne RA, Smith DJ, Kessler D, Wiles N. Antidepressant use and risk of adverse outcomes: population–based cohort study. BJPsych Open. 2022;8(5):e164. doi:10.1192/bjo.2022.563
2. Coupland C, Dhiman P, Morriss R, Arthur A, Barton G, Hippisley–Cox J et al. Antidepressant use and risk of adverse outcomes in older people: population based cohort study BMJ 2011; 343 :d4551
3. Kang, S., Han, M., Park, C.I. et al. Use of serotonin reuptake inhibitors and risk of subsequent bone loss in a nationwide population–based cohort study. Sci Rep 11, 13461 (2021). https://doi.org/10.1038/s41598-021-92821-9
4. Lewis G, Marston L, Duffy L, Freemantle N, Gilbody S, Hunter R, Kendrick T, Kessler D, Mangin D, King M, Lanham P, Moore M, Nazareth I, Wiles N, Bacon F, Bird M, Brabyn S, Burns A, Clarke CS, Hunt A, Pervin J, Lewis G. Maintenance or Discontinuation of Antidepressants in Primary Care. N Engl J Med. 2021 Sep 30;385(14):1257–1267. doi: 10.1056/NEJMoa2106356. PMID: 34587384.