Emotional Blunting with Antidepressants

 

CLINICAL FEATURES:

(1) Reduction of positive emotions:

  • ‘dampened down’ or ‘toned down’
  • not experience the same emotional ‘lift’ or ‘high’.

(2) Reduction of negative emotions:

  • ‘feeling less sad or angry’
  • Reduced ability to cry.

(3) Emotional detachment:

  • feelings of being ‘in limbo’, of ‘unreality’ or ‘disconnection’.
  • feeling as though they were a ‘spectator’ rather than a participant.

(4) Just not caring:

  • feeling apathetic and unmotivated.

(5) Changed personality:

  • feeling lost, leaving them ‘like a shell’.
  • ‘behavior is out of character’.

 


PREVALANCE:

Data is not consistent.

STUDY 1:

  • 20% of patients with SSRIs reported apathy.
  • 16.1% of patients with SSRIs reported loss of ambition.

(Psychother Psychosom. 2004 Nov-Dec; 73(6):380-5)

STUDY 2:

  • ~ one-third on any antidepressant reported apathy
  • ~ 40 % with loss of motivation.

(J Clin Psychiatry. 2006 Nov; 67(11):1754-9)

STUDY 3:

  • In pediatric patients with anxiety disorders: 5% developed apathy with fluvoxamine.

(J Child Adolesc Psychopharmacol. 2006 Feb-Apr; 16(1-2):227-33)

 


ASSESSMENT USING SCALES:

  1. Marin Apathy Evaluation Scale:
  2. Oxford Questionnaire of Emotional Side Effects of Antidepressants 

 


ANTIDEPRESSANTS OF CHOICE ??

Risk is high with most serotonergic antidepressants including SSRIs, SNRIs and TCAs. 

  1. WELLBUTRIN: lowest risk. 

  2. DULOXETINE: highest risk.

 


 

IF ANTIDEPRESSANT SWITCHING IS NOT AN OPTION ?

==> Reduce the dose of antidepressant.

 


 

References:

  • Br J Psychiatry. 2009 Sep;195(3):211-7.
  • Psychiatry (Edgmont). 2010 Oct; 7(10): 14–18.
  • J Affect Disord. 2017 Oct 15;221:31-35.
  • Medicographia.31 (2009):152-156.



 

QUESTION BY MEMBER:

Q: In the studies mentioned, did they have a control group or any before vs. after data? This info is interesting to me. But since those symptoms mentioned can also be from depression or another psych disorder like PTSD, I was curious.

To answer this question effectively, I have briefly summarized each studies below:

 

STUDY 1: (Psychother Psychosom. 2004 Nov-Dec; 73(6):380-5)

  • This study conducted 161 semi-structured telephone interviews of adults who had completed a course of treatment for depression with one of the SSRIs.
  • No control or placebo group. 
  • This study was done to document the existence of psychological side effects associated with SSRIs taken for depression.
  • Diagnosis focused was depression. 
  • Conclusion: Psychological side effects might well be included in measures and discussions of side effects.

 

STUDY 2: (J Clin Psychiatry. 2006 Nov; 67(11):1754-9)

  • Inclusion criteria: patient > 18 yr age + responded to antidepressant therapy following at least 3 months of treatment for major depressive disorder (MDD) + their MDD was considered to be in partial or full remission.
  • These participants were given following scales to monitor these specific side effects such as apathy, fatigue, and inattentiveness: Harvard Department of Psychiatry/National Depression Screening Day (HANDS) scale, the Epworth Sleepiness Scale, the Brief Fatigue Inventory, the Massachusetts General Hospital Cognitive and Physical Functioning Questionnaire (CPFQ), and a study-specific questionnaire.
  • Diagnosis focused was MDD (major depressive disorder).
  • No control or placebo group. 
  • Conclusion: It is likely that these symptoms are both side effects of the antidepressants as well as residual symptoms of MDD.

 

STUDY 3: (J Child Adolesc Psychopharmacol. 2006 Feb-Apr; 16(1-2):227-33)

  • This study used samples from RUPP study of fluvoxamine in pediatric anxiety disorders.
  • RUPP: Johns Hopkins University site of the Research Units on Pediatric Psychopharmacology.
  • They reviewed data for adverse events of at least moderate severity or that required a slowing of drug titration during the protocol.
  • They found only 2 cases: neither had depressive disorder. 
  • No control or placebo group. 
  • Conclusion: Educating patients and families, and close monitoring by clinicians for symptoms of SSRI-induced apathy, are important to limit the impact of this reversible adverse event on compliance and quality of life.

Please do post your questions or comments below. 


Dr. Harvinder Singh, M.D. (Admin)


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