Sera Laney had dealt with anxiety for as long as she could remember, but by her sophomore year in college, amid mounting pressure, that baseline anxiety skyrocketed. Since she was already taking buspirone (BuSpar), a common antianxiety medication, her doctor added fluoxetine (prozac), an antidepressant often prescribed for anxiety.
But instead of relief from her anxiety, Laney’s panic surged within days of starting the antidepressant. She says, “My entire body felt like it was on fire.”
Then, vivid, intrusive thoughts about hurting herself, something she had never thought of before, began flashing through her mind, triggering hours-long panic attacks. “I could not calm down. I had to leave school for a week,” the 22-year-old studying at the University of Alabama says.
This was not just a rough adjustment period to a new antidepressant. Something was clearly wrong. She called her doctor, who told her to stop the drug.
Within a week and a half of starting Prozac, Laney was off the medication and back on buspirone only — but at a higher dose. A year later, when heightened anxiety called for it again, Laney tried another antidepressant. This time, the experience was entirely different: no side effects, no distress — just relief.
Laney’s story illustrates a common dilemma for people starting antidepressants: If the drug that’s supposed to help you causes significant side effects, when should you push through and when should you switch? While many people are told to give these medications time to work and that the side effects will level out, not all side effects are created equal. Knowing the difference can be critical to both safety and recovery.
“I categorize side effects in two main boxes,” says Robert Mazgaj, MD, a psychiatrist at Duke Health in Durham, North Carolina. “The first box is nuisance, bothersome side effects that, often, can get better with more time. The second box means you should stop the medication and then call me.”
Common Side Effects of Antidepressants
The most commonly prescribed antidepressants are selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and atypical antidepressants. Their side effect profiles share some overlap, but they differ in some ways. What’s more, some side effects are temporary and improve within weeks, while others may last as long as you stay on the medication.
Here’s what you should know.
SSRIs: Effective but often accompanied by persistent side effects
SSRIs, such as escitalopram (Lexapro), fluoxetine (Prozac), and sertraline (Zoloft), are among the most commonly prescribed antidepressants. They tend to have predictable side effects, many of which stem from increased activity of the neurotransmitter serotonin throughout the body.
Common side effects include:
- Fatigue or drowsiness
- Gastrointestinal (GI) issues, including nausea, loose stools, and heartburn
- Sexual dysfunction, especially trouble achieving orgasm
- Weight gain
- Brain fog or memory loss
Of these, GI issues are usually short-term, often resolving within one or two weeks as the body adjusts to the medicine. Taking the medication with food can help ease this transition. Memory loss, in the 20%-30% who experience it, can improve with a dose change.
But other side effects are more likely to linger. Fatigue, sexual dysfunction, and weight gain often persist for the duration of treatment, and weight gain may continue over time.
“I gained about 60 pounds over a couple of years on Prozac,” says Cindy Hopper, an Atlanta-based licensed professional counselor, who went on the antidepressant prior to giving birth, knowing from her past pregnancies that she was prone to postpartum depression. She also found that she had a lack of motivation while on the drug and that though she didn’t feel depressed, she felt emotionally flat.
It was that flatness that prompted her to talk to her doctor, who then prescribed an SNRI, says Hopper, who is now 60.
SNRIs: More activating, often faster-acting
SNRIs, such as desvenlafaxine (Pristiq), duloxetine (cymbalta), and venlafaxine (effexor), affect the neurotransmitters serotonin and norepinephrine, which can make them feel more energizing.
Common side effects include:
- Jitteriness or agitation
- Increased sweating
- Mild nausea
Because of their activating effects, SNRIs can be a better fit for people with low energy and motivation but may worsen symptoms in those with significant anxiety.
Compared with SSRIs, SNRIs tend to have fewer long-term side effects:
- Less weight gain
- Lower rates of sexual dysfunction
Like with SSRIs, nausea is typically short-lived, improving within the first couple of weeks.
But jitteriness and sweating may persist, especially at higher doses or in sensitive individuals.
Hopper couldn’t tolerate the sweating. “I remember showing up at a parent-teacher conference, just pouring sweat, like I’d just run in a race,” she says. Working with her doctor, Hopper finally found a medication that worked well for her, and she’s been on it for many years.
Atypical antidepressants and some atypical side effects
This drug class includes medications that don’t fit into the standard SSRI and SNRI categories, such as bupropion (wellbutrin) and mirtazapine (remeron), as well as some newer ones that aren’t yet widely covered by health insurance.
Bupropion (Wellbutrin). As it doesn’t typically cause GI issues or sexual dysfunction, it can be an effective alternative for people who struggle with those side effects on SSRIs. Bupropion’s most noted side effects include reduced appetite and activation or anxiety, which can make you feel jittery.
“I wouldn’t prescribe this one to someone who already has anxiety,” says Nora C. Hart, MD, a family physician at Houston Methodist.
Mirtazapine (Remeron). The most common side effects of mirtazapine include significant sedation and a big increase in appetite leading to weight gain. Doctors might reserve this medication for patients whose depression has left them without an appetite, who are underweight, or who suffer severe insomnia from their depression.
What about antipsychotics?
If you have major depressive disorder and you’re not getting enough benefit from an antidepressant, a doctor might add a second-generation (or atypical) antipsychotic to your regimen. Added to an antidepressant, research shows that they can further alleviate depression.
But these drugs can cause several side effects, such as:
- Abnormal movements, painful muscle contractions
- Constipation
- Dizziness and sedation
- Dry mouth
- Heart and circulatory problems
- High blood sugar, type 2 diabetes
- High cholesterol
- Immune dysfunction
- Jaundice
- Urinary retention
- Weight gain
Some of these side effects may go away or get better after your body adjusts to the medication. A dose adjustment can also help reduce antipsychotic side effects. Changes in lifestyle or habits can help, too. But a rare condition that causes involuntary movements called tardive dyskinesia can be permanent.
Putting Side Effects in Perspective
Side effects aren’t all bad. Some prescribers use them to their patients’ advantage.
“Fatigue, for example. SSRIs as a class generally cause fatigue,” Hart says. “If your depression keeps you awake [or] makes you agitated and restless, I’m going to use an SSRI because that calming effect of the drug helps alleviate one of your worst symptoms.”
It’s also important to note that while one drug in a certain class may cause significant side effects, that doesn’t necessarily rule out the entire class for you. After Laney’s terrifying experience with Prozac, she eventually ended up on another SSRI, sertraline (Zoloft), on which she’s been doing well for a couple of years.
Should I Stay the Course or Move On?
Whether or not to stay the course or jump ship on an antidepressant due to side effects is often a judgment call.
For nausea, doctors typically tell patients to stick it out for at least a couple of weeks to give the body time to adjust — unless you’re throwing up. “If it’s that bad that you’re throwing up, we just switch,” Mazgaj says. “If it’s tolerable but you’re still able to eat, I encourage patients to stick it out for up to a month.”
For other side effects, Hart says, “I would give it at least a month to see how you’re doing.”
After a month’s trial, she recommends that patients ask themselves:
- Do the side effects of this drug outweigh the benefits I’m getting?
- If the side effects seem to be more than the benefits, are they improving?
If the side effects outweigh the benefits and they don’t seem to be improving, it’s reasonable to switch medications.
What does it mean for the side effects to outweigh the benefits? Ask yourself these questions:
- Does this side effect interfere with my ability to live my daily life?
- Does the unpleasantness of the side effect prevent me from enjoying or noticing the lifting of my depression?
- Does the side effect make me feel like I’m not myself?
“If the side effect is burdensome enough that you’re losing hope in your ability to improve your mental health, it’s worth bringing it up with your doctor,” Laney says. “A lot of times, they have a solution that doesn’t even require switching medicines, or it’s really easy to switch medicines.”
How to Manage the Side Effects
If the side effects aren’t severe enough to warrant a switch or you’d just like to make sure you give the drug a fair shake, you can try to make the side effects more tolerable.
Here are some possible solutions:
Nausea and other GI issues. Take the medication on a full stomach; try over-the-counter medicines for nausea, diarrhea, or heart burn.
Fatigue or sedation. Take the medication at the end of your workday so peak sedation happens overnight.
Jitteriness or agitation. Take the medication first thing in the morning; cut back on caffeine and nicotine; talk to your doctor about temporary use of medications for sleep.
Sexual dysfunction. Lower the dose; take a prescription medication to help reverse this side effect.
When to Stop the Meds and Call Your Doctor
One side effect you should never ignore is suicidal thoughts.
“If someone has suicidal thoughts, that’s a hard stop,” says Mazgaj. “Stop the drug, and call me right away. If there are safety concerns, call 911 or go to the ER [emergency room]. But we never want people to stick it out on a medication if they’re having suicidal thoughts.”
Another red flag: Sometimes standard antidepressants can unmask an undiagnosed case of bipolar disorder.
Antidepressants should make you feel better, but “if someone all of a sudden feels euphoric, on top of the world, [or] invincible or has so much energy [that] they don’t need to sleep, that’s another hard stop,” Mazgaj says. On the flip side, he adds, a standard medication could make a person with untreated bipolar disorder feel “profoundly depressed, more dysphoric, or inexplicably irritable.”
If an antidepressant makes you swing really far in either direction, tell your doctor right away. You may need a different type of treatment.
How to Switch Your Antidepressant
If you’ve decided you might be better off taking something different, the first step is to talk to your doctor.
Depending on your current medication and what you’ll try next, it may not be a simple matter of stopping your current medication one day and starting the other the next. A sudden stop could cause withdrawal symptoms or even a return or worsening of your depression.
Switching is usually a planned, medically supervised process. You might be instructed to taper your current medication, which means gradually lower the dose of the medication before stopping completely. Depending on the two medications you’re switching between, you might need to cross-taper. This means gradually lowering the dose of the first one while gradually increasing the dose of the new one.
Some switches might need a washout period, or a break between medications, to avoid drug interactions.
Once you’ve made the switch, you’ll need to give the new drug a fair trial as you did with the previous one.
Most antidepressants take many weeks to show full benefit, and early side effects don’t always predict how you’ll feel in the long term. Switching is often a normal part of treatment for depression, which often includes a trial-and-adjust process. It’s not a treatment failure. With careful management, most people can find an option that balances effectiveness with tolerability.
Switching and readjusting may feel discouraging, but, Laney says, “It’s worth it because, on one antidepressant, you could have the worst side effects in the world, and then on the other antidepressant, you don’t have anything, and it just helps. That was my case.”
