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This article provides a step-by-step approach to counselling a patient on selective serotonin reuptake inhibitors (SSRIs) in an OSCE setting. This article focuses on their use for psychiatric conditions, however, they can also be used for other chronic medical conditions.
Opening the consultation
Wash your hands and don PPE if required.
Introduce yourself including your name and role.
Confirm the patient’s name and date of birth.
Explain the reason for the consultation: “Today, I’d like to talk to you about a medication called selective serotonin reuptake inhibitors, also known as SSRIs. Would that be okay?”
It is important to establish good rapport and an open line of communication: “If you have any questions at any point, or if something is not clear, please feel free to interrupt and ask me. Also, I appreciate that this may relate to topics that can be difficult to discuss, but everything we talk about is confidential, and this is a safe space for you to talk.”
Make sure to check the patient’s understanding at regular intervals throughout the consultation and provide opportunities to ask questions (this is often referred to as ‘chunking and checking’).
Ideas, concerns and expectations
A key component of counselling involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE).
Asking about a patient’s ideas, concerns and expectations can provide insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation. It can sometimes be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided some examples for each of the three areas below.
Ideas
- “Have you heard of SSRIs before?”
- “What do you know about SSRIs?”
- “Do you know reasons why people may take an SSRI?”
Concerns
- “Do you have any particular worries about starting an SSRI?”
Expectations
- “Is there anything in particular you hoped we would cover today relating to SSRIs?”
Patient history
Although the purpose of this station is to counsel the patient, it is a good idea to gather a quick, focused history early in the consultation.
This should include exploration of the patient’s symptoms and management of their condition, including trials of previous medications and their impact, compliance and adverse effects.
Understanding the patient’s care so far will help you tailor any advice and personalise the information for their specific situation.
If the patient has a history of overdoses or has expressed suicidal ideation that involves taking overdoses, limiting the quantity of medication given with each prescription or asking another person to manage the storage and administration of medication should be considered.
Children and young people can be prescribed SSRIs for various psychiatric illnesses. Some studies have reported the risk of increased suicidal ideation with SSRI use in under 18 year olds, hence, management by specialists is recommended.1
Contraindications
Review the patient’s medical history to identify any contraindications, and medication history to identify potential interactions that may prohibit the use of SSRIs.
SSRIs may exacerbate signs and symptoms of mania, so they are not recommended during manic episodes.1 If patients have a history of mania but are not currently experiencing signs or symptoms, SSRI may be used with caution. SSRIs should be used cautiously in patients who have recently taken an overdose. Taking in combination with many recreational drugs (e.g. cocaine, ecstasy, LSD) can cause serotonin syndrome.
What are SSRIs and when are they used?
Selective serotonin inhibitors (SSRIs) are a type of antidepressant medication which, whilst commonly associated with psychiatric illnesses (i.e. depression, anxiety, OCD), are also used for medical indications (i.e. irritable bowel syndrome, fibromyalgia, vasomotor symptoms of menopause).1
Commonly used SSRIs include citalopram, sertraline, fluoxetine, escitalopram, and paroxetine.3
Their mode of action is via blocking the reuptake of the neurotransmitter serotonin in the brain, allowing more serotonin to be available for longer. Serotonin has been shown to impact emotion and sleep.1 Low levels are thought to play a role in not only the low mood aspect of depression but also the biological symptoms such as low energy and sleep disturbances. By increasing the amount of serotonin available, SSRIs are thought to improve mood and motivation and potentially improve the biological symptoms.
Patients may feel a slight benefit after 1 to 2 weeks of starting an SSRI, but generally, it takes 4 to 6 weeks to feel the full benefit.
Example
“SSRIs are a type of medication that can be used to improve mood. Low levels of a chemical messenger in the brain called serotonin are thought to play a role in low mood, sleep and energy issues in depression. SSRIs increase the amount of serotonin in the brain, which should improve your mood and motivation and may help you engage in activities and therapies, which should also help manage your mental health.”
“Some patients start to feel a slight benefit after 1 to 2 weeks, however, the full benefit is generally seen after 4 to 6 weeks.”
How to take SSRIs
Overview
SSRIs most commonly come in tablet form, but some can also be available in liquid form.
They are typically prescribed as a once-a-day dose.
All SSRIs can be used to manage depression, but their starting and maximum doses are generally different. They are prescribed at the lowest possible dose first and then, if tolerated, gradually increased until the optimum dose and symptom control are reached. Starting doses include sertraline 50 mg, fluoxetine 20 mg and citalopram 30 mg.3
SSRIs used for other psychiatric indications are condition-specific. For example, fluoxetine can be used in the management of bulimia nervosa, and paroxetine can be used in the management of post-traumatic stress disorder.3
Fluoxetine is the SSRI of choice for those under 18 years; however, there is a reported risk of increased suicidal ideation.
Missed dose
If the patient misses a dose, they should take it as soon as they remember unless the next dose is due. If the next dose is due, omit the missed dose and take the next dose as normal.
Advise the patient that they should take their SSRI every day, as missing doses or stopping abruptly can lead to unpleasant symptoms associated with discontinuation syndrome. These can include:
- Flu-like symptoms
- Electric shock sensations
- GI upset
- Anxiety
- Dizziness
- Seizures
Symptoms will resolve once the patient starts taking their SSRI regularly again.
Check the patient’s understanding
It is important to “chunk and check” with the patient at this point to ensure they understand how to take an SSRI.
Example
“You should take your SSRI as prescribed every day. It can be taken with or without food.”
“SSRIs are initially prescribed at the lowest possible dose and, if tolerated, gradually increase until the ideal dose for you is reached.”
“SSRIs can be used alone as a treatment for depression, however, evidence shows that they are best used alongside talking therapies.”
“It can take one to two weeks to see any benefit and may even take up to four to six weeks to see the full benefit. If you don’t feel that there has been any benefit, then we can try another SSRI.”
“It is important that you take your SSRI every day. Missing doses can lead to uncomfortable withdrawal symptoms and reduce the overall benefit of the medication. If you miss a dose, you should take it as soon as you remember unless your next dose is due. In that case, you should omit the missed dose and take the next dose as normal. If you experience side effects after missing doses, they should resolve once you start taking your SSRI regularly again.”
“Is there anything you aren’t clear on and would like me to go over again? If not, would you mind repeating back to me your understanding of SSRIs and how you should take them?”
Side effects and interactions
As with all medication, there are side effects associated with SSRI use.
Educating patients about what to expect when starting an SSRI, as well as signs for serious side effects and the importance of seeking prompt medical attention should these develop, is an important part of SSRI counselling.
Side effects are usually mild and resolve within the first week of starting an SSRI or after a dose increase. It is important to inform patients of the risk of worsening their mood when first starting an SSRI and what to do if that happens.1
Common side effects of SSRIs include:
- Nausea and abdominal pain
- Changes to bowel habits
- Agitation and anxiety
- Headaches
- Dizziness
- Changes to sleep
- Sexual dysfunction (reduced sex drive, erectile dysfunction, difficulty orgasming)
Less common, but serious side effects include:
- Hyponatraemia: nausea and vomiting, confusion, muscle weakness, restlessness
- Significant worsening of mood or suicidal ideation
Suicidal ideation
There is a risk that after starting an SSRI or after a dose change, a patient’s mental health can significantly worsen, and some can even experience suicidal ideation.1 It is essential to educate patients about this and advise them to seek medical attention immediately. Providing contact information for crisis lines and other mental health charities can also be helpful.
Interactions
Many prescribed medications, recreational substances and everyday dietary choices can interact with SSRIs to cause adverse effects; therefore, it is important to advise patients to discuss new medications with a healthcare professional and to be transparent about any recreational drug use.
Serotonin syndrome
Serotonin syndrome is a potential risk associated with SSRIs, as well as some other types of antidepressants.1 It is rare, but if untreated, it can be life-threatening. This typically occurs when SSRIs interact with another medication or a recreational drug, resulting in the levels of serotonin rising dangerously high.
Examples include tricyclic antidepressants (TCAs), St John’s wort, MDMA, cocaine, anti-epileptics, and ondansetron.
Features of serotonin syndrome include:
- Neurological: agitation, confusion
- Metabolic: sweating and shivering
- Musculoskeletal: muscle twitching or rigidity
- Gastrointestinal: diarrhoea
- Cardiovascular: tachycardia, hypertension
Severe signs include high fever, arrhythmias, tremors, and loss of consciousness.
Example
“You may experience mild side effects on starting SSRIs and potentially after dose increases, however, these usually wear off quickly in the first week.”
“The most common side effects are nausea, changes in bowel habits, headache and agitation. Some patients can also struggle with sexual difficulties too.”
“Not all patients who take SSRIs experience side effects, but it’s good to be aware of them before you start. If you find that these side effects are too bothersome for you, you should contact your doctor as they may be able to resolve them by reducing your dose or by trailing an alternative SSRI.”
“Sometimes, when starting an SSRI or after a dose change, people can feel that their mental health worsens. If you experience this, then you should seek medical attention immediately. Typically, your doctor will have a follow-up review with you a week after starting an SSRI to check in on your mood and how you are tolerating the new medication.”
“It is also important to be aware of some of the rare but serious side effects that can happen when taking an SSRI. If mixed with other medications or recreational drugs, you can risk developing a serious side effect called serotonin syndrome. This is where the levels of serotonin get dangerously high. If you experience severe diarrhoea, a racing heartbeat, feeling sweaty or shivery, muscle twitches or confusion, you should seek medical attention immediately.”
“You should ask your doctor or pharmacist before taking any over-the-counter medications such as ibuprofen or supplements such as St John’s wort, as these can increase your risk of developing side effects.”
Lifestyle advice
It is important to educate patients taking SSRIs about how lifestyle can affect their experience with the medication. Some SSRIs can cause dizziness, drowsiness or blurred vision, so it’s important to advise them that this could be a risk when driving or operating heavy machinery.1 They should also be made aware that it is not advised to drink alcohol whilst taking SSRIs as this can exacerbate side effects, such as drowsiness.
Though the mechanism is unclear, SSRIs can affect temperature regulation, making patients more vulnerable to developing heat stroke or exhaustion. It is important to advise the patient to be aware of this during the summer or when exercising to ensure they stay adequately hydrated.
It is important to advise the patient that if they become pregnant, they should inform their doctor right away as this could have implications for the management of their mental health condition.
Example
“If you experience side effects such as dizziness, drowsiness or blurred vision, you should avoid driving or operating machinery. Your doctor might recommend an alternative medication which does not cause these side effects. If symptoms persist, you should inform the DVLA and your workplace’s occupational health service.”
“SSRIs can impact how we regulate our temperature, which makes us more sensitive to heat. It is important, particularly in the summer, when exercising or in hot weather, to be conscious of this and drink plenty of water. This will help to reduce the risk of heat exhaustion and heat stroke.”
“It is important to inform your doctor if you become pregnant whilst taking SSRIs. They are not generally recommended, particularly during the first 3 months, however, there should be a discussion between you and your doctor about the risks and benefits to yourself and the baby regarding stopping or continuing your medication.”
“Would you be able to repeat back to me your understanding of how you should take your SSRI and what to do if you experience bothersome or serious side effects? We can go through it again if you would like.”
Monitoring
A patient should be followed up a week after starting an SSRI. This allows a review of any side effects experienced, how well the patient is tolerating the SSRI, as well as their mental state. Patients should then ideally be followed up in 4-6 weeks to assess the improvement to their psychiatric symptoms, any further side effects, and their compliance. If there has not been the desired improvement despite concordance or side effects are too bothersome, a dose increase of the current SSRI or a trial of another SSRI can be considered.2
Example
“You will need to see your doctor one week after starting an SSRI to discuss how the medication is working for you and to monitor for any side effects. After that, your doctor will normally arrange to see you around one month later.”
“You should contact your doctor at any time if you are concerned.”
Closing the consultation
Close the consultation by summarising what you have discussed. This allows you to emphasise the key points of the consultation.
Finally, thank the patient for their time and offer them a leaflet summarising the key information related to SSRIs. Provide information on mental health resources and where to get help in a crisis.
Dispose of PPE appropriately and wash your hands.
Reviewer
Dr Lousia Ward
ST6 CAMHS
Editor
Dr Jamie Scriven
References
- NHS. Selective serotonin reuptake inhibitors (SSRIs). 2021. Available from: [LINK].
- NICE CKS. Depression. 2024. Available from: [LINK].
- BNF. Antidepressant drugs. 2025. Available from: [LINK].
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