SSRI induced Emotional Blunting and Apathy
Dr. Shyamanta Das
Jeemoni Lahkar
Patients treated with Selective Serotonin Reuptake Inhibitors (SSRIs) frequently complain about experiencing emotional blunting and behavioural apathy. Apathy is a neurocognitive syndrome of reduced goal-directed behaviour or in simple language can be described as lack of motivation. Marin describes Apathy as diminished motivation but that which is not attributable to a reduced level of consciousness, cognitive impairment, and or emotional distress. (1) Among the three sub-types of apathy, behavioural apathy presents itself ‘requirements for prompts’ for physical activity. (2)
Emotional Blunting can be described as reduced reactivity to emotions or a reduced range of emotions. People also describe this as feeling numb or as lacking empathy. SSRIs are the most commonly prescribed antidepressants. They have fewer side-effects and better response as compared to other type of anti-depressants such as SNRIs. However, the etiology of selective serotonin reuptake inhibitor induced apathy or emotional blunting is not known which has resulted in the ignorance of modifications in treatment strategies.
The Hamilton Rating Scale for Depression (HAM-D) and DSM-IV consider apathy as an aspect of depression. To study this side-effect of SSRIs, one has to separate these aspects, even though they are comorbid in certain syndromes, to bring new innovation in treatment strategies. Apathy is seen as reduced motivation and interest in daily activities and does not necessarily include depressed mood, hopelessness or sadness.
Patients being treated with SSRIs have complained about being more productive before they were on the medication. They also experience indifference towards physical activities and also emotionally. Therefore, in the recent years this unwanted and lesser-known side-effect of SSRIs have been given the united term ‘selective serotonin reuptake inhibitor-induced indifference’.
One of the earliest studies on these side-effects of treatment was published in the Journal of Affective Disorders in 2012 by Dr. Jonathan Price and Professor Guy M. Goodwin of the University of Cambridge. (3) Subsequently, they developed a questionnaire called the ‘Oxford Questionnaire on the Emotional Side-effects of Antidepressants (OQuESA)’. Presently called the ‘Oxford Depression Questionnaire (ODQ)’, it is a 26 item self-report questionnaire covering 4 dimensions including Not Caring (NC), Reduction in positive emotions (PR), General reduction in emotions (GR), and Emotional detachment (ED). Another internet-based survey was conducted in six hundred and sixty-nine depressed patients undergoing treatment and one hundred and fifty recovered controls was conducted by Goodwin et al. in 2017. (4) The study found that emotional blunting was reported in nearly half of the patients being treated with monoaminergic anti-depressants.
RA Sansone and LA Sansone (2010) have separated the broad term of ‘Indifference’ into two approaches – Behavioral perspective and Emotional Perspective. They have also observed that the onset of the syndrome may be delayed and can be fully resolved by lowering and or discontinuing the medication. (5) Wongpakaran et al. conducted a case study in elderly patients undergoing treatment with SSRIs and non-SSRIs. One of the possible causes suggested was frontal lobe dysfunction due to serotonin alteration. (6) Opbroek et al observed that a treatment induced blunting of both positive and negative emotions including ability to cry and creativity. (7)
Other than anecdotal and published case reports, systematic studies of this syndrome are quite limited. In the recent years, a number of studies have been conducted by the epidemiology and etiology of these side-effects still remain clear. Being the most prevalent prescribed drug, it is important to advise the patients on how they might be affected and how to resolve these unwanted side-effects.