This is really a question for your doctor.
this post was submitted on 02 Nov 2023
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I'll echo that this is really something to talk in depth with, with your provider.
That being said, I can relay what I've been told by providers along with the anecdotal.
Any antidepressant is going to need to "build up" in your system to keep you feeling better. But any pill is going to have a cycle through the day. You take it, and it needs time to get that pill taken up from your digestive tract. Towards the end of your dosage, the levels will dip slightly.
If you take it when you wake up, you're having that uptake process happen while you're trying to get going in the morning. If you take it before bed, by the time you wake up, the dosage is going to be stable. That stability will last through most people's normal day, when they need the effects the most. Your two times when the support of the medication are the weakest will be when you (theoretically) have the least external stressors, which is while sleeping.
Secondarily, bedtime rituals are easier to remember because there's no need to rush around getting ready for the day, leading to better compliance with stable dosage. You fall into the habit of bedtime, and there's less to interrupt that patterm.
Now, my personal experience is that taking the pills before bed is better because the affect on dreams is better. SSRIs are notorious for causing dream changes. I'm already hyperphanstastic (extra vivid dreams and mental imagery). If I take my dose in the morning, then I'm at the low point of the dose when sleeping, which tends to cause less pleasant dreams. Since the kind of dreams I have when I'm not on an antidepressant tend to be the sort you don't want, there's no way in hell I'm doing a morning dose as the norm. You really, really don't want the kind of nightmares I have with the hyper vividness I dream in.
Obviously, that's not going to be the case for everyone, but it is true that most people will have less dream disturbances if the take their dose before bed rather than in the morning. It's that gradual uptake minimizing the effects of the meds on dreams, and avoiding the disturbances that can be caused when a dose is falling off.
There's other little things as well, though they tend to be individual. An example of that is pain relief. If that's one of the effects you take them for, the pain reduction of a fresh dose is typically more useful while sleeping, and during the early part of your day.
I was always told to specifically take them in the morning because they give you energy. I've been on quite a few different ones and none of them have made me drowsy. If anything I might get a very slight bit of the opposite effect in that they keep me awake but even then it's barely noticable.
Should you really be asking this here?
Specifically, I do take my meds in the evening for this reason. No need for melatonin when the strattera brings the sleepy vibes.
My other reason is, since I'm doing IF, I don't want to take them on an empty stomach.
Those are just my reasons. Not sure if they help, just thought I'd contribute
My psych actually suggested I take my atomoxetine (for adhd) in the morning. I take the rest of them (to keep darkness at bay) at night.
I've only ever really taken them in the morning, I typically risk forgetting to take them in the evenings causing a headache for myself the next day. Beyond that I assumed most people took them in the morning.
Certain meds can make you drowsy and others can make you groggy but restless, the former are better before bed, the latter are better had in the morning.
What changes if you do not take the SSRI at all for a week or so?
So you normally can be ok for a day or so, might be a little bit more sensitive, some people get panic attacks/heightened anxiety, some get a feeling of emptyness or depression. It really varies on the individual, where they are and what's going on in their life.
There were days were I'd have a meltdown if I missed a day. By comparison; one day about a month or two after having stopped smoking tobacco due to having COVID, I felt like I didn't need it and just stopped with basically no negatives, though I was also in a good place in terms of my life which likely helped.
Personally if people are curious about SSRIs, I'd suggest they look into Vortioxetine, it's technically not an SSRI, which means it has much fewer side effects, but still does the same job as them, just with less foggy cognition/groggyness
If you quit SSRIs cold turkey then you're going to wind up with discontinuation syndrome (aka withdrawls). This is going to vary depending on the person so I am just speaking from personal experience. Typically this will mean your depression or anxiety comming back with a vengance. In my cas it hit way harder than it normally does when I'm just at my baseline unmedicated. I also got extremely agitated over the most minor things. Plus you've got all of the physical symptoms such as tremors, nausea, and bouts of cold sweats. Then you have the one withdrawl symptom that is unique to meds like SSRIs which is brain zaps (aka brain shivers, brain flips brain shocks). Brain zaps are really hard to describe. The best equivalent that I can think of is when you get your reflexes checked and you feel that reflexive muscle twitch; it's basically that feeling except it feels like its comming from right in the middle of your brain and it happens about once per minute for the entire duration of the withdrawls (1-2 weeks). It's not something that is painful but it is annoying, constant, and highly distracting. Basically every time one hit I would lose my entire train of thought which made it impossible to focus on even the most basic things. From what I understand noone knows what actually causes the brain zap sensation but one of the leading theories right now is that they're basically just micro seizures.
This is a very intriguing account, particular your description of the brain zap is highly interseting!
This can literally kill people.
SSRI Discontinuation Syndrome is a massive problem that can lead to severe lasting neurological and psychiatric effects. Starting from Tics, motion deficits, sexual dysfunctions to severe and life threatening mental health episodes (extreme episodes of depression and suicidal thoughts, mania, etc.)
Furthermore sudden intake of the old dose can elevate the risk for the acute life-threatening SSRI syndrome.
Guys and Gals, seriously:
Don't fuck around with SSRIs.
They are absolutely dangerous stuff and messing around with them without experience and training can absolutely ruin the rest of your life.
I started taking mine in the morning because the boost they give your brain can make your dreams unusually intense, resulting in less sleep or worse quality.
Depression I guess ...
Meds affect people differently. I tend to have paradoxical reactions to meds. Have learned to trust my instincts. I mention cuz it's good you're asking questions, educating yourself. Just keep in mind, figuring out what works for you may not match up with other people's experiences.
Paradoxical reactions to SSRIs are quite common and simply mean that the required levels are not yet reached - either by too low of a dose or by (much more common) not taking them long enough. SSRIs take 14-21d of taking the right dosage to properly work.
And please: Do not fiddle around with SSRI dosages and administration: This can absolutely kill or fuck someone up permanently.
Lot of what you said is true. Good advice many people should follow.
Just, paradoxical reactions are a bit more complex, took me decades to figure out. Nyquil has me curled in a ball, twitching, spasming uncontrollably. Nodoze sent me into a violent rage, up all night. Lot of meds, make most sleepy, but me, rush of energy, awake all night. Antipsychotics meant to calm me, instead out of control anger. Benadryl means eyes wide, pulse racing.
It had nothing to do with dosage, plasma levels, titration. There are just some people bizarrely hypersensitive to meds, who have the bizarre 1% side effects the other 99% doesn't get.
But for that 99%, everything you said is true, again good advice and info.
You are absolutely right in terms of most paradoxical reactions - and interestingly they even change during a patient's life. (Everyone working with mental health patients has a good story about a nana on a -pam going totally apeshit, throwing with faeces and definitely not getting any sedation from it).
Nyquil and Nodoz are actually quite common for paradoxical reactions,as are all Benzodiazepines. And there are patients who absolutely do react sensitive to medication. I am a good example for it myself: I am a fairly bulky guy but need minimal dosages for hypnotics like propofol - an amount I would consider barely sufficient for a 50kg nan knocks me out. Give me a Benzo on the other hand and I talk to you when others are already not breathing anymore.
SSRI are a bit different here, though. While I am absolutely sure, that classical paradoxical reactions exist they are extraordinarily rare, simply based on the mechanism of action the SSRI use. A true paradoxical reaction would mean that ones serotonin mechanisms react vastly differently - while this does occur it's extraordinarily rare, most common in already extraordinarily sick patients and would have led to other problems beforehand. There is overwhelming evidence that almost all cases reported are caused by the (almost physiological) initial paradoxical effect, insufficient plasma levels or insufficient adaptation times.
Again, there are patients who still will react strangely to SSRIs (and I am absolutely not a fan of them, I think they are an easy way out for a lot of providers but the cost/risk ratio does not really recommend them). And a lot of patients don't have a good experience with them. But that is not a paradoxical reaction but simply the difference between patients mental reaction to it. Which should be evaluated after proper dosage levels are achieved.
Why I am so particular about that topic? First off we see a lot of patients self therapy with SSRIs lately - changing their dosages, stopping them without any slow reduction,etc. That kills people. And from a broader stance we do see a lot of "self declared reactions" in patients. And that is a huge problem and a huge cost increase for the whole system.
(Buckle up fellas, grandpa is talking about the war again)
To stay with SSRIs: If someone has a proper paradoxical reaction to them we can no longer safely use Triptans against migraine, SNRIs, tricyclic antidepressants, MAOIs, amphetamines, pethidine, tramadol and heaps of other drugs as paradoxical reactions have been linked to Serotonin syndrome. I recently had someone report a penicillin allergy. 10% of all patients report it. Less than 1% of those have it. We couldn't properly interview the patient so we had to use alternative antibiotics. They are more expensive, often less powerful, often reserve-Antibiotics we try to avoid giving directly, have more side effects (in this case they led to the patient needing dialysis for quite some time. This is achieved by putting two finger sized catheters in your vessels. Not pleasant and definitely risky. (This is how I met her, we transferred her to a hospital being able to do that)
Wanna know what happened in reality with the penicillin? The patient took a course of it and suffered from diarrhoea for two days. That's a common side effect from the penicillin killing your gut flora. She told her GP and he explained it to her. When she moved she told her new GP about her "bad Penicillin allergy". Which led to this clusterfuck. There is a good chance the whole shebang she suffered from (Sepsis, Amputation, Dialysis, etc.) could have been avoided as the infection was highly sensitive to... penicillin....
Hope that anecdote explains why I am so critical about this topic. It's absolutely okay and necessary to recognise different drug tolerances (even more so as they are not considering gender, ethnicity,etc. most of the time) - but please do so openly with a healthcare provider and don't self diagnose.