Practices

You can say what an SSRI does in one sentence. It blocks the doorway that carries serotonin back out of the gap between two nerve cells, so more of it stays there for longer and is likelier to be picked up.

Worth being able to say plainly, because most people are carrying something vaguer and more frightening than that. It also sets a fair expectation.…

Serotonin syndrome comes from stacking, and the second agent is usually something nobody thought to mention: a migraine tablet, a cough medicine, a herbal remedy for low mood.

Triptans, tramadol, dextromethorphan, linezolid and St John's wort all count, as do other antidepressants. Someone who mentions in passing that they…

The standing side-effect list is sexual difficulty, less appetite, an unsettled stomach, disturbed sleep and headache. Sexual side effects are common, and almost nobody raises them unprompted.

So ask directly, and ask about sleep while you are there. People do not usually announce these things. They quietly stop taking the tablet and say…

Match the tablet to the person rather than to the diagnosis. For someone flattened and slowed who has said clearly that they will not accept sexual side effects, paroxetine is close to the worst choice available.

It is the most sedating in the class, the least activating, and carries a high risk of exactly the effect they ruled out, with weight gain and the…

If you are the therapist, hand the prescriber the profile and leave them the pick. What you hold that they do not is what this person is like across a week, and what they will absolutely not tolerate.

So write those two things down and send them: the presentation, in plain description rather than jargon, and the non-negotiables. Not a drug name.…

If you know something about a person's history that the prescriber may not, say it. A past eating disorder or a single seizure can change what is safe to prescribe.

Bupropion lowers the seizure threshold, and in someone who is purging, restricting or very underweight that risk climbs meaningfully. The therapist…

If a treatment reliably produces strange sensations, describe them beforehand. Expected strangeness is far easier to sit through than strangeness that arrives unannounced.

With esketamine, feeling oddly detached from your body or the room is the drug doing what it does, not a sign of harm, and it usually clears within a…