Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder, anxiety disorders, and other psychiatric conditions.
SSRIs primarily work by blocking serotonin reabsorption (reuptake) via the serotonin transporter, leading to gradual changes in brain signaling and receptor regulation, with some also interacting with sigma-1 receptors, particularly fluvoxamine, which may contribute to cognitive effects. Marketed SSRIs include six main antidepressants—citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline—and dapoxetine, which is indicated for premature ejaculation. Fluoxetine has been approved for veterinary use in the treatment of canine separation anxiety.
SSRIs are the most widely prescribed antidepressants in many countries. In adults, they are recommended as a first-line treatment for moderate to severe depression, while for mild depression non-drug treatments are preferred unless the patient chooses medication. A 2018 meta analysis of 21 antidepressants showed that all antidepressants (including SSRIs) were more effective than placebo in adults with major depressive disorder.
Medical uses The main indication for SSRIs is major depressive disorder; however, they are frequently prescribed for anxiety disorders, such as social anxiety disorder, generalized anxiety disorder, panic disorder, obsessive–compulsive disorder, eating disorders, chronic pain, and, in some cases, for post-traumatic stress disorder. They are also frequently used to treat depersonalization disorder, although with varying results.
Depression
In adults In 2022, the UK National Institute for Health and Care Excellence (NICE) recommended that antidepressants be offered as a first-line treatment for moderate to severe depression, but for mild depression, non-drug interventions are preferred unless the patient chooses medication. They recommended that antidepressants should not be routinely offered for mild depression and should generally be used only if non-drug treatments fail or the patient prefers medication. In a 2018 review, all 21 studied antidepressants were more effective than placebo for major depressive disorder.
The commonly used definition of antidepressant "response" as a 50% symptom reduction dichotomizes continuous data, which methodologists note can inflate effect sizes, exaggerate drug–placebo differences, and may not reliably indicate clinical significance. A large FDA trial analysis found that SSRIs and other antidepressants produced only modest average benefits over placebo, with about 15% of patients experiencing a substantial drug-specific response. SSRIs and other antidepressants may have average treatment effects that fall below the minimal important difference on common depression outcome measures, leaving their clinical significance in acute moderate-to-severe depression uncertain.
There is no consistent evidence that depression is caused by lowered serotonin activity or concentrations, with some data suggesting that long-term antidepressant use may reduce serotonin levels.
In children The NICE Guideline recommends that SSRIs should not be used to treat depression in children and young people, except for fluoxetine, which may be considered for moderate to severe depression when psychological therapies alone are insufficient. In the United States, they are approved for use in pediatric patients; however, individuals under 25 years of age should be closely monitored for an increased risk of suicidality, as indicated by the FDA black box warning.
SSRIs have the best outcomes when combined with cognitive-behavioral therapy. Their benefits are modest and tolerability varies. The benefits may be clinically unimportant and there are uncertain effects on suicide risk.
Social anxiety disorder SSRIs show some evidence of effectiveness for social anxiety disorder, including reducing relapse and disability, but the overall quality of evidence is low to moderate and tolerability is slightly lower than placebo.
Post-traumatic stress disorder Two SSRIs are FDA-approved for PTSD: paroxetine and sertraline. The 2023 VA/DoD guideline for PTSD recommends the SSRIs sertraline and paroxetine as first-line pharmacological treatments when trauma-focused therapy is unavailable or not preferred; evidence for other SSRIs is insufficient, and medications are recommended to be tailored to each patient's individual needs. A 2022 Cochrane review found that SSRIs improve PTSD symptoms in 58% of patients compared with 35% on placebo (RR 0.66) and are considered first-line treatment.
Generalized anxiety disorder SSRIs are recommended by the National Institute for Health and Care Excellence (NICE) for the treatment of generalized anxiety disorder (GAD) in adults who have not responded to initial interventions such as education, self-help strategies, or psychological therapies.
SSRIs are more effective than placebo for treating GAD with similar overall acceptability, though they increase dropout due to adverse effects.
Obsessive–compulsive disorder In Canada, SSRIs are a first-line treatment of adult obsessive–compulsive disorder (OCD). In the UK, they are first-line treatment only with moderate to severe functional impairment and as second-line treatment for those with mild impairment, though, as of early 2019, this recommendation is being reviewed.
SSRIs are more effective than placebo for reducing OCD symptoms and global severity in children and adolescents, and combining them with exposure therapy is probably more effective than using an SSRI alone.
Panic disorder SSRIs are approved to treat panic disorder. SSRIs may be more effective than placebo in reducing panic disorder symptoms, but they are associated with a higher risk of adverse effects and may be less well tolerated.
Eating disorders Antidepressants are recommended as an alternative or additional first step to self-help programs in the treatment of bulimia nervosa. SSRIs (fluoxetine in particular) are preferred over other anti-depressants due to their acceptability, tolerability, and superior reduction of symptoms in short-term trials. Long-term efficacy remains poorly characterized.
Similar recommendations apply to binge eating disorder. SSRIs provide short-term reductions in binge eating behavior, but have not been associated with significant weight loss.
Clinical trials have generated mostly negative results for the use of SSRIs in the treatment of anorexia nervosa. Treatment guidelines from the National Institute of Health and Clinical Excellence recommend against the use of SSRIs in this disorder. Those from the American Psychiatric Association note that SSRIs confer no advantage regarding weight gain, but that they may be used for the treatment of co-existing depression, anxiety, or OCD.
Stroke recovery SSRIs have been used off-label in the treatment of stroke patients, including those with and without symptoms of depression. A 2021 meta-analysis of randomized controlled clinical trials found no evidence pointing to their routine use to promote recovery following stroke. A 2022 meta-analysis of randomized controlled trials suggested that citalopram could improve dependence, motor ability, and cognitive function in stroke patients, without similar findings for fluoxetine.
Premature ejaculation
SSRIs are effective for the treatment of premature ejaculation. Taking SSRIs on a chronic, daily basis is more effective than taking them prior to sexual activity. The increased efficacy of treatment when taking SSRIs on a daily basis is consistent with clinical observations that the therapeutic effects of SSRIs generally take several weeks to emerge. Sexual dysfunction ranging from decreased libido to anorgasmia is usually considered to be a significantly distressing side effect which may lead to noncompliance in patients receiving SSRIs. However, for those with premature ejaculation, this same side effect becomes the desired effect.
Other uses SSRIs such as sertraline are effective in decreasing anger, and fluoxetine has been proven effective in reduction of attack frequency and intensity for Raynaud syndrome.
Side effects Side effects vary among the individual drugs of this class. They may include akathisia.
Sexual dysfunction SSRIs can cause various types of sexual dysfunction such as anorgasmia, erectile dysfunction, diminished libido, genital numbness, and sexual anhedonia (pleasureless orgasm). Sexual problems are common with SSRIs. Poor sexual function is one of the most common reasons people stop the medication.
The mechanism by which SSRIs may cause sexual side effects is not well understood . The range of possible mechanisms includes (1) nonspecific neurological effects (e.g., sedation) that globally impair behavior including sexual function; (2) specific effects on brain systems mediating sexual function; (3) specific effects on peripheral tissues and organs, such as the penis, that mediate sexual function; and (4) direct or indirect effects on hormones mediating sexual function. Management strategies include: for erectile dysfunction the addition of a PDE5 inhibitor such as sildenafil; for decreased libido, possibly adding or switching to bupropion; and for overall sexual dysfunction, switching to nefazodone. Buspirone is sometimes used off-label to reduce sexual dysfunction associated with the use of SSRIs.
A number of non-SSRI drugs are not associated with sexual side effects (such as bupropion, mirtazapine, tianeptine, agomelatine, tranylcypromine, and moclobemide).
Several studies have suggested that SSRIs may adversely affect semen quality.
While trazodone (an antidepressant with alpha adrenergic receptor blockade) is a notorious cause of priapism, cases of priapism have also been reported with certain SSRIs (e.g., fluoxetine, citalopram).
Post-SSRI sexual dysfunction Post-SSRI sexual dysfunction (PSSD) refers to a set of symptoms reported by some people who have taken SSRIs or other serotonin reuptake-inhibiting (SRI) drugs, in which sexual dysfunction symptoms persist for at least three months after ceasing to take the drug. The status of PSSD as a legitimate and distinct pathology is contentious; several researchers have proposed that it be recognized as a separate phenomenon from more common SSRI side effects.
The reported symptoms of PSSD include reduced sexual desire or arousal, erectile dysfunction in males or loss of vaginal lubrication in females, persistent premature ejaculation (even in patients without a previous history of the condition), difficulty having an orgasm or loss of pleasurable sensation associated with orgasm, and a reduction or loss of sensitivity in the genitals or other erogenous zones. Additional non-sexual symptoms are also commonly described, including emotional numbing, anhedonia, depersonalization or derealization, and cognitive impairment. The duration of PSSD symptoms appears to vary among patients, with some cases resolving in months and others in years or decades; one analysis of patient reports submitted between 1992 and 2021 in the Netherlands listed a case which had reportedly persisted for 23 years. The symptoms of PSSD are largely shared with post-finasteride syndrome and post-retinoid sexual dysfunction, two other poorly understood conditions which have been suggested to share a common etiology with PSSD despite being associated with different types of medication.