I’ve spoken about vision problems with certain medications and adverse reactions but lately, one of my most important S/Es to warn about is apathy. This can be scary if a patient or the provider is not aware of it and it basically made me come out of my cave to rant about it!
I somewhat touched on the topic of how SNRIs/SSRIs can eventually be less effective because of serotonin receptors. However, we can’t technically prove this phenomenon so I didn’t go into any real details and overall severe apathy can occur, regardless of the situation.
I could treat it as an adverse reaction, but I don’t want to mark something off that can be self-limiting or wasn’t given a full chance. I try to explain how medications take 4-6 weeks to work possibly due to side effects, not the reason to not prescribe them. Plus, most insurances only cover meds that have been out for 20 years. I try to limit adverse reactions to things that are truly difficult or life-threatening.
I’ve had patients who will tough it out, stabilize, and be fine but I definitely had others who I would consider hospitalizing if I wasn’t able to decrease the apathy. Communicating these risks and noticing the differences are KEY. I’m going to assume most providers like myself, do f/ups once a month for <15 minutes on a good day so the patient has to be just as diligent about these concerns as well:
Major Signs of Apathy
- NO MOTIVATION: this is not the same as ADHD or depression, which is life-long or associated with work, school, etc. What to watch for is a sudden NEW ONSET that’s isolated from any particular situation. Also, these people usually maintain their focus so it’s no need to start a stimulant. If the person has ADHD, then the culprit would still go back to the antidepressant, not increasing the stimulant. I’m just making this point because that’s what the patients would assume but just note they will still have apathy if you don’t do something about the antidepressant.
- Blunted/Limited Emotions: whether a situation is good or bad, the emotions are indifferent. The patient would complain that people think they have an attitude or are irritated when in actuality they feel the emotions but they can’t fully express them even though they really try…This is similar to mood incongruence and it’s not intentional. Usually, my patients know it’s a problem because they’re also perplexed, and instead of being happy about a wedding, baby shower, or even bad news, etc. they don’t have a clear emotional response and somewhat feel like my patient told me, sociopathic.
- Extra Increased Crying: this is tricky because the mood is restricted so why are they crying all the time without a source or a tragedy? It goes back to the first point, the lack of motivation -the person isn’t cleaning, tending to the family, self, or work, has guilt, shame, isolated (from not leaving the house/bed), scared (mainly because they think they’re on the verge of hurting themselves or doing something bad), they think they’re a disappointment/failure, regressing…etc. This is different from depression because the person is going into despair but it’s to get BETTER, not because life is getting worse.
How to Manage
Just to be clear, the person may have one or all of the symptoms above. The goal is to monitor for increased signs of apathy before the patient has a crisis. I do have some patients that want that apathy effect, but major symptoms will require some kind of intervention so I’ll go over a few considerations that helped me:
- COMMUNICATION: I know I sound like a broken record but before/during/after the apathy episode, there needs to be some form of understanding of what to do… First, calm the patient down and let them know, this is NOT them but mainly the medication. They need that reassurance so they won’t continue to feel hopeless. However, I still explained an increase in depression and/or any SI thoughts needs to be treated in the hospital to keep them safe from themselves.
- Look for other reasons for apathy: take note if the patient has certain conditions, medications, liver going bad, or other reasons that can affect the response to medications… It goes back to reassuring the patient to not blame themselves and the urgency to discuss some better options.
- Change or Decrease the med: so if I d/c or taper off the SSRI/SNRI, I would trial bupropion, atypical antidepressants, or usually go to lamotrigine. I’m trying to improve the apathy and stop the mood from getting worse. Sometimes my patients will just tell me, “I already stop taking the meds”, which is okay because they’re trying not to make the apathy worse so don’t beat them up. The depression is still there and could get worse, which is why you want a new treatment plan ASAP instead of waiting for the next follow-up. A quicker solution may be just lowering the dose and/or adding folic acid (to increase the supply of neurotransmitters).
- What NOT to do: this is my general rule for severe apathy/depression, I avoid TCAs, certain mood stabilizers/antipsychotics, or meds that are high maintenance, cause drowsiness (they need to get out the bed), and/or an OD. Lithium can be great but make sure the patient will be cooperative and reliable with the expectations so sometimes it’s my last resort. These people are already somewhat bummed out, so I try not to cause extra demands.
In Conclusion
There’s not much literature about apathy with medications. There was a Korean study suggesting how apathy was relieved after d/cing an SSRI and adding olanzapine, methylphenidate, and modafinil but the person had dementia. I wouldn’t prescribe a stimulant for apathy, it’s not approved or studied for that indication. You can stop apathy by simply d/cing the SSRI, the other meds weren’t necessary. Nothing technically treats dementia and many other illnesses, but with adults, I warned about apathy like it’s a complication because that’s how it would present. Quick Sidenote: women on their cycle, pregnancy, and kids/teenagers growing or whatever that will affect metabolism can also cause a breakthrough of psych symptoms BUT apathy is different…I’ll still switch or d/c the med depending on the severity and quickly prescribe something else. Alright, my rambling is complete.
Additional Information
- Antidepressants & Emotional Blunting: Causes, Symptoms & Treatment –Very Well Mind
- Is your antidepressant making life a little too blah? –Harvard Health
- Junko Ishizaki, Masaru Mimura, “Dysthymia and Apathy: Diagnosis and Treatment”, Depression Research and Treatment, vol. 2011, Article ID 893905, 7 pages, 2011. https://doi.org/10.1155/2011/893905 –Graphic Above
- Padala PR, Padala KP, Majagi AS, Garner KK, Dennis RA, Sullivan DH. Selective serotonin reuptake inhibitors-associated apathy syndrome: A cross-sectional study. Medicine (Baltimore). 2020 Aug 14;99(33):e21497. doi: 10.1097/MD.0000000000021497. PMID: 32871995; PMCID: PMC7437849.
- Sertraline-Induced Apathy Syndrome –Psychiatry Online
