A reader writes in:
I might suggest that in some cases, the more outre side effects of SSRIs are not reported because the person taking the drug is afraid of being thought insane. I had unbelievable rage while I was taking Effexor, and never told anyone about it because I was afraid of not being believed, and also afraid that there was something else seriously wrong with me.
I am a highly intelligent and naturally moral person, and never hurt anyone despite my desire to do so, though I did put my fist through a wall at one point. But I had extremely disturbing violent impulses while on the drug, including a desire to maim or kill my beloved cats, and a strong desire to physically assault the woman I was dating at the time. All of this vanished completely when I decided to voluntarily go off the drugs, which I had been told I would need for the rest of my life. As it happened, the psycho-emotional disorder I had was consistently missed by therapists and clinicians, and were not an appropriate treatment.
This may or may not account for the peculiar side effects, but at any rate -- my thought is that possibly these things go unreported due to shame and fear on the part of the patient.
So we don't give medical advise here on Shrink Rap. I borrowed this comment, however, because I'm struck with how often patients withhold critical information. If a patient tells me that since we started a medication, he's had a new symptom, if that symptom is intolerable to him, or in any way worrisome, I don't sit there thinking they are crazy. I stop the medicine. If the side effect sounds like it's a little uncomfortable but the overall quality of someone's life is better with the medication, I simply restate the facts and my thoughts about whether the good outweighs the bad, I let the patient chime in with their thoughts (I'm not in their body), and I consider the circumstances before the medication was started as well as the response to the medicine. If someone was suicidally depressed and unable to function , then maybe it's worth tolerating a dry mouth in exchange for the ability to return to work and not be sad or suicidal?
It's not just medications-- it's anything major going on in someone's life. If something huge is going on in a patient's life, the doctor needs to know. "I'm more depressed lately," has one meaning in the context of a medication change and another meaning in the setting of a recent loss.
What psychiatrists can't do is know what someone is experiencing without being told. We don't have crystal balls, we don't have ESP, we aren't mind readers, we don't "know" what you're thinking, feeling, worrying about, distressed by, unless a patient tells us in fairly precise terms.