What follow-up questions should be asked when managing a patient on a Selective Serotonin Reuptake Inhibitor (SSRI) for anxiety and depression?

Follow-Up Questions for SSRI Management in Anxiety and Depression

When managing a patient on an SSRI for anxiety and depression, you must systematically assess five critical domains at every follow-up: symptom response, suicidality, adverse effects, medication adherence, and environmental stressors.

Timing of Follow-Up Assessments

Contact the patient within 1 week of initiating SSRI therapy, then regularly at 4 and 8 weeks using either in-person visits or telephone contact. 1 Both methods are equally reliable for monitoring treatment response and adverse events in depression management. 1

Essential Questions to Ask at Every Follow-Up

1. Symptom Response Assessment

• "How are your depressive symptoms compared to when we started?" Use standardized instruments (PHQ-9 for depression, GAD-7 for anxiety) at baseline, 4 weeks, 8 weeks, and end of treatment. 1

• "Are you noticing any improvement in your anxiety symptoms?" Expect statistically significant improvement within 2 weeks, clinically significant improvement by week 6, and maximal improvement by week 12 or later. 1

• "Which symptoms are better, which are the same, and which are worse?" This helps distinguish between partial response and treatment failure. 1

2. Suicidality Screening (Critical at Every Contact)

Ask directly about suicidal thoughts at every assessment, especially during the first months of treatment and after any dose changes. 1, 2

• "Have you had any thoughts about harming yourself or ending your life?" 1

• "Have you noticed any new or worsening thoughts about death or dying?" 2

• "Are you having any sudden changes in mood, feeling more agitated, restless, or having trouble sleeping?" These may signal increased suicide risk. 2

The absolute risk of suicidal ideation with SSRIs is approximately 1% versus 0.2% with placebo (number needed to harm = 143), but close monitoring remains essential per FDA black-box warning through age 24. 1

3. Adverse Effects Monitoring

Systematically inquire about specific adverse effects using a checklist approach, as most emerge within the first few weeks of treatment. 1

Common Adverse Effects to Ask About:

• "Are you experiencing any nausea, diarrhea, or stomach upset?" These are the most common reasons for discontinuation. 1

• "How is your sleep—any trouble falling asleep or staying asleep, or sleeping too much?" 1

• "Have you noticed any headaches, dizziness, or feeling unusually tired?" 1

• "Any changes in your appetite or weight?" 1

• "Are you experiencing any sexual problems, such as decreased interest in sex or difficulty with arousal or orgasm?" Sexual dysfunction is common but often underreported. 2

Serious Adverse Effects Requiring Immediate Attention:

• "Have you felt unusually restless, agitated, or unable to sit still?" This may indicate behavioral activation, more common in younger patients and those with anxiety disorders. 1

• "Have you had racing thoughts, greatly increased energy, or felt like you needed much less sleep?" These suggest possible mania/hypomania. 1, 2

• "Any unusual bleeding, bruising, or nosebleeds?" Especially important if taking NSAIDs or aspirin. 1, 2

• "Have you experienced confusion, severe headache, muscle twitching, racing heartbeat, sweating, or fever?" These may indicate serotonin syndrome, a medical emergency. 1, 2

For patients with baseline anxiety symptoms, specifically ask: "Has your anxiety gotten worse in the first 2 weeks?" Early anxiety worsening may predict poorer outcomes in patients with significant baseline anxiety, though it does not predict poor response in those without baseline anxiety. 3, 4

4. Medication Adherence Assessment

Explicitly discuss medication adherence, as discrepancies between what physicians communicate and what patients remember are common. 5

• "Are you taking your medication every day as prescribed?" 1

• "Have you missed any doses? If so, how many in the past week?" 1

• "Do you understand how long you need to take this medication?" Clarify that treatment should continue for at least 4-6 months for a first episode. 1, 5

• "What concerns do you have about taking this medication?" Addressing concerns proactively reduces discontinuation. 5

Patients who receive explicit instructions about expected duration of therapy and have discussions about adverse effects are significantly less likely to discontinue treatment prematurely. 5

5. Environmental and Psychosocial Stressors

• "Have there been any new stresses in your life since we last spoke?" 1

• "How are things at work/school and at home?" 1

• "Do you have adequate support from family or friends?" 1

• "Are you having any financial difficulties or problems with housing, transportation, or other basic needs?" These practical problems can significantly impact treatment response. 1

Treatment Adjustment Algorithm

If symptoms are stable or worsening after 8 weeks despite good adherence, re-evaluate and revise the treatment plan. 1

• Add psychological intervention to pharmacotherapy, or vice versa 1
• Change to a different SSRI 1
• Increase dose if not at maximum (slowly titrate to avoid exceeding optimal dose) 1
• Consider referral to psychiatry for complex cases 1

Special Monitoring Considerations

For patients with history of alcohol abuse, monitor for signs of continued alcohol use, which worsens both depression and anxiety and reduces medication effectiveness. 6 Sertraline is preferred over benzodiazepines in this population due to significantly lower dependence risk. 6

For adolescents and young adults, monitor height and weight during treatment, and be especially vigilant for behavioral activation, which is more common in younger patients. 1, 2

Patients requiring 3 or more follow-up visits are significantly more likely to continue therapy, suggesting that frequent contact improves adherence and outcomes. 5

Critical Pitfall to Avoid

Never assume patients understand treatment duration or adverse effects without explicit discussion. Only 34% of patients report receiving instructions about medication duration even when 72% of physicians report routinely providing this information. 5 Discuss adverse effects proactively at every visit—patients who discuss adverse effects with their physicians are 51% less likely to discontinue therapy. 5