What are the common side effects of Selective Serotonin Reuptake Inhibitors (SSRIs) that the SADMANS pneumonic helps remember in patients, particularly adults or adolescents with a history of depression or anxiety disorders?

SADMANS Mnemonic for SSRI Side Effects

The SADMANS mnemonic helps clinicians remember the most common side effects of SSRIs: Sexual dysfunction, Anxiety/Agitation, Diarrhea/GI distress, MAO inhibitor interactions (serotonin syndrome), Appetite/weight changes, Nausea, and Sweating/Sleep disturbances. 1

Sexual Dysfunction (S)

• Sexual dysfunction is the most prominent and underreported side effect of SSRIs, occurring in the majority of patients but often not disclosed in clinical trials 1, 2
• Specific manifestations include delayed ejaculation or ejaculation failure (14-17% in males), decreased libido (6-11% overall), anorgasmia, and erectile dysfunction 3, 4
• Paroxetine demonstrates significantly higher rates of sexual dysfunction compared to other SSRIs like fluoxetine, fluvoxamine, and sertraline 1
• Sexual side effects are strongly dose-related and represent a leading cause of treatment discontinuation and non-compliance 3, 2

Anxiety/Agitation (A)

• Behavioral activation and agitation occur commonly, particularly early in treatment (first month) or with dose increases 3
• The American Academy of Child and Adolescent Psychiatry recommends slow up-titration and close monitoring, especially in younger children, to minimize this risk 3
• Anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, and akathisia have been reported across all age groups 4, 5
• Behavioral activation typically improves quickly after dose reduction, distinguishing it from true mania/hypomania which may persist and require active intervention 3

Diarrhea/GI Distress (D)

• Nausea and vomiting are the most commonly reported adverse effects and the leading cause of SSRI discontinuation, occurring in 21-30% of patients 3, 1, 4
• Diarrhea/loose stools affect 18-24% of patients, with sertraline showing higher rates than other SSRIs 1, 4
• Other gastrointestinal complaints include dry mouth (9-16%), constipation (4-8%), dyspepsia (6-13%), and abdominal pain 3, 1, 4
• Approximately 63% of patients receiving SSRIs experience at least one adverse effect during treatment 3

MAO Inhibitor Interactions/Serotonin Syndrome (M)

• Concomitant use of SSRIs with MAO inhibitors is absolutely contraindicated due to severe risk of serotonin syndrome 3, 6
• Serotonin syndrome is characterized by mental status changes (confusion, agitation, anxiety), neuromuscular hyperactivity (tremors, clonus, hyperreflexia, muscle rigidity), and autonomic hyperactivity (hypertension, tachycardia, diaphoresis, hyperthermia) 3
• Advanced symptoms include fever, seizures, arrhythmias, and unconsciousness, which can be fatal 3
• Risk increases dramatically when combining SSRIs with other serotonergic medications including opioids (tramadol, meperidine, methadone, fentanyl), stimulants, dextromethorphan, triptans, and illicit drugs 3, 6
• Serotonin syndrome occurs in 14-16% of SSRI overdoses 3

Appetite/Weight Changes (A)

• Changes in appetite and weight occur commonly with SSRI treatment 1
• Anorexia affects 2-8% of patients, while some SSRIs (particularly paroxetine and mirtazapine) cause higher weight gain than sertraline or venlafaxine 1
• Weight changes are dose-related and vary significantly among different SSRIs 1

Nausea (N)

• Nausea is the single most common side effect, occurring in 21-30% of SSRI-treated patients compared to 9-18% with placebo 1, 4
• The American Academy of Family Physicians identifies nausea as the most frequent reason for treatment discontinuation 3, 1
• Nausea typically occurs early in treatment and may improve with continued use 1

Sweating/Sleep Disturbances (S)

• Increased sweating affects 7-15% of patients across all SSRIs 3, 1, 4
• Insomnia occurs in 16-28% of patients, representing a common reason for discontinuation 3, 4
• Somnolence and fatigue affect 10-13% and 10-12% of patients respectively 3, 1, 4
• Sleep disturbances can be bidirectional, with some patients experiencing insomnia while others report excessive drowsiness 1

Additional Critical Side Effects

Neurological Effects

• Headache occurs in up to 25% of patients, making it one of the most frequently reported side effects 1, 4
• Dizziness (7-14%), tremor (5-11%), and paresthesias (2%) are common neurological complaints 3, 1, 4

Discontinuation Syndrome

• Sertraline and paroxetine are particularly associated with discontinuation syndrome, characterized by dizziness, nausea, headache, fatigue, irritability, anxiety, insomnia, and sensory disturbances 3, 6
• Symptoms typically occur following missed doses or abrupt discontinuation and resolve within 1-2 weeks 6
• Medication should be tapered rather than abruptly discontinued to minimize withdrawal symptoms 3

Special Populations

• In children and adolescents, additional side effects include fever, hyperkinesia, urinary incontinence, aggressive reaction, sinusitis, epistaxis, and purpura 4
• Third-trimester SSRI exposure causes neonatal withdrawal syndrome presenting with continuous crying, irritability, jitteriness, tremors, hypertonia, respiratory distress, feeding difficulty, and rarely seizures 6