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Given the impact spinal cord injury (SCI) has on mobility and function, being concerned about potential medical side effects is understandable. Depression and anxiety are more common in people with SCI, but good management of these conditions after an acute SCI can help with better rehabilitation outcomes and related functional recovery.

Medications are an important tool for managing SCI complications like pain, spasticity, and bladder dysfunction. As such, it is common for patients to be reluctant to add on another medication. As pharmacists, it is our role to help patients and families better understand and navigate the potential benefits and side effects with any new medication.

Treatment for anxiety and depression can range from medications, peer support, cognitive behavioral therapy, and more. Many people are reluctant to try medications for these conditions due to side effects and other risks, however it is important to also consider the potential benefits such as increased mood and reduced anxiety. These effects can improve a patient’s ability to participate in rehabilitation and normal day-to-day activities.

The mainstay of treatment for these two conditions are selective serotonin reuptake inhibitors (SSRI), serotonin norepinephrine reuptake inhibitors (SNRI), and tricyclic antidepressants (TCA). It can take up to four weeks after starting these types of medications to see an initial response to depression or anxiety, and up to 12 weeks to see whether the effects are appropriate or an adjustment is needed to get the desired result. Side effects usually occur within the first two weeks, so it is important to follow up with the prescribing physician to determine if changes are needed. There are also some additional benefits possible with these types of medications that might be helpful for some other chronic conditions, such as improvement in neuropathic pain and insomnia.

These classes of medications also have some uncommon side effects to consider. While they could happen to anyone, they may affect or complicate SCI related issues like spasticity and difficulty with temperature regulation. If your injury is T6 or above and you have noticed you don’t sweat when you’re hot, you may be experiencing how autonomic dysfunction affects your body’s ability to regulate your temperature. Medications like SNRIs, SSRIs, and TCAs may reduce your ability to sweat due to how they interfere with your body’s control of secretions, especially if combined with other medications like oxybutynin that have similar effects. Due to this decreased ability to sweat, your body may not be able to cool itself down, which could lower your heat tolerance and increase your risk of heat stroke. In this situation, it’s important to take steps to stay cool and avoid heat stress, like seeking out shade especially during peak times, staying hydrated, and using a fan or spray bottle.

A rare but known risk of these medications is serotonin syndrome, a collection of symptoms that include fever, muscle rigidity, muscle twitching, and high blood pressure that can happen to anyone but may complicate, worsen, or appear to mimic common SCI complications. People with SCI may already have muscle spasms secondary to their injury, which may increase their sensitivity to similar symptoms of serotonin syndrome. Unfortunately, there are not many direct studies of antidepressants comparing people with SCI to those without SCI to confirm whether there is an increased risk.

Serotonin syndrome can arise from an increase in activity in the central nervous system related to prescription and over the counter medications, herbal products, and medication interactions. It is important to always review and discuss any changes with a healthcare practitioner. To help prevent side effects, it is common for clinicians to start with increasing the dose slowly over a few weeks or months. Similarly, if stopping or switching medications, we typically taper them over a few weeks to avoid withdrawal side effects.

With these medications, side effects are often reversible and manageable if identified early. It is important to have a frank discussion with your healthcare provider about concerns related to the medications or your other conditions. Doing this will help us create a personalized medication and treatment plan, including what medications we can try, what to monitor for, and when to follow up to re-evaluate. There are a number of treatment options available and your healthcare team can create a plan to meet your end goals.

Remember that you may not need to take these medications forever. They are meant to help improve your current health and wellbeing to a level you are comfortable with. Communicate with your healthcare team throughout the process to determine if or when it’s appropriate for you to stop.