Copyright 2006 by the American Psychological Association 0002-9432/06/$12.00 DOI: 10.1037/0002-9432.76.1.134 Emotional Effects of Sertraline: Novel Findings Revealed by Meditation Use of selective serotonin reuptake inhibitors continues to increase, as does concern about previouslyunrecognized, subtle side effects and questions about whether these drugs produce effects on healthysubjects. The authors report novel emotional effects identified by an experienced, psychologicallyhealthy meditator who is a psychiatrist and researcher. On a meditation retreat, the subject identified aspecific profile of emotional changes related to sertraline use. In particular, cognitive abilities and theemotions of fear and anger seemed unaffected. However, the emotions of sadness, happiness, rapture, andlove were dramatically reduced in intensity and duration.
Keywords: sertraline, meditation, emotion In recent years, the use of selective serotonin reuptake inhibitors reduced measures of negative affect and hostility and increased (SSRIs) has increased dramatically, making them among the most scores on social affiliation in healthy subjects (Knutson et al., commonly prescribed medications in medical practice. This in- 1998). A third study found that paroxetine and sertraline induced crease reflects both pharmacological and social factors. In terms of impairment in measures of cognitive, attentional, and psychomotor pharmacology, compared to earlier antidepressant compounds, function in healthy, older adults, even though none of these sub- SSRIs have fewer side effects, lower lethality, and a broader jects complained of related difficulties (Sherman, 2002). Clearly, spectrum of action. Social factors include an increase in the ap- there is cause for concern about possible subtle psychological side parent incidence and severity of depression as well as increased social acceptance of antidepressant therapy by both patients and A novel approach to investigating subtle effects of SSRIs is to clinicians (Borch-Jacobson, 2002; Jain & Jain, 2002; Kramer, utilize subjects with exceptional introspective abilities. Consider- 1993; Olfson et al., 2002; Pignarre, 2001).
able evidence now supports classic claims that meditation practice However, there is growing concern that SSRIs may have pre- may significantly enhance perceptual capacities. Perceptual sensi- viously unrecognized, subtle side effects, such as apathy and tivity, discrimination, processing speed, and empathy all appear to cognitive blunting. The American Psychiatric Association Text- be enhanced, as measured by, for example, reaction time, evoked book of Psychiatry (Hales, Yudofsky, & Talbott, 1999) refers to potential, Rorschach, tachistoscopic, and phenomenological re- “apathy syndromes,” characterized by “loss of motivation, in- ports. These perceptual changes are associated with a wide variety creased passivity and feelings of lethargy and ‘flatness’” (p. 1038).
of psychological, biological, and therapeutic effects, including More dramatic extensions of this phenomenon, such as a “frontal changes in dopamine activity (for reviews, see Kjaer et al., 2002; lobe” syndrome, have also been reported (Abel, Igbal, & Holzer, Murphy & Donovan, 1997; D. Shapiro & Walsh, 1984; S. Shapiro 1998; Garland & Baerg, 2001; Hoehn-Saric et al., 1991; Hoehn- et al., 2002; S. Shapiro & Walsh, 2003; Walsh, 2000; Walsh & Saric, Lipsey, & McLeod, 1990; Opler, Ramirez, & Lee, 1994).
Vaughan, 1993; West, 1987). We therefore offer a case study of an Recent research has also examined whether these medications experienced meditator who reported intriguing effects of sertraline exert effects on people who are not suffering from Axis I diag- on meditation experiences and affect.
noses. Goodwin (1997) expressed the belief that any drug thatalters abnormal personality is likely to alter normal personality as well. However, to date, the research data have been mixed. Onestudy found no effects of fluoxetine on self- and observer-rated measures of mood, general well-being, or quality of life in healthy The subject, Roger Walsh, was a 51-year-old caucasian male trained in subjects (Gelfin, Gorfine, & Lerer, 1998). Conversely, paroxetine medicine, psychiatry, and neuroscience who had practiced meditation forover 20 years. That the subject had developed a degree of perceptual andintrospective sensitivity is suggested by the amount of meditation practice, Roger Walsh, Department of Psychiatry and Human Behavior, College teachers’ evaluations, his phenomenological reports, and the results ob- of Medicine, University of California, Irvine; Bruce Victor, MD, Depart- tained when he was a subject in a study of meditators’ perception (Brown ment of Psychiatry, Medical School, University of California, San Fran- & Engler, 1986a, 1986b; Walsh, 1977, 1978). He was in good physical and cisco; Robin Bitner, MD, Department of Psychiatry, Langley Porter Psy- mental health, except for a diagnostically undefined gastric motility disor- chiatric Institute, University of California, San Francisco.
der, for which SSRIs were prescribed. A trial of fluoxetine resulted in We thank Drs. Owen Wolkowitz, Shauna Shapiro, Lorena Hillman, and disabling side effects of lethargy, abulia, and amotivational syndrome.
Frances Vaughan for their helpful comments on this article.
He was subsequently switched to 50 mg sertraline daily and remained on For reprints and correspondence: Bruce Victor, MD, Department of this for a year. The only side effects identified during this time were mild Psychiatry, Medical School, University of California, 1819 Union Street, insomnia, occasional anorgasmia, and reduced frequency and intensity of San Francisco, CA 94143. E-mail: peak experiences. Peak experiences are brief altered states of conscious- ness marked by feelings of ecstatic affect and a transpersonal self-sense, subject was taking sertraline, they were dramatically less intense that is, a self-sense extending beyond the usual personal, egoic, and and less long lasting than in any previous retreat.
somatic boundaries. Peak experiences can occur spontaneously in anyone Ceasing and recommencing sertraline provided further observa- but are especially common in psychologically healthy individuals and in tions. After the subject ceased all sertraline, the emotions of long-term meditators (Maslow, 1971; Alexander, Rainforth, & Gelderloos, sadness, happiness, rapture, and love slowly reverted to their usual intensity and patterns. At the end of 5 days, there was significant,though still partial, normalization. However, during those 5 days the subject’s gastric motility disorder exacerbated significantly,and on the 5th day he resumed 50 mg sertraline per day. Over the The subject did a 3-week retreat to practice the Buddhist brahma vihara remaining 3 days of brahma vihara practice, the four emotions of meditations, 2,500-year-old practices that focus on transforming emotions sadness, happiness, rapture, and love once again regressed to less (Goleman, 1988; Tin, 1975; Walsh, 1999, 2000). The brahma vihara intense and less enduring profiles. The net result of this cessation practices employ the continuous recitation of appropriate phrases to culti- and recommencement of medication was a tidy, albeit inadvertent, vate emotional qualities, such as love and compassion. Done continuously three part ABA single-case study design, a design that is particu- over days or weeks, the effects can be dramatic. The desired emotions, suchas love, may develop to remarkable degrees, as may accompanying emo- larly valuable for assessing intervention effects in single individ- tions, such as happiness and rapture,1 and related qualities, such as con- uals (Masters, Burish, Hollon, & Rim, 1987).
In these meditative states, the mind is described as remarkably pliant or malleable. Just as a person trained in relaxation can rapidly elicit anexperience of calm, so, too, an experienced brahma vihara meditator is said to develop “mental pliancy” and can quickly elicit specific mentalqualities, such as those just described (Epstein, 1975; Nyanaponika, 1998; There are clearly significant limitations to this study. First, it was a single-case study using only subjective measures. Futurestudies would benefit from using multiple subjects and both sub-jective and objective measures. Second, the ABA design, though valuable, was suboptimal, as the 5-day washout B phase and the For the first 6 days of the retreat, the subject continued to take final C phase, in which sertraline was reintroduced, were both 50 mg sertraline daily. For the next 5 days, he reduced this to 25 relatively short. Third, the fact that the subject is a psychiatrist may mg as part of a preplanned gradual withdrawal to observe how the perhaps make his observations more clinically astute but also gastric motility disorder responded. During these initial 11 days (6 raises the possibility of expectancy effects.
on 50 mg and 5 on 25 mg), he observed that the effects of the However, there are several factors that suggest that the observed brahma vihara meditations were very dramatically less marked changes were significantly more than expectancy effects. These than in previous retreats he had done of this kind. In particular, the include the dramatic nature and intensity of the changes and their emotional qualities of happiness, rapture, and love, which previ- specificity. In addition, the subject had not noticed any emotional ously had been intense to the point of ecstasy, were now far less effects during the previous year or on a previous retreat doing a intense and faded more rapidly than in the past.
different kind of meditation and so was not expecting emotional After 11 days, the subject realized that this difference might be effects to emerge at this late stage.
due to the sertraline. He therefore immediately began a systematic Despite these significant limitations, the study offers unique exploration of its subjective effects and, after a day, ceased taking opportunities and data. These include the rare—indeed, unique— the medication. This exploration made use of the mental pliancy— combination of observations by a mental health professional with the ability described above that brahma vihara meditations con- long-term introspective training, identification of a novel and fer— of eliciting certain mental qualities at will.
highly specific profile of SSRI-induced emotional effects, and the A specific profile of medication effects on mental qualities and finding that these effects were observable only during a specific capacities was observed. There were no discernable effects on kind of intensive meditation practice.
nonemotional factors. For example, when the attentional and cog-nitive factors of concentration, initial attention, and sustained attention2 were elicited, they appeared to arise to their normaldegree and then to follow their usual pattern of diminishing slowly This report holds several implications. First, it suggests that over a matter of minutes. The same was true of the emotions of constrictive emotional side effects can begin at low doses, indeed, at what would be considered an appropriate “starting” dose of However, a very different intensity and time course were ob- sertraline. Second, this report demonstrates how subtle and diffi- served for the four emotions of sadness, happiness, rapture, and cult to detect these side effects can be, as the subject first identified love. When deliberately elicited, each of these emotions began toarise as usual and could be clearly experienced. However, within 1 Rapture is an intense joy or ecstasy associated with concentrated, clear a matter of seconds and before peaking, they simply disappeared awareness, accompanied by pleasurable somatic sensations and piloerec- and could no longer be felt. In particular, the three positive emotions of happiness, rapture, and love are usually extremely 2 The classical Pali terms found in meditation texts for these mental strong and enduring during brahma vihara retreats, far more capacities are ekagatta (concentration), vitakka (initial attention), and powerful than at any other time. However, on this retreat, while the vicara (sustained attention).
the decline in affective range only while on a meditation retreat.
tional effects became strikingly obvious. Only in retrospect did he Thus, although the subject did not experience the full frontal lobe recognize as a drug effect a slightly heightened sense of equanim- syndrome described in some articles, he did note a drastically ity during the previous year and Vipassana retreat.
reduced ability to attain exceptionally positive and salutary emo- This equanimity was confirmed independently by two people. A tions and states of mind. Third, this article, therefore, corroborates meditation instructor spontaneously commented that the subject’s previous reports regarding affective constriction but extends pre- experiences seemed just like those of someone doing an equanim- vious findings by pointing to a specific profile of affective ity meditation practice. Likewise, the subject’s wife, herself a psychologist, spontaneously retrospectively described the subject Fourth, the present report suggests that sertraline and perhaps as having been “more mellow and easier to get along with” while other SSRIs may inhibit some exceptionally positive and salutary he had been on sertraline. This suggests that family members may emotions and states of mind, such as those cultivated by contem- sometimes be more sensitive to subtle behavioral changes than are platives. Fifth, there is a disconcerting possibility that some of the the subjects themselves and that interviewing family members may inhibition may be chronic. In part because of his long-term med- be a valuable research strategy for detecting such changes.
itation practice, the subject was used to periodically experiencing If the subject’s experiential and behavioral changes do reflect a highly valued peak experiences during daily life. These were drug-induced increase in equanimity— or what the psychiatrists reduced in frequency and intensity while he was taking sertraline, Zetzel (1970) and Kramer (1993), respectively, called affect tol- and this reduction seemed to continue, and only slowly recover, erance and experience tolerance—this would be consistent with a recent study of meditators taking antidepressants who claimed that Sixth, because the subject was not suffering from an Axis I one of the drug’s most dramatic effects was to enhance equanim- mood or anxiety disorder, these observations corroborate reports ity. These reports of heightened equanimity, both in this article and that SSRIs may induce psychological effects in healthy individuals in the group study, suggest that an increase in equanimity might be (Knutson et al., 1998; Sherman, 2002). However, this report also a factor accounting for the remarkably broad-ranging therapeutic extends Knutson et al.’s findings to include more subtle negative benefits of SSRIs (Bitner, Hillman, Victor, & Walsh, 2003).
changes as well as the positive ones they described. Furthermore, The subject’s initial failure to recognize drug-induced subjective the highly specific profile of emotions affected is consistent with changes is consistent with the growing concern that there may be the claim that these agents could provide researchers with power- a wide range of subliminal psychological side effects of pharma- ful tools for the ‘pharmacologic dissection’ of distinct phenome- cological agents that usually go unrecognized—for example, pos- nological aspects of normal personality (Knutson et al., 1998).
sible effects of some cholesterol-lowering drugs on attention, The seventh pharmacological implication concerns meditators dexterity, and car accidents (Muldoon, 1997). Perhaps meditators needing antidepressants. There are now several million meditation and other introspectively trained subjects may be able to detect practitioners in the United States alone, and this population seems subtle side effects and alert researchers to variables warranting particularly resistant to using medications, in part because of concerns about possible costs to their practice and in part becauseof lack of available information on such effects (Carr, 1999; Epstein, 1993; Moon, 2001; Victor, 1996, 1999). The present studysuggests that there may be possible costs but that they may perhaps Though limited by its single-case design, this report suggests a be limited to specific types of meditation.
number of important possible implications. (a) Pharmaceuticalsmay induce a variety of usually subliminal side effects, (b) med- Using Meditators for Psychopharmacological Research itators may be able to recognize some of these and alert researchersto them, and (c) different types of meditation may be differentially For much of the 20th century, introspection was anathema to effective in revealing these side effects. (d) SSRIs may have experimental psychology but essential to clinical psychology and effects—including affective constriction— on psychologically psychiatry. Within recent years, the balance has shifted, and in- healthy individuals, (e) may produce a specific profile of effects on trospection is increasingly recognized as a valuable, even essential, different affects, and (f) may limit the intensity not only of strong component of psychological and neuroscientific research (Flanna- negative emotions but of strong positive emotions also. These gan, 1991, 1997; Varela & Shear, 1999; Wallace, 2000). In addi- implications suggest that more sophisticated studies of medita- tion, it has been suggested that individuals trained in both science tors—such as double-blind, placebo-controlled designs employing and introspective disciplines, such as meditation or yoga, might both subjective and objective measures—are warranted to attempt prove especially valuable subjects (Tart, 1972, 1975; Wallace, to detect subtle psychological effects of pharmaceuticals.
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