SSRIs are the most widely used class of psychiatric medications, helpful for depression, anxiety, OCD, panic, PTSD, anger, and certain personality disorders (Why should the same drug treat all these things? Great question!) They’ve been pretty thoroughly studied, but there’s still a lot we don’t understand about them.
The SSC Survey is less rigorous than most existing studies, but its many questions and very high sample size provide a different tool to investigate some of these issues. I asked fifteen questions about SSRIs on the most recent survey and received answers from 2,090 people who had been on SSRIs. The sample included people on all six major SSRIs, but there were too few people on fluvoxamine (15) to have reliable results, so it was not included in most comparisons. Here’s what we found:
1. Do SSRIs work?
People seem to think so:
Made me feel much worse: 6%
Made me feel slightly worse: 7.4%
No net change in how I felt: 23.7%
Made me feel slightly better: 41.4%
Made me feel much better: 21.4%
Of course, these statistics include the placebo effect and so cannot be taken entirely at face value.
2. Do some SSRIs work better than others?
I asked people to rate their experience with the medication, on a scale from 1 to 10. Here were the results:
Lexapro (356): 5.7
Zoloft (470): 5.6
Prozac (339): 5.5
Celexa (233): 5.4
Paxil (126): 4.6
Paxil differed significantly from the others; the others did not differ significantly among themselves. In a second question where participants were just asked to rate their SSRIs from -2 (“made me feel much worse”) to +2 (“made me feel much better”), the ranking was preserved, and Lexapro also separated from Celexa.
This ranking correlates at r = 0.98 (!?!) with my previous study of this taken from drugs.com ratings.
I don’t generally hear that Paxil is less effective than other SSRIs, but I have heard that it causes worse side effects. The survey question (probably wrongly) encouraged people to rate side effects as “negative efficacy”. My guess is that the difference here is mostly driven by side effects.
3. Do SSRIs work better for anxiety than for depression?
I’ve heard a few people mention this, and it makes sense as one reason why they remain so popular among patients and doctors while rarely producing large effects on specialized depression tests.
On the same scale as above:
Anxiety (391): 5.9
OCD (24): 5.8
Depression (1203): 5.3
Panic (26): 5.5
Anger (26): 5.2
There is a pretty strong effect in favor of anxiety over depression. There were not enough OCD, panic, or anger patients to get a clear picture of where those fell in relation to the other two. As far as I know this is the first study to back this claim up. But since I didn’t directly ask about dose, we can’t rule out that doctors give higher doses for anxiety and higher doses work better.
4. How many people experience side effects on SSRIs?
70% of people taking the drugs had at least one of the side effects on the list below:
(on this list, mild is exclusive of severe. So for example if 10% of people had mild side effects and 5% of people had severe side effects, a total of 15% of people had at least mild side effects)
MADE DEPRESSION WORSE:
The more recently someone took the SSRI, the more side effects they were likely to have. While I can imagine innocent explanations for this, the most likely is recall bias: after a while, people forgot about some side effects. The real numbers are probably a little higher than this.
Most people’s side effects went away quickly after stopping the SSRI, but 15% of people who stopped the medication more than five years ago said their side effects never went away. Although post-SSRI-sexual-dysfunction is sort of known to the psychiatric consensus, this is a shockingly high number, which doesn’t seem consistent to me with how little you hear about this; I’m not sure what to think. The survey wasn’t really designed to ask which side effects these were, but just eyeballing the individual entries it looks like mostly sexual, with a small amount of emotional thrown in. But these are just the two most common side effects, so it doesn’t necessarily mean these two are more persistent than others.
5. Do some SSRIs produce worse side effects than others?
I think the psychiatric consensus on this question is that Paxil has worse side effects than the others, which are all equal.
This survey failed to directly replicate that. Four of the five side effects elicited (sexual difficulties, fatigue, emotional blunting, cognitive problems) were the same across all drugs. The only one that differed was worsened depression, which was slightly less common on Zoloft. This was technically significant but given the number of tests I would not put too much stock in this.
I forgot to ask about a few important side effects, including weight gain. I suspect that Paxil scored worst on the “overall” category because it produced worse side effects in the categories I forgot to ask about, or because people remembered it had side effects but couldn’t remember exactly what they were. Overall this survey doesn’t really make me doubt the consensus that it is probably worst.
6. How many people have trouble discontinuing SSRIs?
Good question! This has been a topic of interminable debate in the medical community, with some saying these problems are very common and others saying they are very rare. This survey found:
59% don’t remember having any issues at all
22% remember having a few minimal issues but not really thinking about them
14% remember having moderate issues that caused significant distress but were not disabling
5% remember having severe issues that seriously impacted quality of life
6. What factors made SSRI discontinuation easier or harder?
Hard to tell.
Everyone believes that a more gradual taper makes things easier, but the survey quite clearly found that people who reported longer tapers had worse problems. I’m pretty sure this is because if their doctor expected them to have problems (or they started it and did have problems) they put them on a longer taper. But this kind of thing makes it hard to make any real recommendations. However, people who came off their medication accidentally because they ran out did have by far the worst time, suggesting that cold turkey discontinuation really isn’t the way to go.
The longer a person had been on SSRIs, the harder their taper was likely to be. However, I’ve heard some people give overly dire warnings like “If you’re on these drugs for more than five years, don’t try coming off”. These were not justified. Even among people who were on the medication over five years, 49% tapered with “no issues”, and only 15% reported severe issues.
People with anxiety and OCD reported more difficult discontinuation than people with depression. This could be either because these conditions require higher doses, or because people with anxiety and OCD are more likely to notice and worry about minor symptoms.
Psychiatric consensus says that Paxil is the hardest SSRI to get off, and Prozac is the easiest. This survey confirmed that result. On a scale from 0 – 10, where 0 is the easiest discontinuation and 10 is the most difficult:
Prozac separated from Zoloft, Lexapro, and Paxil, but not from Celexa. The average person had only a 59% chance of having no discontinuation symptoms; the average person on Prozac had a 71% chance.
In any case, almost everybody’s taper was successful eventually. Only 0.5% of people said they gave up and stayed on the SSRI because they found discontinuation too difficult.
This survey had few surprises.
Already when giving someone an SSRI, I debate between Lexapro and Prozac. Lexapro is usually the most effective (by a tiny hair), but Prozac is the least likely to cause discontinuation syndrome. Although a natural strategy might be to taper Lexapro (or something else) very slowly in order to match Prozac’s slow half-life, studies show this doesn’t work (why not?), and this survey confirms it. There is no obvious right answer between these two as first-choice SSRI. This study does confirm my prejudice that giving Paxil is an obvious wrong answer and you should never do it outside specific rare circumstances.
The main surprise was the high number of people who claim their SSRI side effects never went away. Although this is a known very rare possibility, the survey suggested it was much less rare. One can imagine innocent ways this could happen: for example, someone goes on SSRIs for ten years, comes off, and is surprised to find their sex drive is lower than it was when they were a teenager ten years ago. This probably requires more careful and rigorous study than can be done in a silly online survey – and so will probably never happen.
Scott, what do you think of microdosing psychedelics like LSD compared to SSRI or other traditional antidepressants?
I’m not Scott, but don’t do this. I did this and it amplified depression/anxiety in a way that I’d never experienced these two feelings before. I’ve had positive experiences with these psychedelics, which is what makes it tempting, but say it out loud from the skeptics perspective and you’ll realize it’s not a good idea – “Why don’t I just do a little bit of these incredibly mind altering drugs every day”
Scott, what do you mean when you use the word “significant” in this post? Which p-value did you choose?
And, since you are running many tests on this survey data, did you apply any statistical correction (e.g. Bonferroni) ?
0.05. These weren’t the result of a fishing expedition (you can see some preregistrations) so I didn’t worry about corrections too much.
Multiplicity != HARKing (hypothesizing after the results are known)
I took Paxil for anxiety for about 11 months 12 years ago when I was 28.
Before I took it I had no problems sexually, since a week taking it I’ve been completely impotent with no improvement at all.
I haven’t been told anyone because
1. AFAIK there aren’t any treatments.
2. They might tell me they think its psychological, and want me to jump through the associated hoops etc.
3. I’m not in a relationship and can’t see myself being in one in the near future.
Sorry this happened to you. If you ever decide to open up about it to a doctor, ask them about buspirone and bupropion, which can sometimes help SSRI-related sexual dysfunction. Also Viagra/Cialis/etc, which work about as well for PSSD as for anything else.
Scott, over the past 6 years or so I’ve been prescribed each of the 6 SSRIs, each with significant negative side effects. However, my psych team here in Detroit won’t prescribe an SNRI. I’m wondering if you could reccomend any good psychiatrists in SE Michigan?
If you want to be 100% sure it is not psychological, I would recommend a trick from Robert Sapolsky’s book. He says that all men naturally get erections in their sleep, unless they have a physiological issue. His cheap test for whether or not you have psychologically induced ED is to wrap stamps or a piece of paper around your penis while you sleep. If you wake up with the paper torn, you have ED that’s psychological.
I presume in your case it is physical, just figured I’d post as someone whose “physical” sexual dysfunction turned out to be mostly psychological in the end.
Long time reader, first time commenting. I took Paxil for a couple of months, about fifteen years ago. Discontinued because it didn’t help my depression, the emotional blunting was awful(I was in a world of grey, somehow much worse than the usual grey of depression), and I went from being very interested in food and sex, to being hardly interested at all. I don’t feel that my interest in sex or food ever fully
recovered to pre-Paxil levels. I’m female, late 30s.
What are the chances your sample is biased on this? After all, you do talk on and on about SSRIs on this blog. I don’t remember you mentioning SSRIs having long effects after ending use, but still.
I’m still struck by the fact that it does make depression worse for some people (I guess most drugs have paradoxical responses) which makes me wonder the extent to which their efficacy can be attributed to regression to the mean.
In other words are SSRIs like a safe way to give your brain a slap and see if anything shakes loss. Keep trying and eventually, you might see success.
To cash this out more precisely I guess the question is how likely do you think it is that SSRIs have only a very minimal or indirect relationship between the underlying syndromes called depression.
I have a good friend who tried SSRIs for anxiety. They worked, for that purpose–but they also gave her severe depression and completely destroyed her sex drive.
One suggestion for a tie-breaker between Lexapro and Prozac: fluoxetine is on Walmart’s $4 drug list, escitalopram is not (it’s $9 for a month’s supply). Depending on your patient population, you may see easier access boosting compliance with Prozac vs Lexapro.
This has been my hunch for my own history. I’ve been on and off antidepressants for 16 years now (since I was 17), and my drive ain’t what it used to be. But at the same time, there’s still a very clear difference in sexual function between when I’m on and off SSRIs.
No matter which SSRI I take, I’ve never noticed the “emotional blunting” thing people talk about, so I’m somewhat surprised and heartened to learn I’m in the majority there.
Your findings seem roughly inline with a 2018 meta-analysis of 21 different antidepressants, with the notable exception of Paxil. Annotated forest plot: https://imgur.com/4gbJk54
Meta-analysis (on which Ioannidis is listed as an author, which increase my trust): https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32802-7/fulltext
Minimally related: any idea why tianeptine isn’t prescribed in the US? The studies I’ve read indicate that it has good efficacy, few side effects and low addictive potential (the latter is at odds with internet/reddit reports, but I suspect that people consume massively more tianeptine when using for recreational purposes than the 35mg dosage in these studies).
I’ve got a review here where I compare it to the other study this one correlated at 0.98 with; I didn’t think they were too similar.
Ah should have known you had scoured that meta-analysis already. TBH I took the meta-analysis as authoritative because Ioannidis is listed as an author. Perhaps I have too much trust in meta-experts.
A few thoughts:
1) What role do you think heterogeneity of effects plays? If we had perfect data from all planned subgroup analyses and pooled those effects, might we see reduced variance for certain groups?
2) re: “pharma-sponsored trials are about five times more likely to get positive results than non-sponsored ones” – what is your thinking on the relative biases and motivations at play? For example, what is the motivation of non-COI’d researchers in the study on antidepressants? What are their relative rates of null result publication? Is it possible that the non-pharma funded studies are more likely to be underpowered, due to economics? Research on research integrity ironically can suffer from the same study design & statistical problems of the research it studies. (Perhaps this is covered in the study you cite; I’ll give that a read)
2.a) As an aside, I read many clinicaltrial.gov preregistrations these days and find that those produced by pharma companies are more comprehensive and well-structured. In certain respects, I think they are less sloppy than certain academics. It’d be interesting to analyze Academics vs Pharma: who ultimately produces more reliable research? I’m not convinced its the former.
(Btw, np if you don’t want to re-open the can of worms of discussing this meta-analysis.)
We had someone at some point who reported (ETA: persistent) sexual side effects, and I suggested that they try masturbating more frequently to see if that helped (as I suspect sex drive may have a “set point” behavior, where our bodies tend to expect about the same amount of sex as they have been recently getting). Does anyone know if they reported back?
How many of the sexual dysfunction cases can be due to correlated issues. For example, if people usually take SSRIs for 6 months, what percentage of people of similar age would experience sexual dysfunction across the same time period. Also, dealing with impotence, what possibilities exist that vasculature issues responsible for ED might also be responsible for depression?
Seeing these tightly bunched ratings I’m reminded of what Chekhov supposedly said about treatments for disease: if there is one recommended treatment, that’s good, but if there are several, and all are considered equally effective, that means none of them work and the disease is incurable. I watched the first episode of The Sopranos (1999) recently, and it was almost painful to see how excited the characters were about the new antidepressants.
There is a pretty strong effect in favor of anxiety over depression.
One possible explanation for that is that anxiety is experienced more strongly than depression; in numerical terms, depression runs from zero to five and anxiety from zero to ten. A decrease in anxiety from eight to six is felt as a greater effect than a decrease in depression from four to three.
Are these results publishable?
We can only read them because Scott just published them..
If he gets another to psychiatrist to spend some time and chime in, it’ll be even peer reviewed.
He can probably add more information about the calculations he did and use LaTeX to make a nice pdf to upload to arxive, too.
I was curious about why Effexor (Venlafaxine) wasn’t asked about.
Is it not prescribed so much anymore? I gather it’s very close to Lexapro chemically, but people I know and my own experience showed that it produces a pretty different effect profile. For awhile it seemed like Effexor was being prescribed very quickly after the first antidepressant (often Zoloft) didn’t yield the desired results, and that it was seen to be more effective but also with more side effects and one of the biggest discontinuation syndromes.
It’s not an SSRI and I didn’t want to venture into other antidepressants.
As Scott says, Effexor (venlafaxine) is an SNRI. The question is interesting to me, though, having tried it. I was prescribed Effexor for depression when I was in my mid-thirties, a little over twenty years ago. I noticed one side effect immediately: halos of color around objects in my visual field, similar to those one might see during a trip on LSD or psilocybin. Having had positive experiences with psychedelics, I took this as a sign that the drug was working. The colors went away after two days or so.
I developed a remarkable emotional flatness and gained a lot of weight. My sex drive was not greatly affected, and I had no difficulty in getting or keeping an erection, however, it became almost impossible to come to orgasm. This effect seemed to me also very similar to the effect of psychedics, so I was not greatly surprised.
Within a few months (I don’t remember how many) I quit the drug; although I cannot remember any specific symptoms I recall this phase as being quite unpleasant and disorienting. I expected my sexual function to recover, and it did, but not completely.
Before Effexor I was used to trying to delay orgasm during sex, afterwards I became used to trying consciously to hurry it up — sex became less rewarding as a result.
Of course my sexual function has continued to change with age; the time and effort required for orgasm has continued to increase and I cannot say whether it is the same as it would have been without Effexor. My sex drive has naturally also decreased, but that is neither unexpected nor, really, unwelcome.
I have not taken any psych medications since, and would be reluctant to do so. I would not take Effexor under any circumstances.
Yes, I’d forgotten you were limiting this to SSRIs. I was disappointed because like Buttle here I had quite a lot to say about Effexor.
I experienced Effexor (post-partum depression, and had already tried Zoloft and Lexapro and gotten partial help but not enough) as a sledge hammer nuclear bomb. It did eradicate the depression, but also nearly every thing else. Wow, what a powerful drug that is. Two months of discontinuation syndrome, OMG what a nightmare.
While I was on it, layers and layers of crazy nightmare dreams, waking up out of one into another and yet again into another, like nothing I’ve ever remotely experienced. My hair fell out (not all of it, but a lot). Same experience as Buttle describes in terms of sexual side effects. Wow, did I mention what a powerful drug that was? I hope to never touch it again as long as I live. But kind of glad it exists for the very most serious situations that it might help. That was not my situation and it seems pretty inappropriate that it was prescribed to me.
After that I was prescribed Wellbutrin (brand name) which was totally fine until the next refill was filled with generic (by Teva) and it was clearly metabolized differently because I had that serotonin syndrome nightmare, which passed in about twelve hours after I realized I was having a drug-related reaction. Very very scary.
I felt by the end of my year of adventure through four different antidepressants and several things on the side to manage the side effects and discontinuation syndromes that I could write a book about that year. None of the depression I experienced came near to being as bad as all of that and once I finally made it through the discontinuation syndrome from the Effexor and survived the generic Wellbutrin, I was no longer depressed. Today if that happened again, I think I would hook myself up with some hallucinogens with all due speed. (not recommending that across the board, just what I would do)
Anyway, I’m glad there are drugs. And boy do they suck.
People with anhedonia often report it was caused by ssris even after stopping them. For example here : link text
Is it fair to say “stay off of anti-depressants if you can at all avoid them”?
The negative consequences might only affect a minority of people, but seem quite sure.
The negative consequences of untreated depression are also reported to be quite severe.
It’s fair to say “stay off of medicine if you can at all avoid it.” Because every medicine has potential negative effects. That’s why the Hippocratic oath starts, “first do no harm.” A large part of that is, don’t administer treatment if you can avoid it. There’s nothing special about antidepressants in that regard.
But, as Evan P said, for many people untreated depression and anxiety are far worse than the side effects of antidepressants. Every treatment choice should involve a weighing of the risks vs benefits for that individual person. Also, there is no good evidence (Scott’s data above notwithstanding) that any of the common antidepressant side effects are permanent even a small amount of the time. Sometimes you just have to try a medicine to see if the tradeoffs are acceptable to you.
The unexpectedly high percentage of people experiencing what they think might be irreversible harm to their sexual function is scary. Even more so because so many people are first put on SSRIs in adolescence. Both the parental pressure aspect to this and the lack of informed consent aspect to this are really disturbing. I work with quite a few young adults who are resentful of the fact they were put on SSRIs in their teens as a result of what seems to them in retrospect to be “designated patient” effects — meaning the family system was messed up, so they were medicated.
My sense is that many prescribing doctors still don’t adequately inform their patients about the well-known potential risks of SSRIs, even when most of those risks (aside from suicide) are seen as temporary and/or reversible. How can we begin to prepare kids and their parents for the real possibility that these drugs might permanently impact their sex lives?
As an aside, I’d read somewhere awhile back that some women report similar effects of having taken birth control pills in adolescence. I don’t know if there’s been more research done on this, but it feels like another potential arena of risk to a group of patients who are choosing an intervention without adequate information about possible long-term costs. Is there even a theoretical group of researchers who would have the resources and incentives to look into such a thing?
I also wonder why SSRIs are so commonly prescribed given their side effects. Why not the more benign bupropion as a first choice? Probably even ketamine is less harmful.
Epistemic status: physician and psychiatric patient, currently using Bupropion
AFAIK, the side effects of bupropion (seizures and increased chance of suicide) tend to be more feared by psychiatrists. Also, it supposedly has a tendency to increase anxiety, and since depression and anxiety disorders tend to be comorbid, SSRIs are preferred
Yes, I’m with you about bupropion. My memory is the risk of seizure turned out to scare doctors away but was overblown when the research was looked at more closely. It does seem harder for people with anxiety to tolerate at least at the beginning, but watching people adjust to that it seemed to me that the increased agitation often subsides. I’ve seen this happen even with very high anxiety people, but as with all these drugs, it’s pretty individual.
The lack of sexual and other side effects with bupropion suggests to me too it should be considered more first-line and that some patients could be supported through the increased agitation to see if it subsides in order to avoid the more problematic side effects of the SSRIs. It seems like bupropion can also help with motivation for some people with depression in a way that the SSRIs don’t always do as well, but that’s an anecdotal impression.
I hadn’t read that bupropion had an increased risk of suicide that’s significantly greater than other antidepressants. Do you have a source for that?
I don’t have a proper source at hand; I remember hearing in medical school that, when used for smoking cessation, it had an increased risk of suicide, but a cursory review of the literature seems to show newer studies found no correlation
“Benign” is in the eye of the beholder. It seems not implausible that if you prescribe teenagers the drug that will cause 0.01% of them to have seizures, 0.01% of their parents will sue you for bignum dollars, whereas if you prescribe teenagers the drug that will cause 10% of them to have dramatically reduced sex drives, 10% of their parents will thank you.
Could you add the generic names for the SSRIs? US-specific brand names don’t tell me much without googling.
Is it significant that the distribution of opinions about efficacy of SSRIs (section 1) looks surprisingly close to the distribution of opinions about whether SSC meet ups are enjoyable from the Irvine meeting thread?
This is not a coincidence because nothing… nah, it’s a coincidence.
You are one of the biggest outlets to discuss post-SSRI-sexual-dysfunction. It’s possible that some of your readers came to the blog because of that post, giving your readers a higher than average share of the population.
One can imagine innocent ways this could happen: for example, someone goes on SSRIs for ten years, comes off, and is surprised to find their sex drive is lower than it was when they were a teenager ten years ago.
My sex drive is nearly gone these days, but part of me wonders if that’s just because I’m in my 40s. I do plan to talk to my doctor about it.
I was on Citalopram for a year and a bit, and my final verdict was that the effect (in terms of simply not having any depressing thoughts, and I can say that I definitely didn’t for that period) wasn’t worth the overall cost to me in terms of feeling a bit muffled, sexless and numb.
Also, the experience of going on them and then off them again really made the whole exercise even more unpleasant. (One feels for about a week like one has been on a class A bender for a weekend – like, you know, if you turn your head too quickly, you feel a bit dizzy.)
I’d say the more likely explanation is that those who experience severe side effects quit taking it so anyone who has been taking it for a long time will belong to the group that doesn’t suffer severe side effects.
I went through what I considered (and two shrinks considered) a serious depressive episode when I was in my late 30s (I wrote about it here: ). I flatly refused to take medication. My shrink sent me to a second shrink to try and convince me. I have no greater insight to offer. I don’t judge people who take it, nor do I think they made a mistake that I avoided.l
My rationale was simple: If medication made my depression go away, then my medication was making me…not me. I know others don’t feel this way.
I know people who change their names on a whim and I’m like what the hell? Your name is you.
I made it through. I think my fear of death had something to do with it.
Yeah, people seem to differ in… willingness to change their aspects.
I am probably at the opposite end of the scale. Well, I usually don’t change things about myself, but that is mostly habit and laziness. The idea of a change doesn’t scare me existentially.
For example, I am not changing my name, because then I would have to remember the new one, and people around me would be confused. But if someone offered me a lot of money for changing my name irreversibly, I would be like “okay, here comes the easy money”. Especially if I could choose the new name, i.e. it would not be something silly or difficult to pronounce.
I would be afraid to make changes that have a potential to make me stupid. Like, if there is a pill that replaces depression with mania, I wouldn’t take it, because maniacs do crazy things. But just making the depression go away with no side effects… sure, I would take such pill at any moment. Just like I would take a pill to make a physical illness go away.
My reasoning — which is probably a rationalization, and therefore utterly unconvincing for you — is the following: People change all the time. It’s usually called “growing up”.
At some moment in your personal history you were shitting in diapers. Good luck you weren’t too scared to grow out of it! Now what makes your current state so privileged, compared with your previous states?
Or, imagine that you start exercising, to improve your health, but as a side effect the exercise will also make you a bit less depressed — does this thought also make you about exercising? Are you worried about eating chocolate, or walking in sunshine? Because all these things change your mood a bit.
Wow, that’s the 100% opposite way I view the world. I barely associate myself with my name at all, it’s just a command word to get my attention. I wake up every day and am a brand new person, stuffed full of memories of some past idiot’s life. I’m a new person every day. Not necessarily a better or worse person, but definitely there is no chain of me-ness stretching back through time.
One of the nice things about being 50+ is the reduced sex drive! Never been on any of the drugs mentioned and my sex drive is about half what it was at 30. Thank God!
But no sex drive? Don’t think I’d like that.
I would like to comment on the mysterious condition known as PSSD.
I’ve done alot of research over the years on this and found the majority of people suffering SSRI induced sexual dysfunction, are also suffering the symptoms of anhedonia, and alot of other symptoms that match the diagnosis for severe depression.
Is it possible that SSRIs worsen a person’s depression, or makes it manifest in a different form? We know well that sexual dysfunction, and anhedonia are seen in depression.