On the Therapeutic Action of SSRI Medications

November 15, 2002. I read with interest Richard Gottlieb's “A Psychoanalytic Hypothesis Concerning the Therapeutic Action of SSRI Medications” and would like to comment on his suggestion that “the essential benefits of these medications derive from their capacity to modify aggression.”

The modification in aggression he describes has been well documented in the clinical and laboratory research literature (Fava 1998; Fuller 1996; Grimes and Milloni 2002). However, I think it is highly unlikely that serotonin reuptake inhibition—which creates a cascade of changes at the precortical and cortical levels—has such a unitary mechanism of action. While “selective” viz-à-viz serotonin reuptake inhibition, serotonin's effect on the brain is hardly specific. Antonio Damasio (1994), while supporting Gottlieb's general impression that enhancing serotonergic function tends to reduce aggression, also notes that “serotonin is one of the main neurotransmitters … whose actions contribute to virtually all aspects of behavior and cognition” (p. 76). Moreover, given the generally accepted importance of aggression in mental functioning among psychoanalysts, the improvement of any individual—by any means—will of necessity result in a modification of aggression in a favorable direction. However, this does not mean it is through a primary modification of aggression that the intervention has its effect. It is far more likely that the commonality Gottlieb is describing derives from the way in which serotonin reuptake inhibition—by virtue of its nonspecificity—can be therapeutic. Thus, many depressives experience a shift in their internal world whereby selfand object representations are less aggressively tinged. This is particularly striking, from the analytic perspective, in patients for whom masochistic character traits have appeared intractable. A study by Coccaro and Kavoussi (1997) specifically studied the SSRI fluoxetine and impulsive aggressive behavior in personality disorders and simila