Is it normal to feel worse before you feel better on antidepressants?

If you are having thoughts of suicide or self-harm, call or text the 988 Suicide and Crisis Lifeline, or chat at 988lifeline.org. In an emergency, call 911.

Starting an antidepressant (or having your dose increased) doesn’t always feel the way you’d expect. If you’re more anxious or on edge rather than feeling better, it’s easy to assume something has gone wrong. In most cases, nothing has, though it helps to know which feelings are expected and which ones aren’t.

Why some antidepressants may make you feel worse before they help

You’re not imagining it, and it isn’t a sign the medication is wrong for you.

Serotonin is a chemical your brain uses to send signals between nerve cells. It helps control your mood, your sleep, your digestion, and how anxious you feel. When the amount of it changes, all four can change with it.

SSRIs (selective serotonin reuptake inhibitors) are antidepressants that slow how quickly the brain reabsorbs serotonin, which leaves more of it active in the brain. The mood-lifting effect they’re prescribed for typically takes up to six weeks to build, a timeline we cover in our guide to starting treatment for depression. The gap between starting a medication and feeling its benefit is exactly why side effects can show up well before any relief does.

One leading explanation for why the early days feel this way is that a rise in serotonin activity may affect the brain’s anxiety-related circuits before it affects the circuits tied to mood.

SSRIs can temporarily increase anxiety in the first week or two on their own, which is why doctors often start at a lower dose when someone already has severe anxiety. Clinicians sometimes call this early reaction “SSRI activation syndrome”, and it has a fairly predictable set of symptoms.

What SSRI activation syndrome feels like

Activation syndrome can show up in the first one to two weeks of antidepressant treatment, or sometimes after a dose increase. It improves significantly as your body adjusts.

• Inner restlessness or a physically wired feeling, what clinicians call “hyperactivity” or “akathisia“
• Trouble sleeping
• Irritability
• Acting more impulsively than usual
• Heightened anxiety or edginess
• Stomach symptoms, including nausea, diarrhea, or loose stools

All of these symptoms are signs that your body is adjusting to the medication, and they typically improve after one to two weeks.

How long do the early side effects usually last?

As a general pattern, most early side effects tend to ease within the first few weeks as your body adjusts, while the medication’s own mood-lifting effect can take up to six weeks to fully build. Two different internal clocks are running at once, which is why early side effects may show up before the benefit does, but many early side effects become easier to manage with time.

When it’s normal, and when to call your doctor right away

Most of what you feel in the first couple of weeks is ordinary adjustment, but there are a few signs that are more serious. Knowing the difference can help you understand what to expect and when to reach out to your clinician.

What’s expected as your body adjusts:  

• Mild extra anxiety or restlessness
• A rockier few nights of sleep
• Feeling keyed up
• Headache
• Stomach upset, including nausea, diarrhea, or loose stools

Contact your doctor right away if you notice:

• Any thoughts of suicide or self-harm
• Agitation that feels severe or unbearable
• Symptoms that look like mania, such as euphoria, racing thoughts, or barely needing sleep
• Activation that isn’t improving after several weeks, or feels like it’s getting worse instead of better

Important: Antidepressants can sometimes unmask mania in someone who didn’t know they had bipolar disorder. Sudden manic-looking symptoms need prompt attention rather than a wait-and-see approach.

Antidepressants carry a boxed warning for increased suicidal thinking in young adults under 24, particularly in the early weeks of treatment or after a dose change. If you’re in that age group, or you started or changed a dose in the last few months, it’s worth letting family or a caregiver know the warning signs too, in case you’re not able to call your doctor yourself.

If you are having thoughts of suicide or self-harm, call or text 988 to reach the 988 Suicide and Crisis Lifeline, or chat at chat.988lifeline.org. In an emergency, call 911.

Serotonin syndrome

Serotonin syndrome is a separate, rare reaction, not part of ordinary activation symptoms. It causes a high fever, muscle twitching or stiffness, a racing heart, and confusion, and it needs emergency care the same day, not a routine appointment.

Should you keep taking it, or stop?

Don’t stop or change your dose on your own. Stopping some antidepressants abruptly can cause their own withdrawal-like symptoms. If the early period feels tolerable, staying the course while checking in with your doctor is a normal, common path.

Tell your doctor if symptoms continue to worsen after several weeks, or if side effects are making it hard to function day-to-day. They’ll weigh that against your history and decide what to do next. That might mean adjusting your dose or moving you to a different type of antidepressant.