SNRIs
Adding norepinephrine: venlafaxine, duloxetine, desvenlafaxine
This topic helps you understand the medications your clients take so you can support them and communicate with prescribers. Never suggest starting, stopping, or changing a dose; that is always the prescriber's call.
The serotonin-norepinephrine reuptake inhibitors (SNRIs) add norepinephrine to the serotonin effect, which changes what they are good for and what they cost. This lesson covers when that trade is worth making, the blood pressure issue, and why stopping venlafaxine abruptly is its own problem.
The SNRIs: adding norepinephrine
How it works: Blocks serotonin reuptake at lower doses and adds norepinephrine effects as the dose rises, a second lever for energy, motivation, and concentration.
What clients notice: Both mood lift and more drive, sometimes with a wired feeling early on. A common next step when an SSRI has not delivered.
Watch for: Dose-related blood pressure elevation.
Your role: If a client reports sudden flu-like misery, dizziness, or brain zaps, ask about missed doses before assuming relapse, because venlafaxine discontinuation is fast and harsh. Watch for early activation, insomnia, rising anxiety, SI in younger clients, and any headaches or pounding that might reflect blood pressure. Psychoeducate hard on adherence and never running out.
How it works: Blocks reuptake of both serotonin and norepinephrine at all doses, helping mood and anxiety while also dampening pain signaling in the spinal cord.
What clients notice: Better energy, less pain interference, steadier mood. Clients with co-occurring depression and chronic pain may see both improve, which reinforces engagement in therapy and activity.
Watch for: Hepatotoxicity, particularly with heavy alcohol use or existing liver disease.
Your role: Screen for alcohol use honestly and revisit it, since duloxetine plus heavy drinking is a liver risk worth flagging to the prescriber. Useful frame for pain clients: the med treats pain and mood through shared pathways, not because the pain is imagined. Standard monitoring for activation, SI, and mania; urgent referral for jaundice, dark urine, or right-sided abdominal pain.
How it works: The active metabolite of venlafaxine. It blocks serotonin and norepinephrine reuptake with more predictable levels because it skips a liver conversion step that varies between people; clinically, a smoother, simpler venlafaxine dosed once daily.
What clients notice: Mood, energy, and concentration lifting over weeks, mirroring other SNRIs.
Watch for: Blood pressure elevation.
Your role: Same watch list as venlafaxine: missed-dose discontinuation symptoms masquerading as relapse or panic, early activation, SI in younger clients, and blood pressure complaints. Psychoeducate on strict daily adherence and not splitting or crushing the extended-release tablet. Urgent referral for manic switch, SI, or serotonin syndrome signs.
Sudden flu-like misery, dizziness, or brain zaps in an SNRI client usually means missed doses, not relapse. Ask about adherence before revising the treatment story.