Emotional blunting with antidepressants in major depressive disorder patients: A hospital-based cross-sectional study

Abstract

Background:

Around 40–60% of major depressive disorder (MDD) patients treated with either SSRIs or SNRIs have experienced emotional blunting. It is cited as a prevailing cause for discontinuation of antidepressant medications in patients with MDD.

Aim:

To determine the prevalence of emotional blunting with antidepressants in patients of MDD visiting psychiatric OPD in Kashmir.

Materials and Methods:

This was cross-sectional study conducted over a period of 18 months. A total of 369 patients were diagnosed as MDD as per DSM-5. A Hamilton Depression Rating Scale score of ≤7 and those on a single class of antidepressant for at least 2 months were taken up for the study. They were screened for emotional blunting, and those who responded in affirmative as mildly, moderately, or severely were further evaluated by asking them to finish the Oxford Depression Questionnaire.

Results:

The prevalence of emotional blunting in our study was reported to be 46.07%. The mean age of the participants was 40.9 ± 10.6 years with the majority being females (71%), married (69.38%), and from nuclear families (75.88%). Emotional blunting was most commonly associated with duloxetine (73.68%) and least with bupropion (31.82%). Nearly 40% of the patients had considered stopping their antidepressant due to emotional numbing.

Conclusion:

Recognizing and addressing emotional blunting is crucial in optimizing therapeutic outcomes and ensuring patient-centered care in depressive management. Given a significant number of depressive patients taking antidepressants may experience emotional blunting and subsequent discontinuation of the same. Routine assessment and timely management are essential for optimized clinical outcomes in patients with depression.

Major depressive disorder (MDD) has a multifactorial etiology with an estimated heritability of 35%. It affects one in six individuals during their lifetime, with the prevalence ranging from 5% to 17%, and is nearly twice as common in women.[1] The mean age of onset is around 40 years, although recent trends suggest a shift toward adolescents and young adults. It is one of the leading causes of years lived with disability (YLD) globally. By 2030, MDD is projected to be the second-largest contributor to the global disease burden, as measured by disability-adjusted life years (DALYs).[2]

Clinically, MDD manifests as persistently low mood and/or diminished interest in activities, along with various other symptoms like easy fatiguability, poor concentration, altered appetite or sleep, psychomotor changes, guilt or worthlessness, and suicidal ideation. According to DSM-5, these must last for at least 2 weeks and cause significant distress, with no history of manic or hypomanic episodes.[3]

Many theories have been postulated, like psychological factors such as childhood abuse have been linked to structural brain changes that predispose individuals to depression. Biologically, MDD is associated with dysregulation of monoamines serotonin, dopamine, and norepinephrine as well as plasma and CNS GABA deficiency. Endocrine abnormalities, particularly involving the HPA axis, thyroid, and growth hormone, have also been implicated.[4]

Among the less emphasized symptoms reported is emotional numbing or emotional blunting, which leads to a substantial reduction in quality of life. Patients may describe a diminished ability to feel emotions such as joy, sadness, anger, fear, love, or connection to others. This may lead to impaired judgment, reduced social engagement, and emotional detachment.[5] Emotional blunting differs from anhedonia, which is defined by reduced interest or pleasure, and apathy, which reflects reduced motivation and goal-directed behavior.[6,7]

Some consider emotional blunting a residual symptom of depression, while others suggest it may be an adverse effect of antidepressants, especially SSRIs. Studies show a correlation between emotional blunting and higher depression severity scores. However, emotional blunting has also been described in schizophrenia, PTSD, and prolonged grief disorder.[5]

Despite their efficacy, antidepressants, especially SSRIs and SNRIs, are associated with emotional blunting in approximately 40–60% of patients. Many patients describe “not feeling like themselves,” which can interfere with relationships, work, and treatment adherence, potentially leading to relapse. Emotional numbing was first noted among patients experiencing sexual dysfunction while on SSRIs and remains a common cause for discontinuation.[8]

A study showed that 45% of patients believed their antidepressant negatively influenced their emotions, and nearly 39% considered discontinuation.[9] However, patients often remain uncertain whether their blunted affect is medication-induced or related to life stressors.

Two primary hypotheses have been proposed to explain SSRI-induced blunting. The first suggests that increased serotonin alters frontal lobe activity due to its high density of 5-HT receptors, disrupting emotional regulation. The second involves indirect suppression of dopaminergic pathways in the prefrontal cortex via serotonergic modulation, aligning with evidence of inverse 5-HT and DA interaction.[10]

This work explores the prevalence of emotional blunting due to various antidepressants among depressed patients visiting the psychiatric outpatient department of a tertiary care hospital and addresses the gaps in literature by collecting information on this subject.

MATERIALS AND METHOD

Study area and design

This hospital-based, noninterventional, cross-sectional study was conducted at a tertiary care hospital. The study was carried out over 18 months, from November 2022 to April 2024. The sample size was not calculated for this study as it was a time-bound study for 18 months; we have mentioned this also as a limitation of our study.

The study included 369 patients diagnosed with MDD as per DSM-5 criteria,[3] presently in remission (Hamilton Depression Rating Scale (HDRS) score of ≤7), aged 18 years and above, who had been on a single class of antidepressant for at least 2 months and provided written informed consent. Patients were excluded if they had comorbid psychiatric disorders such as bipolar disorder, schizophrenia, intellectual disability, and substance use disorders or were taking other psychotropic medications like antipsychotics, antiepileptics, or mood stabilizers.

After obtaining informed consent, sociodemographic and clinical data were collected through a structured clinical interview and review of treatment records. Emotional blunting was screened using a validated question regarding the emotional effects of antidepressants. Patients who responded affirmatively (mild, moderate, or severe) were further assessed using the Oxford Depression Questionnaire (ODQ), while those reporting no such experience were not administered the ODQ. The Cronbach’s alpha coefficient was 0.91, with good test–retest reliability (0.69 and 0.82).[11] Data were recorded in Microsoft Excel.

Statistical analysis

Data were analyzed using SPSS version 23.0. Descriptive statistics were used for sociodemographic and clinical variables. Chi-square test was applied to analyze relationships between categorical variables, and appropriate statistical methods were used for continuous variables. A P value <0.05 was considered statistically significant.

RESULTS

A total of 369 patients diagnosed with MDD and in remission (HAM-D ≤7) were assessed for emotional blunting. Of these, 170 patients (46.07%) experienced emotional blunting, while 199 (53.93%) did not.

The sociodemographic and clinical correlates of emotional blunting are presented in Table 1.

Table 1.

Sociodemographic and clinical corelates of emotional blunting

	Emotional blunting (+) n=170	Emotional blunting (-) n=199	Total n=369	P
Age group
18-25	11	13	24	0.9844
26-30	26	25	51
31-35	23	30	53
36-40	22	29	51
41-45	22	32	54
46-50	29	35	64
51-55	12	20	32
56-60	9	15	25
61-65	6	9	15
Gender
Male	58	49	107	0.04512
Female	112	150	262
Marital status
Single	33	36	69	0.9379
Married	117	139	256
Separated	10	14	24
Divorced	10	10	20
Family type
Nuclear	118	154	272	0.2182
Extended	13	12	25
Joint	39	33	72
Residence				0.7260
Urban	56	69	125
Rural	114	130	244
Education				0.7687
Upto class 5	8	11	19
Upto class 10	8	9	17
Upto class 12/diploma	25	31	56
Upto graduation	46	54	100
Upto postgraduation	27	41	68
Higher than postgraduation	8	11	19
Illiterate	48	42	90
Occupation				0.006115
Government job	26	63	89
Private job	14	19	33
Business	19	23	42
Student	14	18	32
FARMER	3	4	7
Labourer	8	5	13
Unemployed	86	67	153
Socioeconomic status				0.1382
Lower	22	35	57
Lower middle	82	92	174
Middle	52	47	99
Upper middle	14	21	35
Upper	0	4	4
Total	170	199	369

The prevalence of emotional blunting across different antidepressant agents in depressed patients on monotherapy is shown in Table 2.

Table 2.

Prevalence of emotional blunting as per the antidepressant agent, evaluated in depressed patients on monotherapy

Antidepressant	Total patients receiving antidepressant, (n)	Emotional blunting (+)		Emotional blunting (-)
		Frequency (n)	Percentage (%)	Frequency (n)	Percentage (%)
Escitalopram	95	42	44.21	53	55.79
Fluoxetine	57	26	45.61	31	54.39
Sertraline	44	20	45.46	24	54.54
Venlafaxine	40	18	45	22	55.00
Paroxetine	30	13	43.33	17	56.67
Bupropion	22	7	31.82	15	68.18
Duloxetine	19	14	73.68	5	26.32
Mirtazapine	17	7	41.18	10	58.82
Desvenlafaxine	26	15	57.69	11	42.31
Vortioxetine	6	2	33.33	4	66.67
Others	13	6	46.15	7	53.85
TOTAL	369	170	46.07	199	53.93

The mean dosage of various antidepressants prescribed across the two groups is provided in Table 3.

Table 3.

Mean dosage of various antidepressants prescribed across the two groups

Antidepressant	Mean dosage±standard deviation
	Emotional blunting (+)	Emotional blunting (-)
Escitalopram	16.21±4.72	13.77±4.48
Fluoxetine	44.48±16.69	40.35±14.77
Sertraline	125±53.19	107.29±41.36
Venlafaxine	166.14±71.02	156.31±71.87
Paroxetine	25.04±6.19	23.53±6.06
Bupropion	300±86.60	290±89.04
Duloxetine	42.14±21.55	34.0±5.48
Mirtazapine	21.0±9.87	16.07±6.75
Desvenlafaxine	93.33±37.16	84.09±32.16
Vortioxetine	22.5±10.61	12.5±2.89
Fluvoxamine	150±61.57	105±63.64
Duloxetine	42.14±21.55	34±5.48
Clomipramine	125±35.36	100±0
Nortriptyline	56.25±12.5	50±0

The HAM-D scores along with the duration of illness and treatment are summarized in Table 4.

Table 4.

Values of HAM-D score and duration of illness and treatment

Mean±SD	Emotional blunting (+)	Emotional blunting (-)	P
HDRS Score	2.7±1.6	1.1±0.4	<0.001
Duration of illness	58.1±53.9 Median (IQR): 42 (24-72)	40.9±29.8 Median (IQR): 36 (24-54)	0.004
Duration of treatment	56.8±53.8 Median (IQR): 42 (20-72)	40.6±29.7 Median (IQR): 32 (22-54)	0.010

The scores for different domains of emotional blunting among depressed patients on monotherapy who were in remission (HAM-D ≤7) are detailed in Table 5.

Table 5.

Scores for different domains of emotional blunting among depressed patients on monotherapy, in remission (HAM-D ≤7)

Domain score	Emotional blunting (+)	Emotional blunting (-)	P-value
ODQ Total Score	74.6±27.7	29.4±9.1	<0.001
General Reduction (GR)	25.3±5.2	8.2±2.3	<0.001
Emotional Detachment (ED)	8.6±4.8	5.9±1.9	<0.001
Not Caring (NC)	14.1±5.5	7.0±2.4	<0.001
Positive Reduction (PR)	27.0±5.0	8.0±2.5	<0.001

DISCUSSION

As part of normal human experience, an individual may feel low occasionally in response to various life events. However, the diagnosis of MDD requires the omnipresence of low mood that impacts overall functioning across major domains of daily life. The prevalence of MDD has shown an upward trend. A 2023 national survey indicated that roughly three in ten adults (29%) have been affected by depression during their lifetime.[12] Another study estimated that approximately 280 million people globally suffer from depression, with the condition being 50% more prevalent among females than males, and known to occur in about 10% of women during pregnancy and postpartum.[13] A 2017 Mental Health Survey across 10 districts of Kashmir estimated a probable depression prevalence of 41%, with nearly 10% of the population meeting criteria for severe depression.[14]

While the condition can onset at any age, it typically begins in late adolescence or early adulthood. Nearly 700,000 individuals in this age group lose their lives to suicide every year, with depression often the underlying psychiatric comorbidity. If not treated in a timely and effective manner, MDD may significantly impair productivity during the prime years of life. Data from the NHS revealed that over 8.3 million patients in England received antidepressants in 2021–2022,[15] with SSRIs frequently prescribed. Emotional blunting was reported in 40–60% of SSRI users, with some studies suggesting prevalence rates as high as 71.[16]

Emotional blunting remains under-researched, with no universally accepted definition and an uncertain etiology. Clinicians in Kashmir now prescribe more antidepressants than previously, but research on emotional blunting from the region is lacking. Studying the prevalence of this phenomenon among MDD patients in Kashmir will enhance understanding and guide better management.

In this study, we explored associations between sociodemographic variables and emotional blunting in patients on antidepressant monotherapy. The mean age of participants was 40.9 ± 10.6 years, comparable to other regional and international studies.[17] The relatively higher mean age could reflect stigma among younger individuals delaying treatment. The prevalence of MDD was higher among females than males, consistent with broader research.[18] This disparity may be attributed to hormonal influences, sociocultural roles, and greater emotional expressiveness among women, while men may self-medicate, hide emotions, or display atypical symptoms like irritability or aggression.

Most participants were married, aligning with the average age of marriage and previous regional studies.[18] This is in contradiction to most of the studies conducted so far, indicative of depression being more prevalent among single, separated, or divorced people.[19] Our results may partly be influenced by the impact of our cultural and religious norms, that tend to uphold the ties of kinship and marriage.

The majority lived in nuclear families, a trend supported by regional census data and studies showing higher depression rates in nuclear setups.[20] Two-thirds were rural residents, again consistent with demographic data, although some research indicates higher urban depression rates, especially in older populations.[21,22] Depression was more prevalent among the less educated, consistent with several Indian and international studies. However, dissatisfaction among educated but underemployed individuals could also contribute to depressive symptoms. Half of the participants were from lower-middle socioeconomic backgrounds, in line with studies linking financial strain and lower income to higher depression risk. Patients from higher socioeconomic classes may seek private care, avoiding public facilities due to stigma.[23]

Among SSRIs, escitalopram is the most common, followed by fluoxetine, sertraline, and paroxetine. This matches trends from Malaysia and Singapore.[24,25] Escitalopram’s tolerability and free availability in the hospital supply may explain its preference in our study. SNRIs were the next most commonly prescribed medication. Our results are in favor with studies from India showing sertraline and escitalopram commonly prescribed antidepressants, although they differ from findings in some countries where TCAs remain prevalent, possibly due to prescribing practices, availability, and cost differences.[26,27]

The prevalence of emotional blunting in our sample was consistent with international studies reporting rates between 45% and 60%. Our findings correspond to those of Christensen et al.,[9] who reported emotional restriction in 45% of antidepressant users. The estimates of emotional blunting from our study are also comparable with most of the pre-existing data, reporting variable degrees of the experience of blunting as an adverse effect in 50–60% of the patients on SSRIs or SNRIs.[7] The rates of emotional blunting were similar across age groups and higher among males (54.21%) than females (42.75%), possibly due to men’s more negative perception of the phenomenon. The prevalence of blunting was also slightly higher among single and divorced participants, though the difference was not significant.

Among the antidepressants, duloxetine was most frequently associated with emotional blunting, supported by results procured by a study from Oxford University, in which a ‘restricted range of emotions’ was recounted by almost 75% patients taking the drug.[7] Another study by Bamford et al.[28] concluded that treatment with duloxetine was associated with reduced emotional recognition among healthy volunteers compared to placebo.

Bupropion, by contrast, had the lowest rate, possibly due to its dopaminergic mechanism, which supports emotional regulation. Our findings are in favor with studies showing bupropion is less likely to cause blunting and may even reverse it when used as an augmentation strategy with SSRIs or SNRIs.[29] Around 40% of participants considered discontinuing their medication due to emotional blunting, mirroring Western findings.[30]

The results of our study revealed that patients experiencing emotional blunting had higher HDRS scores at the time of study, in comparison to those who did not report numbing of emotions, suggesting that the phenomenon was related to the current depressive symptomatology. However, had the effect been a mere presentation of the disorder, its frequency would not be expected to vary among the medications prescribed. The phenomenon being a side effect of antidepressants is supported by lower rates of blunting with bupropion and duloxetine, compared to other drugs prescribed to our study participants. The findings are supported by Goodwin et al.,[7] who also found a similar trend of higher HDRS scores associated with higher ODQ scores in their study.[7] Our study found a significant difference in the ODQ scores of MDD patients with and without emotional blunting. We also found that the phenomenon of emotional blunting was directly correlated to the dose of the antidepressant, the duration of the illness, and the total time during which antidepressant monotherapy was received. A study from Oxford University found no correlation between the duration of treatment and the restriction of emotions.[6] We could not find any other study to support or refute our conclusions in this regard. So, our findings warrant further exploration into these variables to better understand and address emotional blunting in clinical practice.

Limitations

Our study lacked a control group for comparison, which is a significant limitation. We also did not calculate sample size prior to the conduct of study. Additionally, being a cross-sectional study restricts our ability to establish causality. Furthermore, the validity of our findings is constrained by the study’s design, which was uncontrolled, nonblinded, and time-limited, small sample size study potentially skewing the representation of the community. There is also a possibility of selection and recall biases affecting our results. Besides, our study was conducted among patients seeking care at a tertiary psychiatric treatment facility, so the findings may not be fully applicable to broader community or primary healthcare settings. Therefore, caution is advised when attempting to generalize our findings.

CONCLUSION

Recognizing and addressing emotional blunting is crucial in optimizing therapeutic outcomes and ensuring patient-centered care in depressive management. Given a significant number of depressive patients taking antidepressants may experience emotional blunting and subsequent discontinuation of the same. Routine assessment and timely management of this adverse effect are essential for optimized clinical outcomes in patients with depression.

Authors’ contributions

Concept, design, literature search: NN, DN, RM. Data acquisition: RM, NN. Data analysis: RM, DN. Manuscript preparation: RM, DN, ZAW. Manuscript editing and manuscript review: ZAW, RR.

Ethics approval and consent to participate

Approval from Institutional Review Board (Government Medical College, Srinagar) was taken (Ref No. IRBGMC-SGR/Psy/761, dated: 20/10/2022). All subjects gave informed consent.

Declaration of patient consent

The author transfers non-exclusive publication rights and confirms the originality of the work.

Data availability

Data can be made available on reasonable request.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.