Five Common Psychiatric Medication Pitfalls for Women—and How to Avoid Them

These five prescribing errors explain many early treatment failures—and each has a fix that can keep you stable and moving forward.

Many medication “failures” are process failures: the wrong starting speed, a missed timing signal, an ignored interaction, an unasked question, a rushed ending. You can do everything “right” — careful diagnosis, reasonable plan, good follow-up — and still get burned.

If you’ve ever decided, “Maybe I’m just too sensitive,” pause. In women, these five pitfalls show up early and often. Each has a fix that is practical, teachable, and usually simpler than adding another medication.

1) Starting an SSRI too high when you’re already anxious

SSRIs (antidepressants that boost serotonin) can help anxiety, but they rarely feel calming on day one. Early on, some people feel temporarily activated: jittery, nauseated, restless, wired, unable to sleep. If you start too high, that activation can feel like proof the medication is wrong for you.

Fix (patient): start low, then raise slowly. For the first two weeks, track once daily, not constantly: sleep, appetite, and your single worst anxiety spike. If symptoms are unpleasant but improving, you may still be on track.

Fix (prescriber): name the start-up phase before the first dose. When a patient expects a temporary “wired” week, they read it as a phase, not a problem. Also, avoid changing multiple variables at once when possible (caffeine, stimulants, sleep meds, SSRI dose). You want a clean signal.

2) Missing PMDD and calling it “treatment resistance”

PMDD (premenstrual dysphoric disorder) is not “bad PMS.” It is a phase-locked pattern: symptoms reliably worsen in the luteal phase (after ovulation, before period) and lift after bleeding starts. When that rhythm is missed, people get labeled “refractory,” and the plan turns into dose escalation, augmentation, switching, and more switching.

Three questions that often clarify the pattern faster than another checklist:

• “What are your worst 7–10 days of the month?”

• “Do you feel a clear lift within a few days of your period starting?”

• “Do you get at least one week where you feel mostly like yourself?”

Fix (patient): track daily symptoms for one cycle (mood, irritability, anxiety, functioning) and mark period dates. One month of good data can prevent years of false conclusions.

Fix (prescriber): treat the pattern, not the identity. When someone functions well most of the month but predictably decompensates during a specific window, increasing an antidepressant year-round can simply replace a brief monthly crash with constant emotional blunting and ongoing side effects. It’s also worth remembering a practical option many patients are never offered: some women respond well to intermittent SSRI dosing—limited to the luteal phase or initiated at symptom onset—rather than continuous daily use.¹²

3) Lamotrigine plus estrogen contraception: when “it stopped working” is an interaction

Lamotrigine is commonly used for bipolar-spectrum depression and mood instability. Estrogen-containing contraceptives can lower lamotrigine levels by increasing clearance, which can make symptoms return even when adherence is perfect.³ The timeline is consistent: stable mood, start a combined pill/patch/ring, then a slide over the next few weeks.

The reverse matters too. Stopping estrogen can increase lamotrigine exposure and side effects (dizziness, blurred vision, nausea, unsteadiness). Any new rash on lamotrigine deserves attention, regardless of context.³

Fix (patient): if you take lamotrigine, treat any start/stop/switch of hormonal contraception like a medication change. Message your prescriber before the change, not after symptoms appear.

Fix (prescriber): build contraception changes into the medication workflow. Document the plan, monitor for 6–8 weeks, and adjust cautiously. If the timeline screams “interaction,” don’t reflexively label it “relapse” and stack meds.

4) Not asking about sexual side effects — and losing the patient quietly

Sexual side effects can change intimacy, self-esteem, and adherence. Many women do not volunteer them. Many clinicians do not ask. The common ending is preventable: silent suffering, then abrupt stopping.

Sexual side effects can include lower desire, arousal difficulty, reduced sensation, and delayed or absent orgasm. Depression and anxiety can also affect sexuality, so the key question is: what changed after the medication started, and what is the cleanest next move?

Fix (patient): one sentence is enough: “My mood improved, but my sexual function changed. I want options that protect both.”

Fix (prescriber): ask routinely, early, and neutrally. Then make one targeted adjustment at a time. Management strategies exist. In some cases, bupropion augmentation (an add-on) can help; dose reduction or switching can also be options depending on diagnosis, response, and goals.⁴

5) Tapering too fast — then mistaking withdrawal for relapse

Withdrawal symptoms can mimic relapse: insomnia, anxiety spikes, crying spells, agitation. They can also include dizziness, “electric zaps,” GI symptoms, and a physical sense of being off. If tapering is rushed, withdrawal becomes “evidence” that you need the medication forever.

Good guidance is consistent on the basics: taper in stages, monitor closely, and slow down if symptoms flare.² If symptoms are severe, holding the dose or stepping back slightly can be safer than powering through.⁵

Fix (patient): think “small steps with pauses.” If each reduction destabilizes you, the taper is too steep for your system right now. Pausing is not failure. It’s how you protect your life while you adjust your dose.

Fix (prescriber): treat the end like the beginning: a written plan, clear parameters, and a rescue rule (pause, or a small step back). Don’t treat three bad days as a verdict on the diagnosis. Timing and pattern matter.One image to keep in your head

These five pitfalls are timing problems. The medication often wasn’t “wrong.” The approach was. When you design for speed, rhythm, interactions, side effects, and an exit strategy, you keep people stable long enough to recover.

FAQs

When should I call my clinician during SSRI start-up?

Call promptly if you develop severe agitation, suicidal thoughts, new manic symptoms (very little sleep with high energy and risky behavior), or restlessness so intense you cannot sit still. If you feel unsafe, treat it as urgent.

What if my prescriber dismisses my concern?

Write it down before the visit: one sentence, the specific change, the timeline. If you are still dismissed, you are allowed to ask for a second opinion or a different prescriber. 

When is a taper “too fast”?

If each reduction triggers symptoms that do not settle before the next reduction, the pace is too rapid. A well-paced taper is boring most of the time.²⁵

References

1. Jespersen C, et al. Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database of Systematic Reviews. 2024.

2. National Institute for Health and Care Excellence (NICE). Depression in adults: treatment and management (NG222), recommendations on stopping antidepressants. 2022.

3. U.S. Food and Drug Administration. Lamictal (lamotrigine) Prescribing Information. 2025. 

4. de Aquino ACQ, et al. Pharmacological treatment of antidepressant-induced sexual dysfunction: systematic review and meta-analysis. Journal of Clinical Psychopharmacology. 2025.

5. Perry T. How to stop antidepressants. Therapeutics Letter (NCBI Bookshelf). 2025. 

Authorship

Frederic Kass, MD — Professor Emeritus of Psychiatry, Columbia University Medical Center; former Clinical Vice Chair, Department of Psychiatry Profile: Medical News Today

Erica Gettenberg, MD — Board-Certified in Adult, Child, and Adolescent Psychiatry; expertise in mood and anxiety disorders and ADHD. LinkedIn: Erica Gettenberg, MD

All vignettes are fictional and for educational purposes only. This is not a substitute for professional medical advice.