The Way Watching TV by Engin Yüksel
SSRIs treat depressed mood, but they often miss the symptom patients care about most
STUDY TYPE: Expert consensus
FUNDING: Johnson & Johnson (make of esketamine/Spravato)
Background
Anhedonia means loss of pleasure or interest in normally rewarding activities. It is a core symptom of depression, affecting 70% of patients with that diagnosis. This expert consensus of six psychiatrists arrives at some direction.
Results
The panel defined anhedonia more broadly than the DSM-5, with three components:
- Anticipatory anhedonia: reduced motivation to pursue rewarding experiences, the inability to look forward to things
- Consummatory anhedonia: reduced enjoyment of activities in the moment, like hobbies, food, sex, social connection
- Cognitive anhedonia: impaired reward learning and decision-making about pleasure
Ask specifically about all three domains: not just “are you enjoying things?” but “are you looking forward to anything?”, “does it feel worth the effort?”, “if you accomplished something, like cleaning a closet, would you feel a sense of reward?”
Anhedonia predicts a worse course, slower time to remission, and elevated suicide risk; particularly anticipatory anhedonia.
For assessment, they recommend the Dimensional Anhedonia Rating Scale:
The PHQ-9 item 1 (“little interest or pleasure in doing things”) captures anhedonia as a screener, but doesn’t distinguish between the three components.
Treatment
The authors created a useful table that ranks treatments by the strength of their evidence for anhedonic depression. The table is a little confusing as it divides treatments by where they stand in the depression algorithm, and then ranks their evidence for anhedonia in the right column.
First Line Depression Medications
Among first-line treatments, only bupropion and the rapid-acting dextromethorphan-bupropion stand out. SSRI and SNRIs are traditionally “first line” for depression, but they may worsen anhedonia by blunting positive emotions. On the other hand, they may indirectly improve it by reducing anxiety or depression.
These drugs may have been first-line in the 1990’s, but with all that we’ve learned since then, I’d suggest rethinking that:
- Withdrawal problems
- Sexual dysfunction (which may be worse for anhedonic patients)
- Decreased bone mineral density
- Weight gain
- Lack of benefit for anhedonia
Second Line Medications for Depression
Among second-line and augmentation agents, the ketamines have the most robust data, but a new trial may bump up pramipexole’s rating here. When the author’s created this ranking, pramipexole only had uncontrolled and basic science data for anhedonia, but this month a randomized trial of pramipexole for anhedonia, where it had a moderate effect size (0.62). That follows a 2025 trial where this dopamine agonist treated refractory depression with a large, sustained effect size.
Pramipexole operates through the same mechanism as other D3 agonists in this table, like the ABC’s: aripiprazole, brexpiprazole, and cariprazine. Like those antipsychotics, it carries a risk of hedonic dysregulation; but unlike them it does not cause tardive dyskinesia, weight gain, metabolic dysfunction, EPS, akathisia, and other problems.
Neuromodulation and Psychotherapy
Anhedonia improves with ECT and TMS, and several psychotherapies are available that target anhedonia, like behavioral activation and positive affect treatment.
Emotional Blunting vs Anhedonia
Emotional blunting is a common side effect of SSRIs. For example, in a six month trial of escitalopram vs agomelatine, 60% reported emotional blunting on the SSRI vs 28% on agomelatine. However, it differs from anhedonia in a painful way. Emotional blunting suppresses both positive and negative emotions, while anhedonia only blunts the positive emotions. The negative ones are still experienced.
Apathy is similar to anhedonia, as both involve lack of motivation, but apathy does not include the emotional distress of anhedonia.
Limitations
The paper was funded by the manufacturer of esketamine. Though the ketamines have robust data in anhedonia, they carry risks that make them questionable as long-term solutions. Many could argue with the evidence here, which was often based on small trials, neurobiology, or secondary outcomes.
Practice Implications
- The importance of anhedonia adds to the reasons to move SSRIs to second-line in major depression.
- Instead, I often recommend bupropion first-line. Despite perceptions, it is as effective as as SSRIs for anxious depression, less likely to impair sleep quality, and no more likely to cause insomnia. I will use pramipexole for treatment-resistant cases, particularly if there is anhedonia, bipolarity, or restless legs.
- SSRIs have an advantage in neurotic temperament and comorbid anxiety disorders (but not anxiety as a symptom)
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
