Exploring Anhedonia in Psychiatric Care

In this Q&A, Brittany Albright, MD, MPH, founder and CEO of Sweetgrass Psychiatry, sheds light on the pervasive and challenging symptom of anhedonia, which can have profound implications on patients’ quality of life, clinical outcomes, and societal costs. Dr Albright highlights the urgency of routine screening for anhedonia, discusses the limitations of conventional antidepressants, such as SSRIs and SNRIs, in effectively addressing this symptom, and examines why emotional blunting can sometimes get in the way of treatment. 

Despite these challenges, Dr Albright remains optimistic about emerging treatments that target anhedonia without compromising emotional depth. By continuing to advance treatment strategies, clinicians can work towards more comprehensive and effective care for patients grappling with this debilitating symptom. 

Answers have been lightly edited for clarity. 

DepressionCare 360: How does anhedonia impact quality of life and functioning in patients with MDD and other psychiatric illnesses?

Brittany Albright, MD: Anhedonia is one of the biggest challenges facing our patients in psychiatry. Anhedonia is a lack of interest or pleasure in activities that folks usually find enjoyable. It is not a diagnosis in itself, but we do find anhedonia and major depression in schizophrenia and bipolar disorder. We also often see it in substance use disorders and most definitely in a lot of neurologic disorders such as Parkinson disease, traumatic brain injury, and stroke. It's a really important symptom that we need to be screening every patient for. 

Why is this important? Above and beyond other symptoms, anhedonia severely affects quality of life and clinical outcomes. It's also one of the most challenging symptoms to treat in our patients. Unfortunately, our medications can sometimes fail. Our patients often can experience relief from other symptoms from our traditional antidepressants, particularly patients with major depression, but anhedonia will still sometimes persist. That's why it's so important that we screen for it and continue to seek new treatment options to treat anhedonia, particularly with major depression. Untreated anhedonia results in longer episodes of depression, greater severity of depression, and higher suicide rates. That is why, even if we help a patient improve, we should not stop until their anhedonia is resolved. That's on an individual level. 

One of the bigger issues facing us as a nation is cost containment. Anhedonia is very expensive. It results in higher utilization of our health care system and higher cost of care in general. It also results in higher rates of disability, as patients often can't work. Not only does it affect our patients on an individual level, but I'm also very concerned on a societal and economic level of the burdens of anhedonia. 

DepressionCare 360: Why do conventional antidepressants often fail to effectively treat anhedonia? What are the limitations of these treatments?

Dr Albright: Unfortunately, our medications fail people all too often. Why do medications not treat anhedonia? Part of the challenge is that, according to some research, we think that SNRIs can sometimes cause emotional blunting, and emotional blunting is different from anhedonia. With anhedonia, patients just experience lower positive emotions and often heightened negative emotions. I don't like labeling emotions as good or bad or positive or negative, but I would say they often experience the “unpleasant” emotions more with anhedonia. With the emotional blunting that I hear patients describe on SSRIs, they just feel less in general. They appreciate that they don't feel challenging emotions quite so strongly, but then they often describe to me that they also don't feel as much of the really lovely and wonderful and enriching emotions as well.

Unfortunately, that is one of the most common reasons that my patients will stop their antidepressants: because they want to feel more. I did have one patient recently stop all of her medications because she said she couldn't cry, and she wanted the human experience of being able to cry. 

Now, it is challenging because, mechanistically, we don't precisely know that SSRIs necessarily cause it, but there's a lot of research that points to anhedonia not only remaining as a pervasive symptom on SSRIs, but emotional blunting as well. I would say that's one of the biggest challenges that we face with conventional treatments. Luckily, there's hope on the horizon. There are a lot of novel medications that don't necessarily have the side effect of emotional blunting that we can employ.

Brittany Albright, MD, MPH, is a Harvard-trained, double board-certified adult and addiction psychiatrist and the founder of Sweetgrass Psychiatry, the largest physician-owned psychiatry practice in South Carolina. After completing her undergraduate studies at Emory University, she earned medical and public health degrees from the University of New Mexico. Dr Albright completed her psychiatry residency at Massachusetts General and McLean Hospitals, where she served as Chief Resident of Addiction Psychiatry. She now serves as an Affiliate Assistant Professor at the Medical University of South Carolina, where she also trained in addiction psychiatry.

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