“Eight or nine years ago I had a couple of young adults become highly agitated and violent in the week after I started an SSRI (paroxetine in both cases). One beat up his girlfriend badly despite the lack of any history of violence previously. (I have since become dissatisfied with paroxetine because it seems to carry the worst risk of every bad side effect of SSRIs -- discontinuation syndrome, sexual side effects, fatigue, etc., with no clear benefits compared with other SSRIs.) But regarding the specific issues of violence and suicidality, I have learned to initiate any SSRI at much lower than recommended dosages in all patients: 12.5 mg sertraline, 5mg fluoxetine, 5 mg escitalopram, and so forth, in order to diminish the tendency of these medications to cause initial agitation. The vast majority of our patients have had psychiatric symptoms for months or more often years, so why not start very low and go very slow in everyone including the young, old, and medically ill? With responsible patients, I often encourage them to increase after several days if they are not experiencing any agitation. I have had almost no problem with initial agitation in adolescents or anyone else since taking this approach.”