Serotonin-Related Paradoxical Effects: Modeling Identity Disruption and Cognitive Lag to Prevent Adverse Events

Background: Selective serotonin reuptake inhibitors (SSRIs) can paradoxically precipitate suicidality, agitation, and behavioral disinhibition in 2-5% of patients, particularly during the first two weeks of treatment. Current explanations—notably "activation theory"—fail to account for observed temporal patterns, demographic vulnerabilities, and patient phenomenology.Methods: We conducted systematic literature review (N=188 sources) combined with computational pattern mining using large language models to identify convergent evidence across pharmacological, phenomenological, demographic, and temporal domains.Results: Five patterns emerged consistently: (1) precise temporal clustering in days 4-14 post-initiation; (2) demographic vulnerabilities (youth, women, trauma survivors, low SES, social isolation, first-time users) independent of depression severity; (3) phenomenology emphasizing identity disruption and disorientation rather than energization; (4) comorbidity patterns involving identity-disturbed conditions (BPD, PTSD, OCD); and (5) identical 10-14 day response timelines across all antidepressants and placebo.Interpretation: We propose the "identity disruption" framework: SSRIs produce rapid neurobiological changes that alter patients' experiential substrate before cognitive/identity adjustment can occur. For patients whose identity is organized around symptoms SSRIs target, this creates acute ontological crisis. Risk factors reflect diminished capacity for identity navigation, not depression severity.Clinical Implications: Treatment protocols must scaffold identity transition through pre-treatment identity assessment, existential psychoeducation, anchor person protocols, and intensive monitoring at days 3, 7, 10, and 14.