Depression is one of the most common problems encountered in medical practice. Since the introduction of imipramine in 1957, dozens of antidepressant medications have been developed. As a rule, these greatly relieve the burden of depression and are extremely useful. Several different classes or groups of antidepressants are now available:
- Serotonin reuptake inhibitors (SRIs)
- Serotonin-norepinephrine reuptake inhibitors (SNRIs)
- Wellbutrin (bupropion)
- Tricyclic antidepressants
- Other unique antidepressant medications that don’t fit into one of the preceding groups
How effective are they?
A few years ago I would have told you that antidepressant medications relieve depression 60-70% of the time. Recently a National Institutes of Health study suggested this figure was too high, especially if a doctor prescribes one drug at a fixed dose and never modifies the treatment regardless of your response. Then the likelihood of complete resolution of your depression is under 35%. The chance you’ll benefit doubles if your doctor is skilled in using antidepressants and modifies the dose or substitutes/adds a second drug as needed. Many people report their depression isn’t gone but it’s a lot better.
Scientific studies also show that good psychotherapy is as just effective at treating depression as medication alone. But adding medication to therapy works better than either alone. Another helpful adjunct is exercise.
The biggest problem with antidepressant medication is that people don’t like the idea of taking them — even when depression severely impairs their ability to function. These medications don’t immediately and magically relieve your symptoms; you gradually feel better over days and weeks. Reluctance to take necessary antidepressant medication is one of the biggest problems in medicine.
How do I know they’re working?
Many people don’t associate the symptoms of depression with the illness of depression. They think that’s just how you’re supposed to feel. Here are the symptoms that will improve with effective treatment:
- Sad or depressed mood much of the time
- Irritable, crabby, quick to snap at people
- Severe fatigue (the most common complaint when patients don’t realize they’re depressed)
- Impaired ability to enjoy the things that usually bring you pleasure
- Can’t concentrate
- Can’t sleep, or sleep all the time
- Weight gain or loss of appetite with weight loss
- A variety of aches and pains
- And, the most serious of all, thoughts of suicide or the desire to hurt yourself
Any other general information about antidepressant medications?
1. Are antidepressants tranquilizers, pep pills, sleeping pills, pain pills, hormone pills, sex pills, or nerve pills?
No, none of these. They are a unique group of medications completely different from Valium, narcotics, etc. They work by restoring normal balance to chemicals in the brain.
2. Are they addicting?
Absolutely not. A person could not become addicted if he wanted to, even if he takes these medications for months or years.
3. Aren’t these like “pep pills” or “uppers”?
Absolutely not. Pep pills give anybody a sudden boost or energy, whether they are depressed or not. They are dangerous, and I rarely use them. Antidepressant pills, on the other hand, will do nothing to a person without depression, but will greatly help a person who has a depression. They are among the safest pills in medicine, much safer than, for example, aspirin or penicillin.
4. How do I use this medication?
Antidepressant medication must be taken regularly, not just when you feel like you need it. In other words, never stop taking the medication because you feel better and think you don’t need it. Stop it only when you and your doctor agree. (The biggest problem with this medicine is that people stop taking it as soon as they feel better. Then their symptoms come back.)
How you can tell when an antidepressant medication is working? When you say to yourself, “Boy I feel terrific! I’m sure I don’t need this junk!” But if you stop it, your depression returns within a few weeks, if not sooner.
5. How long will I have to take this medication?
Usually 3-6 months, but often a year or more. Fortunately, the medications can by taken safely as long as they are needed, even for a lifetime. If you’ve been depressed for years or had recurrent depression, it’s usually best to take an antidepressant for several years.
6. Anything else I should know?
- It is extremely important that you see your doctor again after about the first two weeks of treatment in order to evaluate whether the diagnosis and treatment are correct. Do not stop taking the medications until you are seen, unless side-effects are intolerable on the lowest doses.
- If anything troublesome happens which you think may be due to the medication, call your doctor and tell them what is happening. Many times the problem will have nothing to do with the medication at all.
- You should be able to work, drive and carry out your usual activities while taking the medication. When first beginning the antidepressant, you should use some caution about driving or engaging in other possibly dangerous activity until you see how the medicine will affect you.
- The safety of these medications lies in the fact that you cannot hide from troublesome life situations with them. If for example, you do not have the true medical illness of depression, but instead are only working too hard, you will receive no “energy” from these pills.They work only when the disease of depression is present (or one of the other indications for this medicine), and, in that situation, they give dramatic and gratifying relief of your symptoms. Thus, you can see the difference between these medications and such drugs as alcohol, “uppers,” “nerve pills,” sleeping pills and the like. All of these drugs can be used as an “escape” from life’s problems and, as such, can be habituating. The antidepressants cannot be used that way. This is their greatest safety feature. (In fact, they are safe to use if you have a problem with alcoholism or addiction that is in remission — in other words, you’ve stopped using.)
- These medications could make you feel a little nervous at the start of the treatment. This is temporary. Occasionally, Zoloft will make it hard to sleep, even if you take it early in the day. This is also a temporary effect. Often, starting with a lower dose prevents this problem. Or you might feel groggy. If these problems continue for more than a week or two, call and ask for a different medication. (If you have manic-depressive disorder, any antidepressant may cause severe agitation. If this occurs, stop the medication and call.)
- Many of the good effects of this medication will not show themselves for one to two weeks. When the medication does begin to work, many things will become much better — energy will increase, sex drive will return to normal, headaches will go away, and the tendency to cry and feel irritable will go away; in other words, you will feel like you are back to normal.
- Often, your family and friends will see that you’re improving before you do; the patient may be the last one to recognize they’re feeling better.
- When you do begin to feel back to normal, do not stop the medication. If you do, you will feel worse again in a week or two.
- You cannot get “hooked” on these medications. They are not dope. It makes no difference how much or how long you take these medications. Habituation is simply not possible.
- Once you’ve been taking this medication for a month or more, do not stop it suddenly. (You may get side effects that are the reverse of the initial start-up effects.) Instead, taper the medication slowly over a month and then stop it. (But there’s no need to taper Prozac; you can just stop.)
- Everyone differs in how much of these medications they need. The usual dose ranges from 10-60 mg. per day. With Zoloft, the range is 25-200 mg. per day. We’ll work together to determine the best dose for you.Occasionally, someone who has done well on a lower dose for a few months may begin to feel depressed again. Often, that person will feel better with a small increase in dose.
- You must not mix any antidepressant with MAO inhibitors (e.g. tranylcypromine (Parnate), phenelzine (Nardil), >10 mg selegiline). These are much older antidepressants that are now almost never used because they can themselves cause severe toxicity.
- Mixing too many medications that raise serotonin levels can cause serotonin syndrome. The drugs that can do this include most antidepressants, cough syrup containing dextromethorphan, many pain killers (opioids), certain migraine medications, and amphetamines. Serotonin syndrome is relatively uncommon but can be dangerous. Symptoms may include agitation, tremor, muscle rigidity, and fever. If severe, it can be serious, but it goes away almost immediately after the offending medications are stopped.
Serotonin reuptake inhibitors (SRIs)
“SRI” stands for “serotonin reuptake inhibitor” and relieve depression by keeping the levels of serotonin high in your brain. SRIs are among the safest medications available. Even overdoses are rarely harmful. The brand names of common SRI antidepressants are in boldface. Generic names follow in parentheses:
Zoloft (Sertraline); Paxil (Paroxetine); Prozac (Fluoxetine); Celexa (Citalopram); Lexapro (Escitalopram); Luvox (Fluvoxamine)
Benefits and indications
SRIs are often the treatment of choice for straightforward depression. They are extremely safe and have few side effects. They are usually also the best medications for anxiety, panic attacks, obsessive-compulsive disorder, and bulimia or anorexia nervosa. They are generally ineffective for treating chronic pain.
Potential side effects
SRIs have the fewest side effects of any of the medications for depression. Many people never have a problem taking them. They’re also the safest of the antidepressants.
Sometimes during the first few days of treatment, you’ll feel a little “weird,” like how you feel the day before coming down with a cold. This effect goes away quickly. Nausea can also be a problem initially but usually goes away after the first few days of treatment.
Many people lose a few pounds during the first few months of treatment. However, sometimes after that, they may begin to gain weight. If this occurs, you’ll need a new medication without that side effect. Weight gain can occasionally become a serious problem if you keep taking the medication, so be sure to work with your doctor to resolve this issue. Zoloft, Celexa, and Lexapro are the least apt to cause weight gain.
Some people taking SRIs have interference with sexual function. You may notice lack of interest or desire, or you may have difficulty achieving orgasm. If you’re not in a relationship or this effect is mild, most people don’t mind. If it’s severe, we may need to find another medication.
There have been reports that adolescents started on an SRI may be at increased risk of thinking about suicide in the first month or so they’re on the drug. I don’t treat adolescents, so this has not been an issue for me.
Potential drug interactions
This is usually not an issue. Sometimes, however, people taking high doses of SRIs become anxious or have other nervous-type symptoms if they take other antidepressant medications or certain cold remedies like dextromethorphan (in many over-the-counter cough syrups). Ask your pharmacist before buying cold drugs. Also, Paxil, Prozac or Luvox may interfere with the metabolism of other medications you may be taking. Finally, it’s critical to avoid taking any antidepressant
What else should I know about SRI-type antidepressants?
It usually works best to take all your pills in one dose in the morning. If the medicine makes you groggy, take it 2-3 hours before bedtime. This is sometimes a problem with Paxil, but most people prefer taking Paxil in the morning. Feel free to figure this out yourself.If a medication makes you persistently sleepy after several days of treatment, feel free to cut the dose, or take it every other day. In a week or two, once you get used to it, you should be able to increase the amount you take back to the original dose prescribed.If this doesn’t work, call me. We’ll change to another antidepressant that will not make you to feel so drowsy.
Serotonin–norepinephrine reuptake inhibitors (SNRIs)
SNRIs are almost the same as SRIs, but in addition to increasing the amount of serotonin in your brain, they also increase norepinephrine levels. Indications, side effects, and drug interactions are almost the same as with SRIs. But they are much better at treating chronic pain. Common drugs in this class include Effexor (venlafaxine), Cymbalta (duloxetine), Pristiq (desvenlafaxine), and Savella (milnacipran). You might notice diarrhea at first, followed by constipation. Weight gain or dry mouth can occasionally be a problem. Sexual side effects are less frequent.
I love bupropion. It can make people anxious in the first week or two they’re on it, and it’s usually a poor treatment for anxiety. But it’s a terrific medication for depression. It tends to be energizing. It’s more apt to cause weight loss than weight gain. It’s also marketed as Zyban for smoking cessation and is quite effective in helping people quit cigarettes. The generic bupropion works just as well as the brand names. It doesn’t affect brain serotonin levels and thus won’t cause serotonin syndrome. Bupropion doesn’t do much for chronic pain unless your depression is also worsening the pain (a common occurrence).
This is the original group of antidepressant medications that are now used less frequently, because they are potentially toxic and have more side effects. But used properly, they’re often invaluable. I think they work better than SNRIs (see above) for chronic pain, especially imipramine. They also work well for irritable bowel syndrome and may relieve arthritis pain and help ulcers in the gastrointestinal tract. Common side effects include sweating, rapid heartbeat, constipation, and tremor, although these often improve after a few weeks. Dry mouth can be severe and is one of the more common reasons someone has to stop taking them.
<h2id=”Remeron”>Other, unique antidepressants
One drug that doesn’t fit any other category is Remeron (mirtazapine), which is one of my favorite medications for people who can’t sleep. It’s also great for anxiety. It can cause the “munchies” (carbohydrate craving) and weight gain, but it works especially well in the elderly. It doesn’t increase serotonin levels and probably can’t cause serotonin syndrome.
Trazodone (Desyrel) is an antidepressant that doesn’t do that much for depression but is a great sleeping medication. It’s totally nonaddicting and is often used in addiction medicine. Like any sleeping drug, it can impair alertness the next day, even if you feel wide awake. Occasionally people don’t tolerate trazodone because of restless legs syndrome or it makes them agitated, but these are uncommon. It does increase serotonin levels.