Antidepressants

This page contains general information. This material is NOT complete, and it does not cover all possible precautions, side effects, or interactions. You should always consult your physician when making decisions about your health.

Introduction

The most effective treatment of depression is a combination of psychotherapy and antidepressants.[1] This has been proven repeatedly in medical trials. Antidepressants treat the symptoms of depression, and psychotherapy improves your thinking so that you reduce the risk of depression in the future.

The treatment of depression is two-thirds/one-third. Two-thirds of your recovery comes from better coping skills, and one-third comes from antidepressants. But that one-third is important. The antidepressant helps to jump start your recovery. It improves your energy so that you can do the things you have to do to get out of depression. Without the antidepressant, you may know what you should do, but you don't have the energy to do it.

No one antidepressant is more effective than any other. This has been proven many times. Newer antidepressants do not work better than older antidepressants. There are many antidepressants to choose from. But not every antidepressant works with every person. Finding the right antidepressant is a matter of trial and error.

Unfortunately, no technique has been found to match patients to the right antidepressant. The only technique that is somewhat useful is to first look at antidepressants that have been effective for other members of your family.

Things You Can Do

Avoid alcohol use. Alcohol is a problem for two reasons. First, it is a brain depressant and contributes to depression. Second, it blocks the effectiveness of antidepressants so they can't work as well. Discuss your alcohol use with your doctor. General guidelines are no more than 2 to 3 alcohol drinks per week.

Avoid all psychoactive drugs. Marijuana, opioids, anti-anxiety pills, and cocaine are all major brain depressants. (Learn more about alcohol and substance at the companion website www.AddictionsAndRecovery.org)

Be active. Mild activity, like walking, has been proven to reduce depression symptoms and speed recovery.

Cognitive therapy has been proven to help treat and prevent depression.

Stress management and mind-body relaxation have been proven to help treat and prevent depression.

Are Antidepressants Addictive?

This is one of the more common worries about antidepressant. Antidepressants are not addictive. The definition of an addiction is difficulty controlling how much you use, and continuing to use even though you've suffered negative consequences. Antidepressants do not give you a buzz that you chase after. They are not like alcohol or cocaine. However, if you discontinue an antidepressant abruptly you can experience withdrawal symptoms.

You do not become dependent on antidepressants. If you stop using an antidepressant, your symptoms may return. This doesn't mean you've grown dependent. It may mean that your depression has not been fully treated. Or it may mean that you suffer from chronic depression. If you have chronic depression, your brain can't produce serotonin and dopamine in the necessary quantities, and once you stop taking the antidepressant, you slip back into depression.

First Choice Antidepressants

Many doctors start antidepressant therapy with one of the following medications. These are generally well tolerated and have fewer side effects.

• Celexa (citalopram)
• Lexapro, Cipralex (escitalopram)
• Prozac (fluoxetine)
• Wellbutrin (bupropion)
• Zoloft (sertraline)

These antidepressants fall into a few classes. Most are SSRIs (selective serotonin reuptake inhibitors). Wellbutrin is NDRI (norepinephrine dopamine reuptake inhibitor). In addition to being used on its own, Wellbutrin is sometimes used in conjunction with other antidepressants to reduce their sexual side effects.

Second Choice Antidepressants

• Anafranil (clomipramine)
• Aventyl (nortriptyline)
• Elavil, Levate (amitriptyline)
• Norpramin (desipramine)
• Sinequan, Tridapin (doxepin)
• Surmontil (trimipramine)
• Tofranil, Impril (imipramine)
• Triptil (protriptyline)

These antidepressants are called tricyclic antidepressants (TCAs). They has been around longer than the SSRIs. TCAs are just as effective, but they can have more serious side effects, which is why they are usually not prescribed until you've tried SSRIs first.

Some other commonly used antidepressants include:

• Effexor (venlafaxine)
• Remeron (mirtazapine)
• Luvox (fluvoxamine)
• Paxil (paroxetine)

Effexor and Paxil are associated with the highest likelihood of withdrawal symptoms. But for many people they are extremely effective. Remeron is sedating and is sometimes used for that reason, but it is also associated with weight gain.

Common Side Effects

All medications have side effects. Most antidepressants follow an 80/20 rule. 80 percent of the time they work and help relieve people's suffering. 20 percent of the time they either don't work or have unacceptable side effects. The general rule for antidepressants is that the side effects happen at the beginning and positive benefits happen later on.

When deciding whether to take an antidepressant, you must weigh the potential side effects of antidepressants against the known side effects of being depressed.

The side effects of antidepressants are generally temporary and mild. However, you should report any unusual reactions or side effects to your doctor immediately. If you experience unpleasant or intolerable side effects, consult your doctor first before stopping the antidepressant. Some antidepressants can cause withdrawal symptoms if you stop them abruptly.

The most common side effects associated with SSRIs and SNRIs include:

• Headache
• Insomnia, anxiety, jitteriness, or nervousness (Temporarily increased anxiety is a common side effect when starting these antidepressants.)
• Feeling mentally "spacey"
• Nausea
• Light sensitivity (you are more likely to sunburn)
• Sexual side effects. Both men and women can experience sexual problems including reduced sex drive, erectile dysfunction, delayed ejaculation, or inability to have an orgasm.
• If you're pregnant or breast-feeding, some antidepressants may pose an increased risk. Talk to your doctor.

The most common side effects of Tricyclic antidepressants include:

• Dry mouth
• Constipation
• Drowsiness
• Blurred vision
• Carbohydrate cravings and weight gain
• Bladder problems. It can be more difficult to empty your bladder, and your urine stream may not be as strong as usual. Older men with enlarged prostates may be more affected.
• Sexual side effects. Both men and women can experience sexual problems including reduced sex drive, erectile dysfunction, delayed ejaculation, or inability to have an orgasm.
• If you're pregnant or breast-feeding, some antidepressants may pose an increased risk. Talk to your doctor.

Not everyone experiences the same side effects or intensity. Side effects often go away or lessen within several weeks of starting an antidepressant.

If you use the internet to research medication, keep in mind a certain psychological principle. Most people only write when they have something to complain about. People rarely write when they are happy with a product or service. Therefore internet sites are sometimes skewed. Most of the comments come from the 20 percent of people who experienced side effects.

Their side effects are real and troublesome. But it does not necessarily mean that you will have the same experience.

Potentially Serious Side Effects

Although antidepressants are generally considered safe, they can cause serious health problems, such as liver failure or a dangerous drop in white cell count. This is true of all medication.

While such serious side effects are rare, it's important to get blood work or other tests on schedule and to stick to your treatment regimen. Make sure you understand the risks of the medications and that you're being properly monitored.

A small percent of people can have unusual reactions and end up feeling worse rather than better on antidepressants. Therefore it is important that you are closely monitored and that you report any troubling symptoms or worsening mood to your doctor immediately.

SSRI antidepressants have been shown to increase the lifetime risk of breast cancer from 12.5% to 13.8%.[2]

The Risk of Suicide

Antidepressants slightly increase the risk of suicide in people under the age of 24. Antidepressants however reduce the risk of suicide in people over the age of 25.[3],[4]

A comprehensive review of adolescent trials conducted between 1988 and 2006 concluded that the benefits of antidepressant medications outweigh the risks even in children and adolescents with major depression and anxiety disorders.[5]

Antidepressants after a Major Loss

Antidepressants are effective even if there is an obvious cause for your depression. Sometimes people are reluctant to take an antidepressant after they've suffered a major loss. They think that an antidepressant can't help, or it will block their grieving process.

Even if there is an obvious cause for your depression, the effect is still the same. Your brain doesn’t produce enough neurotransmitters like serotonin and dopamine. Therefore an antidepressant can still help.

Also antidepressants do not block the grieving process. On the contrary, they will give you the energy you need to go through the grieving process. Some people feel that their emotions are flattened on some antidepressants. If this is a significant problem, the usual treatment is to try another antidepressant.

How Will You Know if it's Working?

Recovery from depression follows a very predictable path. Once an antidepressant starts to work, the first two symptoms to go are teariness and thoughts of self-harm. If you are less teary and have fewer thoughts of self-harm, then the antidepressant is starting to work.

Later you will feel improvement in the other symptoms of depression. You will feel more tolerant. Little things won't irritate you as much. Later your energy and sense of enjoyment will improve. But the later symptoms of increased energy and enjoyment can take a few months.

As long as you are less teary and had fewer thoughts of death in the first six weeks, you are on the right track.

How Long Should You Take an Antidepressant?

The 6-6-9 rule.

• It can take up to 6 weeks before an antidepressant is effective.
• It can take up to 6 months to get the maximum effect of the antidepressant.
• You should take an antidepressant for at least 9 months after your symptoms have started to improve, if this is your first episode of depression. (Some doctors use a slightly different approach. They suggest that you should take an antidepressant for at least 6 months after you have achieved stable remission of your symptoms.)
• In the northern latitudes, it is recommended that you do not stop an antidepressant in the fall or winter, when people are more prone to depression.

What to do if your symptoms do not improve? If your symptoms haven't improved, your doctor may suggest either increasing your dose, combining medications, or switching to a new medication. It has been shown that the most common cause of antidepressant failure is an inadequate dose.

Needing a higher dose of antidepressant doesn't mean that you're severely depressed. It may simply mean that your liver breaks down antidepressants quickly, and you need a higher dose to get the same blood level as other people.

Don’t stop your antidepressant after a few months, because you feel better. If you stop too soon, you are at risk of relapsing. You have a 50 percent chance of relapsing within the first 6 months if you stop an antidepressant prematurely, whether or not you suffer from recurrent depression.[6]

Antidepressants cannot make you happy. An antidepressant can simply makes you less depressed. This is one of the common misconceptions about antidepressants.

What will make you happy is having a healthy self-esteem, a job and relationship that you like. No pill can do that. This is where cognitive therapy can be helpful. The problem is that when you're depressed, you don't have the energy to do the things you need to do to improve your self-esteem. That's why an antidepressant can be helpful, because it gets your recovery going. It gives you the energy to do the other things you need to make yourself happy.

Treatment of Recurrent Depression

Recurrent depression is when you've had at least three episodes of depression, or one long period of depression lasting more than five years. Once you've had recurrent depression, you should stop thinking in terms of depression, and start thinking in terms of diabetes. You don't take insulin for just a year and think that you can stop. You realize that your body needs insulin to function properly. It’s the same with recurrent depression. Your brain needs help to produce serotonin and dopamine.

These are the common guidelines for treating recurrent depression.

The first episode of depression should be treated for at least 9 months.
The second episode of depression is sometimes treated for 2 years.
The third episode of depression is often treated for at least 5 years.

Remember the recurrence rates of depression are the following:
After one episode of depression, the risk of another episode is 50 percent.
After two episodes of depression, the risk of another episode is 70 percent.
After three episodes of depression, the risk of another episode is 90 percent.

Which antidepressant should you try next time? 85 to 95 percent of people will respond to the same antidepressant in consecutive episodes of depression.[7, 8]

Antidepressants in Special Cases

Antidepressants for Pain Control

Tricyclic antidepressants are effective for the treatment of chronic pain.[9, 10] In this regard they are superior to SSRIs. Numerous studies have shown that amitriptyline and desipramine in low doses can reduce the symptoms of chronic pain.

The usual dose is 50 mg. This is much less than the dose needed for an antidepressant effect for these two medications, which is 100-200 mg. Desipramine is usually the first choice, since it has fewer side effects. Amitriptyline is more sedating, and helpful for people who have difficulty sleeping. But it tends to cause more dry mouth, constipation, blurred vision, and carbohydrate cravings.

Antidepressants and Pregnancy

A survey of 3472 pregnant women in the United States revealed that 20% had symptoms of depression during pregnancy.[11] Approximately 25% of postpartum depression actually begins during pregnancy.[12]

Not treating depression during pregnancy increases your risk of developing post-partum depression, and increases the baby's risk of being born premature and underweight. Discuss your options with your doctor.

The two antidepressants that are considered most safe during pregnancy are:

• Prozac (fluoxetine)
• Elavil, Levate (amitriptyline)

Antidepressants and Bipolar Disorder

Treating bipolar disorder with an antidepressant increases the likelihood of precipitating a manic or hypomanic episode. This is important because depression may be the initial presentation of bipolar disorder.

Therefore, prior to taking an antidepressant you should be screened for bipolar disorder. That should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression.

Natural Antidepressants

St John's wort (hypericum) has been shown to be as effective as prescribed antidepressants for the treatment of mild depression. St John's wort works on serotonin and dopamine, which are the same neurotransmitters as other antidepressants. It is available over the counter in North America, but it is available only by prescription in parts of Europe.

References

1.         Arnow, B. A., & Constantino, M. J., Effectiveness of psychotherapy and combination treatment for chronic depression. J Clin Psychol, 2003. 59(8): p. 893-905.
2.         Cosgrove, Lisa, Shi, Ling, Creasey, David E., Anaya-McKivergan, Maria, et al., Antidepressants and Breast and Ovarian Cancer Risk: A Review of the Literature and Researchers' Financial Associations with Industry. PLoS One, 2011. 6(4): p. e18210.
3.         Hetrick, S., Merry, S., McKenzie, J., Sindahl, P., et al., Selective serotonin reuptake inhibitors (SSRIs) for depressive disorders in children and adolescents. Cochrane Database Syst Rev, 2007(3): p. CD004851.
4.         Barbui, C., Esposito, E., & Cipriani, A., Selective serotonin reuptake inhibitors and risk of suicide: a systematic review of observational studies. CMAJ, 2009. 180(3): p. 291-7. PMC2630355.
5.         Bridge, J. A., Iyengar, S., Salary, C. B., Barbe, R. P., et al., Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA, 2007. 297(15): p. 1683-96.
6.         Depression Guideline Panel, Depression in Primary Care Vol 2. Treatment of Major Depression. AHCPR Publication No. 93-0551, U.S.D. HHS, Editor, 1993.
7.         Kupfer, D. J., Frank, E., & Perel, J. M., The advantage of early treatment intervention in recurrent depression. Arch Gen Psychiatry, 1989. 46(9): p. 771-5.
8.         Reynolds, C. F., 3rd, Perel, J. M., Frank, E., Cornes, C., et al., Three-year outcomes of maintenance nortriptyline treatment in late-life depression: a study of two fixed plasma levels. Am J Psychiatry, 1999. 156(8): p. 1177-81.
9.         Onghena, P., & Van Houdenhove, B., Antidepressant-induced analgesia in chronic non-malignant pain: a meta-analysis of 39 placebo-controlled studies. Pain, 1992. 49(2): p. 205-19.
10.       Maizels, M., & McCarberg, B., Antidepressants and antiepileptic drugs for chronic non-cancer pain. Am Fam Physician, 2005. 71(3): p. 483-90.
11.       Marcus, S. M., Flynn, H. A., Blow, F. C., & Barry, K. L., Depressive symptoms among pregnant women screened in obstetrics settings. J Womens Health (Larchmt), 2003. 12(4): p. 373-80.
12.       Evans, J., Heron, J., Francomb, H., Oke, S., et al., Cohort study of depressed mood during pregnancy and after childbirth. BMJ, 2001. 323(7307): p. 257-60. PMC35345.