Depression

Medications to Treat Depression

Virginia J. Duffy PhD Psychiatric NP

Depression is treated with many types of psychotherapy and alternative treatments. These treatments often offer relief from the pain of depression. However there are times when medication is necessary to manage depressive symptoms. There are a variety of medications for depression. This article discusses and compares the different types of antidepressants.

Selective Serotonin Reuptake Inhibitors (SSRIs) are the most commonly used antidepressants. They have been on the market for over 20 years. They increase levels of serotonin, a neurotransmitter (substance that fosters chemical activity in the brain) believed to play an important role in depression and anxiety.

SSRIs are used for treatment of depression, anxiety, Obsessive-compulsive disorder (OCD), and occasionally other illnesses. (Fibromyalgia, chronic fatigue, pain).

SSRIs have much fewer side effects than the older antidepressants (tricyclics such as Elavil); they are not as lethal in overdose, and work well for most people. They are much more expensive then tricyclics.

All SSRI's are effective although side effects may differ somewhat. Because individuals are different, some may react more positively to one particular medication then to another.

Choosing between the SSRI'S is usually dependent on the side effect profile (see below), and the prescriber’s and patient’s preference and experience. They are usually the first choice in depression and often the first choice in anxiety disorders.

With anxious patients it is helpful to start low and increase the dose slowly in order to minimize the side effect of activation. Anxious patients can be very sensitive to this side effect.

Higher doses of medications are often needed in Obsessive Compulsive disorder and Panic disorder.

1. Prozac ™
This may be more activating initially. It has a long half-life and therefore stays in the system longer. Once a day dosing is usual; recently Prozac ™introduced a once a week dose.

2. Paxil ™
May be more calming initially, weight gain can be a problem. Once a day dosing is the norm.

3. Zoloft ™
May have fewer interactions with other medications. Weight gain may be a problem. May cause more stomach upset and diarrhea. Once a day dosing is the norm.

4. Luvox ™
Sometimes used for OCD, multiple dosing. Not used frequently in US. Needs higher doses that may cause drowsiness.

5. Celexa ™
Said to be "more" selective for a particular type of serotonin and therefore thought to have less side effects and interactions. May have less weight gain. Once a day dosing is the norm.


6. Lexapro ™
Similar to Celexa some feel it was manufactured because the patent on Celexa was running out. Said to work quicker then the other SSRIs.

Side Effects - SSRI's

Most SSRI’s have similar side effects. Some patients do better on one than on another. This cannot be determined before a trial of the medication is given.


1. Nausea - This is a common problem. Taking the medication with food helps and this side effect. It usually passes in time.

2. Headache - This is usually mild and goes away with time (about one week) if it continues it may be necessary to change medication.

3. Activation or Sedation- Patient can feel either activated (hyper, jittery) or sedated. Patients with anxiety / panic are more likely to feel activated. To avoid this start with a low dose and increase as tolerated. Sedation will often disappear with time but occasionally a change in medication is necessary.

4. Sexual dysfunction- this can be a significant problem with some antidepressants. Use may result in decreased sexual interest or ability. Most common treatments for sexual dysfunction include: drug holidays (holding the drug for one or two days once the patient is stable, (cannot be done with Prozac due to staying in the body longer), changing medication, or using an additional medication. (Some such drugs include: Periactin, Amantadine, Yohimbine, Ginkgo others. All have only limited success.) Talk to your prescriber if this is an issue for you.

5. Weight Gain- This can be a problem that is often not taken seriously enough. Weight gain may start after you have been on the medication for a while. It may be necessary to change to a different antidepressant.

6. Agitation / Aggression There has been some anecdotal reports about patients becoming more aggressive on SSRIs. The research does not support this. However, that concern should be taken seriously, and attempts made to avoid a drug the patient is concerned about. The same is true about the reports of increased suicide.

TRICYCLICS

This is an older class of antidepressants that are no longer the first choice. They can have severe side effects including sedation, weight gain, effects on the heart, and drug interactions. These drugs are used in anxiety, depression and some pain syndromes. They are much less expensive than SSRI's. These drugs are lethal in overdose!

•  Nortriptyline

•  Desipramine

•  Imipramine

•  Amitriptyline

•  Doxepin

Other Antidepressants

These drugs are thought to affect a number of neurotransmitters (serotonin, dopamine, nor-epinephrine being the major ones.)

1. WELLBUTRIN ™- This should not be used in patients with a history of seizures. Said to cause less sexual dysfunction and weight gain. Now has a sustained release formula but still is usually given twice a day. This is the same drug as Zyban, which is used for smoking cessation. Obviously, they should not be used together.

2. Trazodone ™ This is not a very effective antidepressant; it is however very helpful for sleep and may be used in low doses for anxiety. It should be used in caution with men due to possible priaprism (This is an involuntary erection that in the worst case may not go away).

3. Effexor XR ™- Thought to have fewer interactions. Less weight gain and sexual dysfunction. (There is a new medication out that is similar to Effexor called Pristiq).

4. Remeron ™- said to have less sexual dysfunction and fewer interactions. Weight gain can be a problem. Used at lower doses (15 mg) this is a good sleep aid, but is not powerful enough to be an antidepressant. At higher doses no longer specifically helpful with sleep.

5. MAOI'S- another older class of antidepressants with many dietary restrictions and interactions. Not currently used very often. (I.e.: Nardil ™, Parnate ™.)

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