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Antidepressants: Selecting one that's right for you

Posted Mar 18 2010 10:57am

Antidepressants are often the first treatment choice for adults with moderate or severe depression. Although antidepressants may not cure depression, they can reduce your symptoms. The first antidepressant you try may work fine. But if it doesn't relieve your symptoms, or it causes side effects that bother you, you may need to try another. All antidepressants have pros and cons, and until you try one, you won't know exactly how well it will work for you.

Some people need to try several antidepressants before finding the medication (or a combination of medications) that works best. Because some antidepressants can take as long as eight weeks or more to reach full effect, this trial and error process can take time. But don't give up. A number of antidepressants are available, and chances are you'll be able to find one that works well for you.

Finding the right antidepressant

There are a number of antidepressants available that work in slightly different ways, and have different side effects. Most work equally well to relieve depression, so choosing the right one generally involves subtle differences. When prescribing an antidepressant that's likely to work well for you, your doctor may consider
* Your particular symptoms. Symptoms of depression can vary, and one antidepressant may relieve certain symptoms better than another. For example, if your depression symptoms include low energy, an antidepressant that's slightly stimulating may be the best choice. On the other hand, if you have trouble sleeping, an antidepressant that's slightly sedating may be a good option.
* Possible side effects. Side effects of antidepressants vary from one medication to another and from person to person. Bothersome side effects can make it difficult to stick with treatment. Sexual side effects are a particularly common reason people stop taking an antidepressant.
* Whether it worked for a close relative. How a medication worked for a first-degree relative such as a parent or sibling can indicate how well it might work for you.
* Interaction with other medications. Some antidepressants can cause dangerous reactions when taken with other medications.
* Whether you're pregnant or breast-feeding. Many antidepressants may not be safe for your baby when taken during pregnancy or when you're breast-feeding. Work with your doctor to find the best way to manage your depression when you're expecting.
* Your other health conditions. Some antidepressants may cause problems if you have certain mental or physical health conditions. On the other hand, certain antidepressants may help treat other physical or mental health conditions along with depression. For example, bupropion (Wellbutrin) may relieve symptoms of both attention-deficit/hyperactivity disorder (ADHD) and depression.
* Cost and health insurance coverage. Some antidepressants can be very expensive, especially if there's no generic version available.
* Results of genetic tests. In some cases, blood tests can help pinpoint genetic factors that might influence your response to certain antidepressants. The test doesn't predict which antidepressant will work best for you. But it may suggest which ones may not work, and which ones may cause the worst side effects. This type of testing isn't widely used yet, but it's becoming more common.

Types of antidepressants

Certain brain chemicals called neurotransmitters are associated with depression, particularly the neurotransmitters serotonin (ser-oh-TOE-nin), norepinephrine (nor-ep-ih-NEF-rin) and dopamine (DOE-puh-mene). Most antidepressants relieve depression by affecting these neurotransmitters. Each type (class) of antidepressant affects these neurotransmitters in slightly different ways.

Selective serotonin reuptake inhibitors (SSRIs)
Many doctors start depression treatment by prescribing an SSRI. SSRIs are safe and relieve depression for most people. However, like many antidepressants, they can cause sexual side effects — most commonly failure to achieve orgasm in women, and delayed ejaculation in men. SSRIs include
* Citalopram (Celexa)
* Escitalopram (Lexapro)
* Fluoxetine (Prozac, Prozac Weekly)
* Fluvoxamine (Luvox, Luvox CR)
* Paroxetine (Paxil, Paxil CR)
* Sertraline (Zoloft)

Serotonin and norepinephrine reuptake inhibitors (SNRIs)
SNRIs include
* Venlafaxine (Effexor, Effexor XR). Venlafaxine may work for some people when other antidepressants haven't. It can cause side effects similar to those caused by SSRIs. Venlafaxine can raise blood pressure, and overdose can be dangerous or fatal.
* Desvenlafaxine (Pristiq). Desvenlafaxine is similar to venlafaxine. It may be less likely to cause sexual side effects and other side effects than does venlafaxine, but more research is needed to confirm this.
* Duloxetine (Cymbalta). Duloxetine may help relieve physical pain in addition to depression — but it isn't clear yet whether it works better than other antidepressants for pain relief. Duloxetine can cause a number of side effects. Nausea, dry mouth and constipation are particularly common. You shouldn't take Duloxetine if you're a heavy drinker or you have certain liver or kidney problems.

Atypical antidepressants
These medications are called "atypical" because they don't fit neatly into other categories. Generally, atypical antidepressants cause fewer sexual side effects than other antidepressants do. Atypical antidepressants include
* Bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL) has the fewest sexual side effects of all antidepressants. It may also suppress appetite, and it may help you stop smoking if you're trying to quit. People with seizure disorders or who have bulimia or anorexia shouldn't take bupropion.
* Trazodone. This mild antidepressant is often prescribed as a sleep aid because it can be very sedating.
* Mirtazapine (Remeron, Remeron SolTab). Like trazodone, mirtazapine can be sedating. It may increase lipid levels and cholesterol.
* Nefazodone. This antidepressant is effective, but isn't commonly prescribed because it has been linked to dangerous liver problems.

Tricyclic and tetracyclic antidepressants
These older antidepressants are effective, but are usually not a first-choice treatment for depression because of numerous side effects such as dry mouth, constipation, difficulty urinating, sedation, weight gain and sexual side effects. In some cases, a low dose of a cyclic antidepressant may be added to another antidepressant such as an SSRI to increase the antidepressant effect. Overdosing on a cyclic antidepressant can be deadly. These medications are not usually given to older adults or people who have low blood pressure or certain heart problems. Tricyclic and tetracyclic antidepressants include
* Amitriptyline
* Clomipramine (Anafranil)
* Doxepin (Sinequan)
* Imipramine (Tofranil, Tofranil-PM)
* Trimipramine (Surmontil)
* Desipramine (Norpramin)
* Nortriptyline (Pamelor, Aventyl)
* Protriptyline (Vivactil)
* Amoxapine
* Maprotiline

Monoamine oxidase inhibitors (MAOIs)
Monoamine oxidase inhibitors are used as a last resort because of numerous bothersome and potentially dangerous serious side effects. However, MAOIs can be effective for some forms of depression when other medications haven't worked. Side effects can include dizziness, dry mouth, upset stomach, difficult urination, twitching muscles, sexual side effects, drowsiness and sleep problems. MAOIs can cause potentially fatal high blood pressure when combined with certain foods and beverages and certain other medications. MAOIs include
* Isocarboxazid (Marplan)
* Phenelzine (Nardil)
* Tranylcypromine (Parnate)
* Selegiline (Emsam, Eldepryl, Zelapar)

Emsam is a type of MAOI that you stick on your skin (transdermal patch). It appears to have fewer side effects than MAOIs in pill form have, and with lower dose patches, dietary restrictions may not be needed.

Antidepressants and risk of suicide

Although studies have shown that antidepressants are generally safe, in some cases children, adolescents and young adults ages 18 to 24 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting an antidepressant or changing a dosage. Because of this risk, they must be closely monitored by loved ones, caregivers and health care providers while taking antidepressants. The Food and Drug Administration (FDA) now requires that all antidepressant medications carry a warning about suicide.
Making antidepressants work for you

There are several steps you can take to get the best results:

* Be patient. Once you and your doctor have selected an antidepressant, it may take four to eight weeks for it to be fully effective. In some cases, it may take 12 to 14 weeks to achieve the full effects of an antidepressant. And with some medications, you can take the full dosage immediately. With others, you may need to gradually increase your dose. Talk to your doctor or therapist about coping with depression symptoms as you wait for medications to take effect.
* See if the side effects improve. Many antidepressants cause side effects that improve with time. For example, initial side effects when starting an SSRI can include nausea, loose bowel movements, headache and insomnia, but these symptoms usually go away as your body adjusts to the antidepressant. Sexual side effects may be eased by adding or substituting bupropion.
* If it doesn't work — try something else. If you have no significant improvement in your symptoms after six weeks, talk to your doctor about trying a different antidepressant (switching) or adding a second antidepressant or another medication (augmentation). A medication combination may work better for you than does a single antidepressant.
* Take your antidepressant consistently and at the correct dose. If your medication doesn't seem to be working or is causing bothersome side effects, call your doctor before making any changes.
* Don't stop taking an antidepressant without talking to your doctor first. Some antidepressants can cause significant withdrawal-like symptoms unless you slowly taper off your dose.
* Try psychotherapy. In most cases, combining an antidepressant with mental health counseling (psychotherapy) is more effective than taking an antidepressant alone. It can also help prevent your depression from returning once you're feeling better.

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