Jump to: Types of Antidepressants Talking to Your Doctor
Medication can be an effective intervention for treating the symptoms of depression. Not all antidepressants, however, work the same way. The antidepressant your doctor will prescribe you often depends on your particular symptoms of depression, potential side effects, and other factors.
Most antidepressants work by affecting chemicals in the brain known as neurotransmitters. The neurotransmitters serotonin, norepinephrine, and dopamine are associated with depression. How medications affect these neurotransmitters determines the class of antidepressants to which they belong.
Article continues below
- Pain, anxiety, and depression
- Why these conditions often occur together and how to treat them when they do.
- What are Antidepressants? Effective Antidepressants to Treat Depression
- What are Antidepressants?
- 5 Types of Antidepressants
- Top 12 Most Popular & Effective Antidepressants: A Psychiatrists’ List
- Top 10 Most Popular Antidepressants by Prescription and Sales
- Top 7 Most Consistently Popular Antidepressants
- Help Is Needed to Overcome Depression
- Your Guide to Antidepressants and Staying Well
- History and Evolution
- What Are the Different Types?
- What Are They Prescribed For?
- Antidepressants vs. Self-Medication
- What Happens When You Stop Taking Your Medication?
- How to Get Help for Depression
- What are the different types of antidepressants?
- Antidepressants: What is the best medication for depression?
- Signs and symptoms of depression
- SSRIs and SNRIs for depression
- Ketamine and esketamine for depression
- Spravato© (Esketamine) nasal spray for depression
- How long does it take for antidepressants to start working?
- Can antidepressants make depression worse?
- Stopping and changing antidepressants
- Are antidepressants safe when pregnant or breastfeeding?
- Which antidepressant will work for me?
- Related posts:
Do you feel depressed?
Take one of our 2-minute Depression quizzes to see if you or a loved one could benefit from further diagnosis and treatment.
Take Depression Quiz Take Partner Depression Quiz
Types of Antidepressants (List of Medications)
Selective serotonin reuptake inhibitors (SSRIs) – SSRIs are the most commonly prescribed type of antidepressants. They affect serotonin in the brain, and they’re likely to have fewer side effects for most people. SSRIs can include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft).
Serotonin and norepinephrine reuptake inhibitors (SNRIs) – SNRIs are the second most commonly prescribed type of antidepressants. SNRIs can include duloxetine (Cymbalta), desvenlafaxine (Pristiq), levomilnacipran (Fetzima), and venlafaxine (Effexor).
Norepinephrine-dopamine reuptake inhibitors (NDRIs) – Bupropion (Wellbutrin) is the most commonly prescribed form of NDRI. It has fewer side effects than other antidepressants and is sometimes used to treat anxiety.
Tricyclic antidepressants – Tricyclics are known for causing more side effects than other types of antidepressants, so they are unlikely to be prescribed unless other medications are ineffective. Examples include amitriptyline (Elavil), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), nortriptyline (Pamelor), and protriptyline (Vivactil).
Monoamine oxidase inhibitors (MAOIs) – MAOIs have more serious side effects, so they are rarely prescribed unless other medications do not work. MAOIs have many interaction effects with foods and other medications, so people who take them may have to change their diet and other medications. SSRIs and many other medications taken for mental illness cannot be taken with MAOIs.
Other antidepressants that don’t fit into a category are known as atypical antidepressants.
Talking to Your Doctor
It is important to communicate regularly with your doctor when you are taking an antidepressant, especially if you are prescribed any other medications. Keep track of your symptoms so that they can find the best medication for your depression, and also keep track of any side effects you experience. If you’re having trouble finding a medication that works, drug-genetic testing can help your doctor determine appropriate options. If you become pregnant or are breastfeeding, be sure to ask what medication is safest.
Some antidepressants carry warnings that they may increase suicidal thoughts, particularly among young people. Be sure to communicate with your doctor if you experience any suicidal thoughts while on the medication or monitor your child if they are taking an antidepressant.
Above all, it’s important to not get discouraged if an antidepressant isn’t the right fit for you. With patience, observation, and communication, you and your doctor can find the medication that best fits your symptoms and needs.
DISCLAIMER: The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other healthcare provider. This article mentions drugs that were FDA-approved and available at the time of publication and may not include all possible drug interactions or all FDA warnings or alerts. The author of this page explicitly does not endorse this drug or any specific treatment method. If you have health questions or concerns about interactions, please check with your physician or go to the FDA site for a comprehensive list of warnings.
Article Sources Last Updated: Jul 17, 2019
Pain, anxiety, and depression
Why these conditions often occur together and how to treat them when they do.
Updated: June 5, 2019Published: May, 2010
Everyone experiences pain at some point, but in people with depression or anxiety, pain can become particularly intense and hard to treat. People suffering from depression, for example, tend to experience more severe and long-lasting pain than other people.
The overlap of anxiety, depression, and pain is particularly evident in chronic and sometimes disabling pain syndromes such as fibromyalgia, irritable bowel syndrome, low back pain, headaches, and nerve pain. For example, about two-thirds of patients with irritable bowel syndrome who are referred for follow-up care have symptoms of psychological distress, most often anxiety. About 65% of patients seeking help for depression also report at least one type of pain symptom. Psychiatric disorders not only contribute to pain intensity but also to increased risk of disability.
Researchers once thought the reciprocal relationship between pain, anxiety, and depression resulted mainly from psychological rather than biological factors. Chronic pain is depressing, and likewise major depression may feel physically painful. But as researchers have learned more about how the brain works, and how the nervous system interacts with other parts of the body, they have discovered that pain shares some biological mechanisms with anxiety and depression.
Shared anatomy contributes to some of this interplay. The somatosensory cortex (the part of the brain that interprets sensations such as touch) interacts with the amygdala, the hypothalamus, and the anterior cingulate gyrus (areas that regulate emotions and the stress response) to generate the mental and physical experience of pain. These same regions also contribute to anxiety and depression.
In addition, two neurotransmitters — serotonin and norepinephrine — contribute to pain signaling in the brain and nervous system. They also are implicated in both anxiety and depression.
Treatment is challenging when pain overlaps with anxiety or depression. Focus on pain can mask both the clinician’s and patient’s awareness that a psychiatric disorder is also present. Even when both types of problems are correctly diagnosed, they can be difficult to treat. A review identified a number of treatment options available when pain occurs in conjunction with anxiety or depression.
- Cognitive behavioral therapy (CBT) is not only an established treatment for anxiety and depression, it is also the best studied psychotherapy for treating pain.
- Relaxation training, hypnosis, and exercise may also help.
- Some antidepressants or anticonvulsants may alleviate pain while treating a psychiatric disorder, but be aware of potential drug interactions.
Various psychotherapies can be used on their own to treat pain in patients with depression or anxiety, or as adjuncts to drug treatment.
Cognitive behavioral therapy. Pain is demoralizing as well as hurtful. Cognitive behavioral therapy (CBT) is not only an established treatment for anxiety and depression, it is also the best studied psychotherapy for treating pain. CBT is based on the premise that thoughts, feelings, and sensations are all related. Therapists use CBT to help patients learn coping skills so that they can manage, rather than be victimized by, their pain. For example, patients might attempt to participate in activities in order to improve function and distract themselves from focusing on the pain.
Relaxation training. Various techniques can help people to relax and reduce the stress response, which tends to exacerbate pain as well as symptoms of anxiety and depression. Techniques include progressive muscle relaxation, yoga, and mindfulness training.
Hypnosis. During this therapy, a clinician helps a patient achieve a trance-like state and then provides positive suggestions — for instance, that pain will improve. Some patients can also learn self-hypnosis.
In one study, investigators asked 204 patients with irritable bowel syndrome to complete self-assessment questionnaires before, immediately after, and up to six years following hypnosis training. They found that 71% of participants reported the technique reduced both gastrointestinal distress and levels of depression and anxiety.
Exercise. There’s an abundance of research that regular physical activity boosts mood and alleviates anxiety, but less evidence about its impact on pain.
The Cochrane Collaboration reviewed 34 studies that compared exercise interventions with various control conditions in the treatment of fibromyalgia. The reviewers concluded that aerobic exercise, performed at the intensity recommended for maintaining heart and respiratory fitness, improved overall well-being and physical function in patients with fibromyalgia, and might alleviate pain. More limited evidence suggests that exercises designed to build muscle strength, such as lifting weights, might also improve pain, overall functioning, and mood.
Avoiding drug interactions
Many psychiatric drugs and pain medications are metabolized by cytochrome P450 enzymes in the liver, creating the potential for harmful drug interactions. Here are a few common examples.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are helpful for both long-term and short-term pain, acting to alleviate pain and reduce inflammation. However, both NSAIDs and SSRIs individually increase risk of gastrointestinal bleeding when used on an ongoing basis, so combining these drugs may raise the risk of bleeding even further. Prolonged use of NSAIDs can cause kidney failure in people who already have reduced renal function. Finally, use of NSAIDs and lithium together can lead to toxic levels of lithium in the bloodstream.
Acetaminophen reduces pain and does not increase risk of bleeding as much as NSAIDs. But acetaminophen is metabolized through the liver by the same enzymes that interact with many SSRIs and other psychiatric medications. Liver function should be monitored in any patient taking acetaminophen for prolonged periods while also taking a psychiatric drug. Patients with liver damage from hepatitis C or alcohol dependence should also use acetaminophen with caution or avoid it altogether.
Lidocaine is sometimes used to treat nerve pain. Both this drug and TCAs affect heart rhythm, however, so they should be used together with caution.
Opioid analgesics are used to treat moderate to severe pain. In addition to being mindful of the usual cautions, such as risk of dependency, clinicians and patients should be aware of several potential interactions. For example, tramadol (Ultram), an opioid, can interact with SSRIs to increase risk of seizure in patients who take both drugs at once. Opioids may also interact with benzodiazepines to cause respiratory difficulties. A patient who is taking a benzodiazepine should start an opioid at a low dose and titrate slowly up. Codeine and hydrocodone may be less effective when taken along with psychiatric medications that compete for the same liver enzyme (such as paroxetine , bupropion , and duloxetine ).
Some psychiatric medications also work as pain relievers, thereby alleviating two problems at once. Just remember that pharmaceutical companies have a financial interest in promoting as many uses as possible for their products — so it is wise to check that evidence exists to support any “off label” (not FDA approved) uses for medications.
Other patients may prefer to take one medication for the psychiatric disorder and another for pain. In this case, it’s important to avoid drug interactions that can increase side effects or reduce medication efficacy (see sidebar).
Antidepressants. A variety of antidepressants are prescribed for both anxiety and depression. Some of these also help alleviate nerve pain. (The evidence is less convincing about their ability to treat other types of pain, such as backaches, which are usually of muscle rather than nerve origin.) The research most strongly supports the use of serotonin and norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants (TCAs) as double-duty drugs that can treat both psychiatric disorders and pain. The findings are more mixed about the ability of selective serotonin reuptake inhibitors (SSRIs) to alleviate pain.
The SNRI duloxetine (Cymbalta), for example, can also be used to treat the pain from diabetic neuropathy or fibromyalgia. Venlafaxine (Effexor) is also used for nerve pain, fibromyalgia, and headaches. Likewise, mirtazapine (Remeron) may help prevent chronic tension headaches.
One randomized controlled trial found that bupropion (Wellbutrin), which affects dopamine and norepinephrine, was helpful at alleviating chronic nerve pain, but not chronic low back pain unrelated to nerve damage. This may be an option for patients suffering nerve pain and depression. Be aware, however, that in some patients, bupropion may increase anxiety and contribute to insomnia.
The TCAs amitriptyline (Elavil), nortriptyline (Aventyl, Pamelor) and desipramine (Norpramin) are prescribed to treat nerve pain (such as diabetic neuropathy) and chronic headaches. When used to treat pain, TCAs are usually prescribed at a lower dose than when they are used to treat depression.
All drugs may cause unwanted effects. SSRIs, for example, may increase risk of gastrointestinal bleeding. TCAs can cause dizziness, constipation, blurred vision, and trouble urinating. Their most serious side effect is a dangerously abnormal heart rhythm, so these drugs may not be appropriate for people with heart disease. An overdose can fatally disrupt heart rhythm, so that danger must be weighed carefully against possible benefits in patients who have an elevated risk for attempting suicide.
Mood stabilizers. Anticonvulsants are also sometimes used to stabilize mood. These medications exert their effects by constraining aberrant electrical activity and hyper-responsiveness in the brain, which contributes to seizures. Because chronic pain in particular involves nerve hypersensitivity, some of these medications may provide relief. For example, pregabalin (Lyrica) is FDA-approved for treating diabetic neuropathy, postherpetic neuralgia, and fibromyalgia, and research also suggests it can treat generalized anxiety disorder.
Combining psychotherapy and drugs
Patients with anxiety or depression sometimes find that combining psychotherapy with medication offers the most complete relief. A randomized controlled trial, the Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study, suggests that a combination approach might also work for people suffering pain in addition to a psychiatric disorder.
The trial enrolled 250 patients with chronic pain in the lower back, hip, or knee. Participants also had at least moderate depression, as measured by a standard clinical instrument. One group was assigned to 12 weeks of antidepressant therapy followed by a 12-week pain self-management intervention based on principles of CBT. In the “usual care” group, which served as a control, researchers informed participants that they had depression and should seek advice or treatment. Results were considered significant if participants reported at least a 50% reduction in depression severity and at least a 30% reduction in pain. At the 12-month mark, both depression and pain were significantly reduced in 32 of 123 intervention patients (roughly one in four), compared with 10 of 127 usual care participants (about one in 12).
As a service to our readers, Harvard Health Publishing provides access to our library of archived content. Please note the date of last review on all articles. No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.
THURSDAY, Feb. 22, 2018 (HealthDay News) — Antidepressant drugs actually do help ease depression, countering debate over whether the medications do what they’re supposed to, a large research review has found.
Some antidepressants, though, are more effective and better tolerated than others, the findings showed.
The researchers analyzed data from 522 trials — published and unpublished — that included more than 116,000 participants. Of the 21 antidepressants studied, all of them worked better than a placebo.
“In the short-term, for acute depression, antidepressants seem to work modestly,” said study author Dr. John Ioannidis. He’s a professor of disease prevention at Stanford University in California. “They do have some benefit, on average, but they are not a panacea. Clearly, we need more effective interventions.”
Antidepressants sold in the United States that the study found to be most effective included:
- Effexor (venlafaxine)
- Lexapro (escitalopram)
- Paxil (paroxetine)
- Remeron (mirtazapine)
- Trintellix (vortioxetine)
Those that made the least-effective list of antidepressant drugs sold in the United States included:
- Luvox (fluvoxamine)
- Oleptro (trazodone)
- Prozac (fluoxetine)
When the researchers checked which depression drugs were tolerated the best, these topped the list:
- Celexa (citalopram)
- Lexapro (escitalopram)
- Prozac (fluoxetine)
- Trintellix (vortioxetine)
- Zoloft (sertraline)
The drugs that were found to be less well-tolerated included:
- Anafranil (clomipramine)
- Cymbalta (duloxetine)
- Effexor (venlafaxine)
- Luvox (fluvoxamine)
- Oleptro (trazadone)
The study authors wrote that there’s been “a long-lasting debate and concern about efficacy and effectiveness, because short-term benefits are, on average, modest and because long-term balance of benefits and harms is often understudied.”
However, Dr. Richard Catanzaro, chairman of psychiatry at Northern Westchester Hospital in Mount Kisco, N.Y., said this review shows that “all of these medications can be effective in treating depression.”
He explained that “all distinguish themselves from placebo, but there’s no hands-down winner.”
And, Catanzaro said, if you’re looking for the most tolerable and the most effective, you’re left with Lexapro and Trintellix.
In addition, Catanzaro noted that while amitriptyline was on the most-effective list, it was also on the least-tolerated list, and he said it’s generally not considered a first-line drug for depression treatment.
What are Antidepressants? Effective Antidepressants to Treat Depression
What are Antidepressants?
Antidepressants are medications used to treat all kinds of depression, from mild depression to major depression with anxiety to depression associated with bipolar disorder or cyclothymic disorder. This category of medications is broad, because there are so many underlying causes of depression, and different medications will work for different people, depending on their needs. Depending on the type of antidepressant prescribed, the medication could take a few weeks to begin lifting depression. It is important for people taking antidepressants to stay in contact with their prescribing physician or psychiatrist in order to keep track of the medication’s effectiveness.
5 Types of Antidepressants
There are five basic categories of antidepressant medications.
- Selective serotonin reuptake inhibitors (SSRIs) : Most prescribing physicians or psychiatrists will begin by prescribing this type of antidepressant. For most people, SSRIs effectively moderate mood, with fewer side effects than other medications. These medications work by blocking some reuptake of serotonin, so mood is elevated. Paxil, Prozac, Celexa, Lexapro, and Zoloft are all commonly prescribed SSRI antidepressants.
- Serotonin and norepinephrine reuptake inhibitors (SNRIs): These medications work by blocking both serotonin and norepinephrine from being absorbed by neurons, so the effects of these neurotransmitters linger in the brain longer, allowing changed communication between neurons and elevated mood. These antidepressants include Cymbalta, Effexor, Fetzima, and Pristiq.
- Tricyclic antidepressants (TCAs): These antidepressants tend to be a little more powerful than SSRIs or SNRIs, and they also cause more side effects. They were some of the earliest antidepressants but have fallen out of favor over time. Tricyclic antidepressants are not prescribed often; usually, they are prescribed in the instance that other antidepressants like SSRIs have not been effective. These medications increase levels of serotonin and norepinephrine in the brain by both blocking reuptake and changing output of the neurotransmitters. Medications in this category include Elavil, Tofranil, and Pamelor.
- Monoamine oxidase inhibitors (MAOIs): These are rarely prescribed, unless all other categories of antidepressants have failed to work. This was one of the first classes of antidepressants on the market, and they work by preventing monoamine oxidase from removing neurotransmitters from the brain, especially norepinephrine, serotonin, and dopamine. There are serious side effects associated with MAOIs, and the medication interacts with several types of foods, including some cheeses, pickles, and wine in ways that can be dangerous or deadly. Additionally, MAOIs interact with many other medications, including birth control pills, over-the-counter decongestants, and some herbal supplements. People who take MAOIs must follow a restricted diet and carefully examine any other medications they take. MAOI medications include Marplan, Nardil, and Parnate.
- Other antidepressants: Wellbutrin is an NDRI (norepinephrine and dopamine reuptake inhibitor); Oleptro and Remeron are sedating antidepressants; and some medications may be combined with antidepressants to increase the effectiveness of the antidepressant.
Although SSRIs and SNRIs are the first go-to prescriptions to treat depression, the above list shows that several categories of antidepressants exist because treatment for mental health conditions is so individual. Some understanding of the most effective prescription treatments for depression can be gathered by comparing some lists of popular antidepressants.
Are You Self-Medicating Your Depression
We Treat Addiction & Depression Simultaneously
Top 12 Most Popular & Effective Antidepressants: A Psychiatrists’ List
Although the antidepressant that works best is a very individual experience and choice, some medications are more popular among both prescribers and patients. One of the first lists of these antidepressants was compiled in 2009 by a group of psychiatrists. Their top 12 most popular and effective antidepressants were:
Top 10 Most Popular Antidepressants by Prescription and Sales
In 2013 and 2014, there were slightly different prescription and sales patterns for antidepressants in the United States. Here are the most popular and prescribed antidepressant medications from that time period:
Top 7 Most Consistently Popular Antidepressants
Between these two lists, the following antidepressants remain popular, widely prescribed, well liked, well tolerated, and induce few side effects. These are, in alphabetical order:
However, as new antidepressant formulas are released, prescribed, and found to have side effects or be widely effective, this list is likely to change. For now, though, it appears that SSRI and SNRI type antidepressants are the most effective forms of medicating most types of depression.
If depression, regardless of underlying cause, is not properly treated as soon as possible, it could lead to substance abuse. People who struggle with all kinds of mental health conditions, like bipolar disorder, anxiety, and depression, may also struggle with substance abuse, as a method of self-medicating their symptoms. Withdrawal symptoms associated with addiction to or dependence on drugs and alcohol, along with the brain chemistry changes caused by drugs and alcohol, can actually make symptoms of depression worse over time.
- Effective Antidepressants to Treat Depression
- Medicinal vs. Holistic Treatment for Depression
- Understand Seasonal Affective Disorder (SAD)
- Common Questions about Postpartum Depression and Treatment
- Comparing Bereavement or Grief to Medical Depression
- How Is a Major Depressive Disorder Different from Everyday Depression?
Help Is Needed to Overcome Depression
People who struggle with both depression and substance abuse have co-occurring disorders. It is important to find effective treatment for both of these conditions at the same time. Experts agree that co-occurring disorders must be treated simultaneously for recovery on both fronts to occur.
As more medical research is conducted into the prevalence of co-occurring disorders, more rehabilitation programs are incorporating this capability into their treatment plans, and they are better prepared to help people struggling with simultaneous substance abuse and mental health issues. With professional help, individuals can learn to manage both their substance abuse and their depression so they can embrace healthier, happier lives.
Your Guide to Antidepressants and Staying Well
Antidepressants are a class of medications used to manage several mental health issues, and are the quintessential class of pharmacotherapeutic agents prescribed for the treatment of major depressive disorder. Depression is the most common mood disorder in the United States, with a prevalence rate of 14.4%. It affects millions of Americans every year and is a lifelong mental health disorder that can severely impact your ability to work and engage in healthy social relationships. It is most commonly diagnosed among adults between the ages of 18 and 64, but most people experience the onset of depressive symptoms in their 20s.1
In many cases, a combination of therapies will be used to treat depression. This therapeutic strategy may include psychotherapy (talk therapy), a complementary self-care regimen, pharmacotherapy (antidepressant medications), or any combination thereof. Medications commonly used to treat MDD include:2
- Selective serotonin reuptake inhibitors (SSRIs).
- Serotonin-norepinephrine reuptake inhibitors (SNRIs).
- Tricyclic antidepressants (TCAs).
This article discusses in more detail these medications and others, including information about:
- The history and evolution of antidepressants.
- The different types of antidepressants (e.g., SSRIs, MAOIs).
- What conditions they’re typically prescribed for.
- Antidepressants vs. self-medication.
- Withdrawal from antidepressants.
- Resources for help for depression, anxiety, and other mood disorders.
History and Evolution
The first drugs designed specifically as antidepressants were the monoamine oxidase inhibitors (MAOIs). In 1952, Irving J. Selikoff and Edward Robitzek began conducting clinical studies of patients who were given isoniazid (a hydrazine antibiotic). Researchers stumbled upon the mood-boosting effects of the drug while researching new ways to treat patients suffering from tuberculosis. During their clinical trials, the researchers noticed a significant improvement in patients’ moods and began investigating the drug’s efficacy of treating depression.3
During this time, researchers discovered that another hydrazine compound—called iproniazid—had an even greater effect on elevating a patient’s mood. They noted that those who took the drug experienced increased appetite, energy, weight gain, and better sleep. Soon afterward, the term antidepressant was coined, and researchers began studying the efficacy of different drugs among patients with depression. What they found was that the MAOI (iproniazid) lead to increases of serotonin levels in the brain, which significantly improved the person’s social functioning.4
In 1957, at a meeting of the American Psychiatric Association, data on the effects of iproniazid as an antidepressant were presented. More studies were conducted, and within a year more than 400,000 patients affected by depression had been prescribed the drug for treatment. This opened the door for a new class of drugs (later known as MAOIs) designed specifically to treat depression. The demand for MAOIs was enormous because up until that point, there were no pharmacotherapeutic interventions for people with depression.3 Iproniazid was introduced onto the market, but quickly withdrawn in 1961 due to adverse effects among patients, including “cheese reaction”, which will be discussed later.4
Despite the negative reaction to MAOIs and their efficacy, the drug was brought back onto the market by members of the American College of Neuropsychopharmacology, who believed that the benefits of the drug heavily outweighed the risk. Today, MAOIs are not commonly used as the first line of defense against depression. Subsequent clinical trials would challenge their efficacy for the treatment of major depression compared with the then-newer tricyclic antidepressants (TCAs).3 Today, their use has almost entirely been replaced by that of newer-generation antidepressants such as the SSRIs and SNRIs.
What Are the Different Types?
A lot of research has been done since MAOIs were first introduced onto the market, and today there are many types of antidepressants available to treat depression, including:
- Tricyclic antidepressants (TCAs): While researching how to improve antipsychotic drugs, scientists discovered that the drug imipramine (brand name: Tofranil) significantly helped people suffering from severe depression. The discovery was exciting given that the serious side effects people experienced with MAOIs did not exist for people using imipramine. In 1959, the medication was approved by the FDA to treat depression, establishing a new class of drugs called tricyclic antidepressants (TCA). Side effects of TCAs include memory impairments, drowsiness, dizziness, weight gain, potential to overdose, orthostatic hypotension, anticholinergic effects (dry mouth, blurred vision, overheating), and decreased blood pressure.1,5
- Selective serotonin reuptake inhibitors (SSRIs): The first study of an SSRI called fluoxetine was published in 1974. The medication was approved by the FDA in 1987 and introduced onto the US market in 1988 as the now-widely-known Prozac. While the side effects of SSRIs are generally mild, some people experience negative symptoms such as weight gain, nausea, insomnia, sexual dysfunction, and discontinuation symptoms.1,5 Since fluoxetine was introduced, many more SSRIs have been approved by the FDA, including:1
- Sertraline (Zoloft).
- Citalopram (Celexa).
- Paroxetine (Paxil).
- Escitalopram (Lexapro).
- Monoamine oxidase inhibitors (MAOIs): As discussed previously, MAOIs were the first successful pharmacological treatment for depression. Monoamine oxidase is an enzyme that breaks down biogenic amines (including serotonin, dopamine, epinephrine, and norepinephrine that contribute to pleasurable feelings) as well as peripherally acting sympathomimetic amines such as tyramine. MAOIs were taken off of the US market at one point due to unwanted side effects from patients after one doctor traced the effects back to the ingestion of certain cheeses, dubbing the phenomenon “cheese reaction.” Doctors discovered that when MAOIs were taken with foods high in tyramine (some fermented foods, alcoholic beverages, aged cheeses, etc.), the combination increased concentrations of tyramine and norepinephrine in a person’s nervous system. This led to side effects such as increased heart rate, hypertension, and sweating. In response to having MAOIs taken off the market, pharmaceutical companies created more effective, reversible, and selective MAOA inhibitors, including moclobemide (Manerix) and brofaromine (Consonar). Although these drugs also produced side effects like nausea and insomnia, they are available in parts of the world. Moclobemide is not available in the United States, however, and brofaromine is no longer being developed as an antidepressant drug.1 Today, MAOIs are not the first choice for doctors prescribing antidepressants and are only prescribed when a person does not respond well to newer antidepressant drugs.4
- Bupropion: The immediate-release drug bupropion, which goes by the brand name Wellbutrin, was approved in 1989. It is referred to as an atypical antidepressant drug because it is in the category of chemicals called aminoketones that interacts with neurotransmitter systems in the brain much differently than other antidepressant drugs do. Bupropion is a dopamine-norepinephrine reuptake inhibitor, and research shows that it is as effective as other antidepressant drugs to treat depression when taken in 3 daily doses. The sustained-release (SR) version was introduced in 1996 and the extended-release (XL) version in 2003. Compared to other antidepressants, it has the lowest risk of sexual dysfunction with the most common side effects being nausea, dry mouth, and insomnia.1 This medication is contraindicated for people with a current or past history of seizures or eating disorders.5
- Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): SNRIs also fall under the atypical antidepressant classification. One of the first drugs in this category, venlafaxine (Effexor), was introduced onto the U.S. market in 1993, and the extended release form of venlafaxine was approved for the treatment of depression in 1997. SNRIs work by selectively targeting the serotonin and norepinephrine transporters in the brain. Some studies suggest that SNRIs are more effective than SSRIs at treating depression, but more studies are needed. Side effects include sexual dysfunction.1 Since the approval of venlafaxine, other SNRIs have been approved by the FDA for the treatment of depression, including:1
- Duloxetine (Cymbalta).
- Desvenlafaxine (Pristiq).
- Milnacipran (Savella).
What Are They Prescribed For?
Antidepressants are mainly prescribed to treat the symptoms of extreme sadness and exhaustion most often associated with depression. As a class of drugs, antidepressants are thought to work by restoring a person’s emotional balance via specific neurotransmitter activity so that they can function in their day-to-day lives. People may also be prescribed these medications to relieve anxiety, sleeping issues, suicidal thoughts, and restlessness.6
So how do antidepressants actually work? In our brains, certain nerve cells, or neurons, interact with each other via the release of signaling molecules called neurotransmitters. When these chemicals (e.g., serotonin and dopamine) are out of balance, it can lead to mental health problems such as depression. Although scientists continue to study and learn more about the exact mechanisms of depression, experts believe that when a person is depressed, there may actually be a problem occurring between interconnected neurons. Taking medications, such as SSRIs or TCAs, can help increase the availability of certain neurotransmitters throughout the brain to improve the symptoms of depression and some other mental health conditions.6
Generally, antidepressants are taken on a daily basis. During the first weeks and months of taking one, the primary goal is to manage depressive symptoms. It’s not always the case that symptoms will disappear completely, but they should improve and feel manageable. To achieve this, most people stay on their medication for a year or two, after which your doctor will assess your condition and make a recommendation for the next phase of treatment. Staying on your antidepressant consistently helps prevent symptoms from reappearing or becoming unmanageable. Those who are ready to discontinue medication (at their doctor’s approval) do well to continue with individual therapy or counseling to manage any minor symptoms that linger. Regardless of what works best for you, this decision should always be made between you and your doctor.6
As you near the end of treatment, your doctor will gradually reduce your dose over a period of several weeks in a process known as tapering. Though antidepressants are not thought to result in the development of physical dependence in the same manner as some prescription medications, such as sedatives, while you taper, you may experience side effects such as trouble sleeping, nausea, or restlessness. This is normal, and it is important that you adhere to whatever regime your doctor has given to you even if you experience these problems. Sometimes, people stop taking their medication as soon as they start feeling better, but this can increase your chances of the depressive symptoms returning. Your improved mood and energy levels are a sign that your medication is working and that you should continue taking it—not that you no longer need it.6
It is important to keep regular appointments with your doctor while you are taking antidepressants. There are many variables that come into play when taking a medication for a mental health disorder, so it’s essential to talk with your doctor about whether your symptoms have improved or worsened, or whether you are experiencing any side effects. Depending on how you are affected by the medication, your doctor may adjust your dose, but you should never adjust the dose on your own. The primary risk of doing this is that the medication may not work as it is intended, and you could experience unpleasant side effects.6
Antidepressants vs. Self-Medication
It is often common for people to turn to negative or maladaptive “self-medicating” activities like drinking alcohol or using drugs to temporarily avoid experiencing the feelings of depression. Other self-medicating activities might include the misuse of prescription medications, self-harming behaviors, or engaging in risky sexual activities, such as anonymous sex with multiple partners.
The safest and most effective way to treat depression is to see a trained medical or mental health professional to receive behavioral therapy, medication, or both. Some people object to taking medication for a mental health disorder because they believe it’s a problem of that can be overcome by sheer will. However, depression is thought to be a disease of the brain that arises from impaired neurochemical functioning. Medication is designed to help correct this brain imbalance. It is often a first step to stabilize symptoms with an antidepressant so you can more effectively take part in other therapeutic options, such as psychotherapy or peer support groups.
It is important to remember that not everyone responds positively to antidepressants, so you should share your full medical history with your doctor before you begin any medication and work closely with an experienced psychiatrist to determine the best way to manage your depression. Like all drugs, these medications can have a number of side effects that could be uncomfortable enough to prompt you to discontinue use or switch to another medication. Unfortunately, side effects often lead people to stop refilling their prescriptions or to stop taking their medication once they start feeling better. In fact, studies show that many patients take their antidepressant for 14 weeks or less.7 What research shows is that long-term treatment is necessary in order prevent depression from returning. Nevertheless, if you are experiencing adverse reactions to medication, speak to your doctor about your options.
Compared to choosing common methods of self-medicating, such as abusing alcohol, gambling, or compulsive sexual behavior, a treatment course with an option to include antidepressants and ongoing therapy presents the wiser choice.
What Happens When You Stop Taking Your Medication?
Depression is a naturally fluctuating condition. Many people begin feeling much better after taking medication for a few weeks and believe that they can stop using antidepressants as a result. However, these early improvements in mood are simply an acute response to the medication and not a true remission.7 Studies show that stopping antidepressant medication prematurely can actually increase the risk of relapse or recurrence, especially when the withdrawal is abrupt.
When people use antidepressants consistently for a long time, it can protect them from experiencing the following:7
- Relapse and recurrence of depressive symptoms
- Worsening of existing depressive symptoms
- Discontinuation symptoms (aka, withdrawal)
The question of when to stop taking antidepressants is one that every person must consider at some point. Because complete remission of depressive symptoms is the goal of therapy, it is important to confirm that your depression has sufficiently resolved before you discontinue your medication. Your doctor will work with you to determine the severity and improvement of your depression using clinical scales. New recommendations state that treatment should be continued for 9 months to prevent relapse, while other experts believe that medication should continue anywhere between 3 years to a lifetime.7
Most drugs use the term withdrawal syndrome when referring to stopping use of a drug. However, in the case of antidepressants, experts prefer the term discontinuation syndrome since the effects of stopping TCAs, MAOIs, SRIs, SSRIs, and SNRIs are usually mild and not long-lasting. In most cases, drug withdrawal symptoms peak in the first week and gradually fade away, however, discontinuation symptoms differ depending on the drug taken and can range widely in their severity.7,8
Some of the discontinuation syndrome symptoms you may experience include:7,9
- Vivid dreams.
- Urinary retention.
- Sexual dysfunction.
- Parkinsonian symptoms.
- Lowered seizure threshold.
- Crying spells.
- Depressed mood.
- Suicidal thoughts.
How to Get Help for Depression
Depression affects every person differently, but a few common signs of the disorder include:10
- Pervasive feelings of sadness.
- Feeling empty.
- Forgetting things.
- Losing interest in things you used to find enjoyment in.
- Trouble making decisions.
- Sleeping a lot.
- Not sleeping enough.
- Feeling hopeless.
- Gaining weight.
- Losing weight without intending to.
- Suicidal thoughts.
Fortunately, depression can be treated, starting by making an appointment with your primary care physician and asking for a referral to a mental health clinician or a psychiatrist. Having an open conversation with your doctor will help them refer you to the appropriate mental health professional.
If you do not have a primary health care provider or you do not feel comfortable visiting with one, a few other places you can go to get help for depression include:
- Community clinics.
- Church resource centers.
- Inpatient treatment centers.
- Outpatient treatment centers.
- Support groups.
- Counselors or social workers.
- Family service agencies.
- Social services.
During your visit with your doctor, they may check to see if you have other health conditions that need to be addressed. For example, a thyroid disease can lead to depression or worsen symptoms.
Getting the help you need will improve not only your life, but those closest around you. Don’t be afraid to reach out to your family, friends, neighbors, community, or religious leaders for support as you begin working through your depression. It can be scary and overwhelming to admit you have a mental health problem, but it is an important and necessary step to healing.
Tips for Staying Well
Once you have gone through the appropriate steps to get treatment for depression and are managing the symptoms well with your treatment team, there are healthy ways to continue to take care of yourself and keep your depression at bay.
In some cases, individuals are able to lessen the impact of their depression by making certain healthy choices in their daily routines. Taking some time to look at areas of your life that may be causing you stress can reveal where to make adjustments. Take an inventory of your physical, emotional, spiritual, economic, and social wellbeing and go from there.
Ways that you can practice self-care while you are being treated for depression and afterward might include:
- Eating healthy: Research shows that adopting a healthy diet can help prevent cancer, dementia, and depression. What you put into your body has a huge effect on your mind. You can talk to your doctor or a nutritionist about what foods they recommend, but some experts emphasize the importance of eating unprocessed fruits and vegetables, seeds, lean protein, nuts and avoiding the consumption of alcohol, processed meats, sugar, flours, and other meats.11
- Getting enough sleep: Many people who suffer from depression also experience sleep problems. Conversely, having a sleep disorder increases the odds you’ll develop depression. Avoid using caffeine, alcohol, or nicotine before bed. You can also practice good sleep hygiene by creating a sleep schedule. Download an app on your phone to track your sleep or to make sure you always get to bed at a certain time. Clear your bedroom of any distractions and, if possible, remove all electronics from your bedroom. You can buy blackout curtains to darken your room and ensure no light disrupts your sleep. Practicing meditation or guided imagery before bed also helps your body relax and calms any racing thoughts. Free apps like Insight Timer have hundreds of sleep meditations to choose from. If you suffer from insomnia, talk to a medical professional before taking medication—some SSRIs can cause or worsen insomnia.12
- Drinking enough water: You could treat yourself to a fancy new water bottle to make drinking water more fun, or you can infuse water to make it taste better. Some people like to squeeze a lemon or drop mint into your bottle for extra (and healthy) flavor.
Explore activities to help improve your mood, including:
- Volunteering: Pick a cause or charity that you feel passionate about because volunteering your time and being of service can be huge contributors to your overall wellbeing. In fact, studies show that people who donate their time feel more socially connected, which helps prevent feelings of loneliness.13
- Doing yoga: Studies show that yoga can be helpful for anxiety and depression because it helps relieve stress, reduces heart rates, lowers blood pressure, and helps people respond better to stress.14
- Getting a pet: Animal-assisted therapy may offer numerous health benefits, with some studies supporting a role in lowered blood pressure, improved cholesterol levels, and a decreased risk of heart disease. They also provide unconditional love, something that feels great if you are struggling with depression. When you interact with an animal, your brain produces oxytocin, the connection hormone that mothers feel when holding their children. This helps boost the levels of serotonin in your brain and leads to feelings of calmness and wellbeing. People with animals tend to experience less loneliness, depression, and anxiety.15
What are the different types of antidepressants?
Here are the main types of antidepressants along with brand names:
- Selective serotonin reuptake inhibitors (SSRIs) were launched in the mid to late 1980s. This generation of antidepressants is now the most common class used for depression. Examples include citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil, Pexeva), fluoxetine (Prozac, Sarafem), and sertraline (Zoloft). Two medicines, classified as “serotonin modulators and stimulators” or SMS’s (meaning they have some similar properties as SSRIs but also affect other brain receptors) are vilazodone (Viibryd) and vortioxetine (Trintellix) Side effects are generally mild, but can be bothersome in some people. They include nausea, stomach upset, sexual problems, fatigue, dizziness, insomnia, weight change, and headaches.
- Serotonin and norepinephrine reuptake inhibitors (SNRIs) are a newer type of antidepressant. This class includes venlafaxine (Effexor), desvenlafaxine (Pristiq and Khedezla), duloxetine (Cymbalta), and, levomilnacipran (Fetzima). Side effects include upset stomach, insomnia, sexual problems, anxiety, dizziness, and fatigue.
- Tricyclic antidepressants (TCAs) were some of the first medications used to treat depression. Examples are amitriptyline (Elavil), desipramine (Norpramin, Pertofrane), doxepin (Adapin, Sinequan), imipramine (Tofranil), nortriptyline (Aventyl, Pamelor), protriptyline (Vivactil), and trimipramine (Surmontil). Side effects include stomach upset, dizziness, dry mouth, changes in blood pressure, changes in blood sugar levels, and nausea.
- Monoamine oxidase inhibitors (MAOIs) were among the earliest treatments for depression. The MAOIs block an enzyme, monoamine oxidase, that then causes an increase in brain chemicals related to mood, such as serotonin, norepinephrine and dopamine. Examples are phenelzine (Nardil), tranylcypromine (Parnate) , isocarboxazid (Marplan), and transdermal selegiline (the EMSAM skin patch). Although MAOIs work well, they’re not prescribed very often because of the risk of serious interactions with some other medications and certain foods. Foods that can negatively react with the MAOIs include aged cheese and aged meats.
- Other medications:
- Bupropion (Aplenzin, Wellbutrin) is a unique antidepressant that is thought to affect the brain chemicals norepinephrine and dopamine. Side effects are usually mild, including upset stomach, headache, insomnia, and anxiety. Bupropion may be less likely to cause sexual side effects than other antidepressants.
- Esketamine (Spravato) is a unique medicine originally developed as an anesthetic and thought to treat depression though its effects on a brain chemical called glutamate. It is administered as a nasal spray and is for use in those who have not responded to treatment by other antidepressants. Its most common side effects include sedation, dissociation (having strange perceptions about time and space, or feeling as if things around you are not real), problems with thinking, and high blood pressure. If any of these side effects occur they are usually mild and temporary.
- Mirtazapine (Remeron) is also a unique antidepressant that is thought to affect mainly serotonin and norepinephrine through different brain receptors than other medicines. It is usually taken at bedtime because it often causes drowsiness. Side effects are usually mild and include sleepiness, weight gain, elevated triglycerides, and dizziness.
- Trazodone (Desyrel) is usually taken with food to reduce chance for stomach upset. Other side effects include drowsiness, dizziness, constipation, dry mouth, and blurry vision.
- Variety of Medications
- Discussing Medications: What You Need to Know
- Questions to Ask About a New Drug/Treatment on the Market
- ADAA Medication Information Resources
- Patient-Assistance Programs for Prescription Drugs
- Can CBD Help with My Anxiety and Depression?
Medication treatment of anxiety is generally safe and effective and is often used in conjunction with therapy. Medication may be a short-term or long-term treatment option, depending on severity of symptoms, other medical conditions, and other individual circumstances. However, it often takes time and patience to find the drug that works best for you.
Medications are commonly prescribed by physicians (family practice, pediatricians, OB-GYNs, psychiatrists), as well as nurse practitioners in many states.
More than 1in 6 Americans take a psychiatric drug (such as an antidepressant or a sedative). according to a 2013 Medical Expenditure Panel Survey (MEPS), which gathered information on the cost and use of health care in the United States. Antidepressants were the most common type of psychiatric drug in the survey, with 12 percent of adults reporting that they filled prescriptions for these drugs, the study said.
Between 2011 and 2014, approximately one in nine Americans of all ages reported taking at least one antidepressant medication in the past month, according to national survey data released by the Centers for Disease Control and Prevention (CDC). Three decades ago, less than one in 50 people did.
Variety of Medications
Four major classes of medications are used in the treatment of anxiety disorders:
Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs relieve symptoms by blocking the reabsorption, or reuptake, of serotonin by certain nerve cells in the brain. This leaves more serotonin available, which improves mood. SSRIs (citalopram, escitalopram, fluoxetine, paroxetine, and sertraline) generally produced fewer side effects when compared with tricyclic antidepressants. However, common side effects include insomnia or sleepiness, sexual dysfunction, and weight gain. They are considered an effective treatment for all anxiety disorders, although the treatment of obsessive-compulsive disorder, or OCD, typically requires higher doses.
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
The serotonin-norepinephrine reuptake inhibitor, or SNRI, class (venlafaxine and duloxetine) is notable for a dual mechanism of action: increasing the levels of the neurotransmitters serotonin and norepinephrine by inhibiting their reabsorption into cells in the brain. As with other medications, side effects may occur, including stomach upset, insomnia, headache, sexual dysfunction, weight gain and minor increase in blood pressure. These medications are considered as effective as SSRIs, so they are also considered a first-line treatment for the treatment of anxiety disorders, but not for obsessive compulsive disorder ,where SSRI’s are the preferred first line treatment.
This class of drugs is frequently used for short-term management of anxiety and as an add on treatment, in treatment resistant anxiety disorders.They are not recommended as a treatment for Post Traumatic Stress Disorder. Benzodiazepines (alprazolam, clonazepam, diazepam, and lorazepam) are highly effective in promoting relaxation and reducing muscular tension and other physical symptoms of anxiety. Long-term use may require increased doses to achieve the same effect, which may lead to problems related to tolerance and dependence.
Concerns about long-term use of the benzodiazepines led many doctors to favor tricyclic antidepressants (amitriptyline, imipramine, and nortriptyline). Although effective in the treatment of some anxiety disorders(but not Social Anxiety Disorder), they can cause significant side effects, including orthostatic hypotension (drop in blood pressure on standing), constipation, urinary retention, dry mouth, and blurry vision.
Contact your physician if you experience side effects, even if you are not sure a symptom is caused by a medication. Do not stop taking a medication without consulting with the prescribing physician; abrupt discontinuation may cause other health risks.
Medications will work only if they are taken according the explicit instructions of your physician, but they may not resolve all symptoms of an anxiety disorder.
ADAA Public Statement – March 6, 2019: On March 5, 2019 the FDA approved a new nasal spray medication- Spravato (esketamine) for treatment-resistant depression, available only at a certified doctor’s office or clinic. Ketamine represents a major step forward in the treatment of depression and suicide prevention. ADAA recognizes that clinicians want to offer their patients evidence-based options which have passed through the numerous stages of FDA testing, and this marks the first FDA approval of a ketamine product for a psychiatric indication. This is also the first antidepressant with a novel mechanism of action that we have had in decades.
The development of the intranasal esketamine formulation with an intermittent dosing strategy offers a new approach to the treatment of refractory depression that could also impact greatly the care of patients with suicidal activity.
While this newly approved treatment offers hope as a fast acting and durable antidepressant option for patients who have not responded adequately to conventional SSRI or SNRI medications, it is important to be cautious. Many patients may seek out esketamine have not received trials with other evidence-based treatments including pharmacotherapy and psychotherapy or rTMS or ECT.
It is also important to note that the long-term efficacy of ketamine is not established and there is also concern about the potential abuse liability factor which will be highlighted by the FDA on the drug’s label.
Patients considering the use of Spravato should ask their doctor what the long-term follow up strategy should be and whether there are any potential negative consequences over time with continued use.
Ketamine News and Research
- Unmet Needs Exist in Ketamine Research, Healio.com, Sanjay Mathew, MD
- Esketamine Nasal Spray Eases Depression Symptoms In Suicidal Patients, NPR.org
- Is Ketamine an Opioid?, PainNewsNetwork.org, Adam Kaplin, MD, PhD and Alan Schatzberg, MD
- Esketamine Nasal Spray Effectively Treats TRD When Coupled With Antidepressants, MD Magazine
- Ketamine isn’t an Opioid and Treats Depression in a Unique Way, Science Daily, Adam Kaplin, MD, PhD
- A Consensus Statement on the Use of Ketamine in the Treatment of Mood Disorders, JAMA Psychiatary, April 2017, Gerard Sanacora, MD, PhD; Mark A. Frye, MD; William McDonald, MD; ADAA Board Member Sanjay J. Mathew, MD; Mason S. Turner, MD; ADAA member Alan F. Schatzberg, MD; Paul Summergrad, MD; ADAA Board Member and Chief Medical Officer Charles B. Nemeroff,MD, PhD; for the American Psychiatric Association (APA) Council of Research Task Force on Novel Biomarkers and Treatments
- J&J’s Ketamine-Based Drug Drives Sea Change for New Depression Treatments, FoxBusiness.com, ADAA Board Member, Sanjay Mathew, MD
- Advocates Cheer FDA Approval of Anti-Depressant Nasal Spray, WashingtonTimes.com, ADAA Board Member Sanjay Mathew, MD
- FDA Approves new Johnson & Johnson Drug for Depression, MarketPlace.org, ADAA Board Member Sanjay Mathew, MD
- Efficacy and Safety of Intranasal Esketamine for the Rapid Reduction of Symptoms of Depression and Suicidality in Patients at Imminent Risk for Suicide: Results of a Double-Blind, Randomized, Placebo-Controlled Study, American Journal, 2018
- Double-blind, placebo-controlled, dose-ranging trial of intravenous ketamine as adjunctive therapy in treatment-resistant depression (TRD), Molecular Psychiatry, September 2018
Discussing Medications: What You Need to Know
Use these guidelines to talk to your health care professional about medications:
- To avoid potentially dangerous drug interactions, let your mental health care provider know all medications you are taking, including prescriptions and over-the-counter drugs, herbal or dietary supplements, and vitamins. And make sure your family doctor knows you are taking medications for an anxiety disorder.
- Learn when to take a new medication and how, such as on any empty stomach or with food, in the morning or evening, and how frequently.
- Find out how long it should take for the medication to start working and what you should expect when this happens.
- Ask: How will the medication help me? What side effects might occur? Should I avoid any foods or beverages? Are drug interactions with other prescriptions a possibility? How often you should see the doctor for a medication check-up?
- Ask for the prescribing physician’s after-hours phone number in case you develop side effects.
- A good source of information about medications and over-the-counter products is your pharmacist, who should have information about all your prescriptions to advise you about possible drug interactions, side effects, and instructions for use.
If your physician does not want to spend the time to answer your questions, you may need a referral to a different physician.
Questions to Ask About a New Drug/Treatment on the Market:
- Is this new drug/treatment appropriate for me?
What are the drawbacks, if any of this new treatment?
What might be the benefits over my current regimen?
Is the price (typically high when a drug is new) worth the added benefit?
Is this treatment ready for widespread use? Meaning, does it have safety established? Do we know how long people need to be on this treatment? Do we know about any long term issues that could result from this?
ADAA Medication Information Resources
- Can CBD Help with My Anxiety and Depression? – ADAA web page
- The Meaning of Medications – Another Look at Complianc – Revisited – ADAA blog post
- A Most Difficult Decision – Medication and Pregnancy – ADAA blog post
- Psychotropic Medications: What You Should Ask Your Doctor – ADAA blog post
- For My Anxiety or Depression: Should I Use Medication or Therapy – ADAA webinar
- Medication for Anxiety: Benefits and Side Effects – ADAA webinar
- Depression: What You Need to Know About Medications – ADAA webinar
Patient-Assistance Programs for Prescription Drugs
Most pharmaceutical companies offer patient-assistance programs for uninsured patients. These programs provide prescribed medication at little to no cost. Eligibility varies; see the Partnership for Prescription Assistance website for more information, or contact companies directly about their patient assistance programs.
- Community Assistance Program (CAP) provides free downloadable prescription cards accepted at over 56,000 pharmacies. Cardholders receive the lowest price available for any particular drug at their chosen pharmacy.
- NeedyMeds is a 501(c)(3) national non-profit information resource dedicated to helping people locate assistance programs to help them afford their medications and other healthcare costs. ADAA is partnering with NeedyMeds to provide information resource pages about various anxiety and depression related disorders. NeedyMeds has provided this 2019 informational sheet with the most popular healthcare cost savings program.
Reviewed/Updated July 2019
Antidepressants: What is the best medication for depression?
Signs and symptoms of depression
Depression can present as a constant, persistent feeling of sadness or depressed mood nearly every day for at least 2 weeks can be associated with loss of interest in activities, weight gain or loss, fatigue, feelings of worthlessness or guilt, decreased ability to concentrate, sleep disturbances or thoughts of suicide.
“Everyone feels sad sometimes,” Alonzo said. “However, depression is not something that easily gets better on its own. There are many treatments, including therapy and medications, that can help.”
Persistent thoughts of suicide with or without a specific plan can constitute a medical emergency and should never be taken lightly. If you or someone you know is having thoughts of suicide, please call 911 and ask for mental health responders, or call the National Suicide Prevention Lifeline at 800-273-8255.
If you are worried that you might be experiencing symptoms of depression, speak with your health care provider. There are easy to answer screening tools your health care provider can administer and they can help set you up with a treatment plan. Treatment plans including a therapist are available for all budgets, including those who might not have health insurance.
Depression looks and feels differently for each person. However, some common depression symptoms are…
- Depressed mood most of the day, nearly every day
- Loss of interest in activities that used to give you pleasure
- Weight loss or weight gain, or changes in appetite
- Difficulty concentrating, or feeling like your thoughts and movements are slow
- Lack of energy
- Trouble sleeping
- Reduced appetite
- Feelings of worthlessness
- Recurrent thoughts of death or suicide, with or without a specific plan
Some people may even notice unexplained back pain or headaches or other physical symptoms that can’t be explained. If you are experiencing any of these problems for more than a few days at a time, then speak with your primary care provider about some next steps.
SSRIs and SNRIs for depression
SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin and norepinephrine reuptake inhibitors) are some of the most commonly prescribed antidepressants. These drugs work by restricting the reuptake process of important neurochemicals that regulate mood, sleep and appetite.
By restricting the reuptake of these important neurochemicals, the brain has more of those chemicals to send across brain tissue. Specifically, these drugs can inhibit the reabsorption of serotonin, norepinephrine and dopamine—all chemicals that directly influence feelings of happiness and stress. By increasing the amount of these important neurochemicals, the brain is able to better regulate mood, sleep, appetite and other feelings that contribute to depression.
“Since SSRIs and SNRIs work by influencing your natural brain chemistry, you may need to wait four to 6 weeks to see the full effect of these medications. Often patients will see a slight decrease in symptoms in about 2 weeks, which is when your healthcare provider will want to see you to check on progress. Patients often describe one of the first positive effects of taking the medication is improved sleep,” Alonzo said. “If you do not see results after a few weeks of starting a new medication, then speak with your health care provider. You may need to adjust your dosage, or need to change to a different medication. The treatment for depression is very personalized, and it is not uncommon for patients to try more than one medication before we found the one that works for you. Don’t stop taking the medication on your own.”
Ketamine and esketamine for depression
Ketamines and esketamines are not used as a first-line treatment for depression. They are often only prescribed when the patient has treatment-resistant depression, or depression that has not responded to other medications and therapies. Ketamine and esketamine are very similar in composition, but esketamine is remarkably more potent than ketamine. Ketamine is approved by the FDA as an anesthetic, but it is being used for treatment-resistant depression off-label, meaning it does not currently have FDA approval for this use.
Ketamines and esketamines can be used for very severe or life-threatening cases of depression that include suicidal ideation that can help the person long enough to give other antidepressants adequate time become effective.
Spravato© (Esketamine) nasal spray for depression
In March of 2019, the U.S. Food and Drug Administration approved the use of Spravato ©, an esketamine nasal spray, in conjunction with an oral antidepressant, for adults who have tried at least two other antidepressant medications, but have not benefitted from them. Spravato© is considered high risk and is only available through a system of tight distribution and monitoring. Spravato© is only to administered under supervision from the health care provider in a health care clinic or office and is not self-administered. Possible side effects after administration include sedation, disassociation, attention and judgement problems, and possibly worsening suicidal thoughts, patient’s will be monitored at the provider’s facility for at least 2 hours.
How long does it take for antidepressants to start working?
“Depending on the medication used, traditional antidepressants like SSRIs and SNRIs can take up to 4-6 weeks for full effect,” Alonzo said. “Spravato© (esketamine) is fast-acting and can potentially help those experiencing thoughts of suicide more quickly, however, it is not appropriate for long term treatment of depression. SSRIs and SNRIs provide a more long-term relief, but take longer to become effective.”
Speak with your health care provider if you are not noticing an improvement in your symptoms of depression after taking your antidepressant medication every day for at least 2-4 weeks. They may decide to adjust your dosage or try a different treatment plan.
Can antidepressants make depression worse?
“Certain antidepressants can increase the risk of suicidal thoughts in especially young people,” Alonzo said. That’s why it is important to stay in close communication with your health care provider as you or your child start a new antidepressant treatment. “Usually, your provider will recommend a follow-up appointment within one to two weeks of starting a new antidepressant to check on your progress and monitor side effects and tolerability. Finding the correct treatment plan for you can take time, but it is worth the effort.”
Stopping and changing antidepressants
Be sure not to stop taking your antidepressant without discussing with your healthcare provider. Abruptly discontinuing your antidepressant can make your symptoms of depression reappear or become worse. Additionally, you may experience other symptoms like headaches, pain, or insomnia and other flu-like symptoms. It is very important to continue to take your antidepressant as prescribed until advised to stop taking it by your healthcare provider.
If you are experiencing annoying side effects with one medication, your health care provider can recommend other medications that may be better tolerated. Additionally, if you are finishing your medication therapy for depression because you are in recovery, your healthcare will most likely taper your medication slowly, for instance you might take your medication every other day for a while to avoid the symptoms mentioned above that occur after abrupt withdrawal. Keep your health care provider in the loop about your symptoms, so they can help you manage your health even better.
Are antidepressants safe when pregnant or breastfeeding?
Overall, the risk of birth defects and other problems for babies and mothers who take antidepressants during pregnancy are low, however, antidepressants may still impact a developing infant by possibly increasing the risk of premature birth, decreased weight and neonatal adaptive syndrome.
Neonatal adaptive syndrome can occur in infants exposed to SSRIs during late pregnancy. Symptoms of neonatal adaptive syndrome include jitteriness, feeding problems and respiratory distress, and can occur in up to 30 percent of infants exposed to SSRIs in utero. These symptoms often go away on their own.
“Women who have untreated depression during pregnancy may be less likely to get the proper neonatal care required, which can impact the health of both the mother and baby,” Alonzo said. “On the other hand, women who take antidepressants may need to switch medications or have their medication prescribed at the lowest effective dose.” It is important that health care providers and expectant mothers have open conversations about the potential risks and the possible benefits associated with antidepressant treatment during pregnancy to make the best, informed decision. Generally, the following antidepressants are options during pregnancy: Celexa © (citalopram), Prozac© (fluoxetine), and Zoloft© (sertraline).
Infant exposure to antidepressants in breastmilk is considered to be very low, and the risks associated with untreated depression or post-partum depression to the mother is generally considered to be higher than the risk posed to the infant. Once again, open discussions about symptoms, treatment options, and risks versus benefits to both the mother and the infant are critically important. Zoloft© (sertraline) and Paxil© (paroxetine) are considered the two best antidepressant choices during breast-feeding with the most positive evidence.
Which antidepressant will work for me?
“Once medication is deemed necessary to treat your depression, your provider will select the best medication for you and will start with a dose that is considered standard for your symptoms. The treatment of depression with medication is very personalized, and it might take more than one trial with more than one medication before we find the right one for you.” Alonzo said. “Finding the best antidepressant medication treatment plan for you may take some time, but these medications are very effective, and combined with therapy, before long we will be discussing your recovery.”
If you or someone you know is struggling with untreated depression, then do not hesitate to reach out for help. Please contact 1-800-273-TALK to reach the Mental Health America 24 hour crisis line, or text 741741 at the Crisis Text Line.
— Katherine Hancock
At Alternative to Meds Center, we employ effective alternatives to Prozac for anxiety, depression and other mental health problems.
Often times, when people run into Prozac side effects or ineffectiveness, they will seek Prozac alternatives help. We are certain that there are alternative solutions besides continuing being medicated with prescription depression drugs.
There are a number of different alternatives to Prozac for depression or other symptoms. This medication is also known as Fluoxetine part of a group of drugs called selective serotonin reuptake inhibitor (SSRI) and is a frequently prescribed treatment for depression and other mental health conditions. There are also a number of Prozac side effects which may occur from taking this drug and in some cases, mental conditions cannot be treated with antidepressants; fortunately options that are antidepressant alternatives to Prozac are available for those who suffer from side effects or ineffective treatment from this medication. Some of the most common alternatives include therapy, other antidepressant drugs, electroconvulsive therapy, and natural Prozac alternative therapies.
Individuals seeking alternatives to Prozac for anxiety or depression may find that their doctor wants to keep them on medication and if this drug isn’t working; the doctor may suggest another similar drug. Doctors often prescribe the following prescription medications as Fluoxetine alternatives: other selective serotonin reuptake inhibitors (SSRIs) such as Paxil (Paroxetine), selective norepinephrine reuptake inhibitors (SNRI’s) such as Cymbalta (Duloxetine), tricyclic antidepressants such as Elavil (amitriptyline), and monamine oxidase inhibitors (MAOIs) such as Nardil (phenelzine). The above mentioned drugs are often very similar in side effects and have similar chances of being ineffective or causing withdrawal symptoms if the drug is discontinued.
Using other antidepressant drugs as alternatives to Prozac for depression or anxiety may not be the answer for most people, as the reasons for seeking alternatives may also be present with other prescription drug treatments. Prozac alternatives therapy is highly regarded and strongly recommended for individuals seeking antidepressant alternatives; many different forms of psychotherapy can help people manage symptoms of depression and help them to make consistent steps toward their desired mental health goal.
Talk therapies can allow a depressed individual to look at their problems from another perspective and find resolutions for these problems through talking with the talk therapist. Talk therapists can also help patients with being more satisfied with their own actions and unlearning the patterns of behavior and thought which may be contributing to depression or resulting from it.
With the many side effects of this medication and situations it is ineffective; some individuals may consider Prozac alternatives natural approaches. Many people fend off depression naturally through forms of Prozac alternatives help, not by taking a trip to the doctor. Depression and other mental conditions are very often a result of internal causal factors.
Heavy metal toxicity, nutritional deficiencies, irregularities in sleep, diet or physical activity; relationships, environmental factors, and many other aspects of one’s life and lifestyle play a role in the symptoms and outcome of depression. When doctors prescribe an antidepressant for a mental condition, it appears as though they are making a quick fix; opposed to testing all areas of the body and mind to ident underlying causative factors as Fluoxetine alternatives treatment does.
Depression is not a quick fix though, and the use of prescription drugs may make depression worse for some by emerging side effects, ineffectiveness, dependency issues, and withdrawal symptoms. Effective treatment for depression may be achieved through discovering the underlying reasons that cause depression and instead of trying to fix depression symptoms with drugs; addressing the underlying causes of depression may truly alleviate the symptoms rather than being covered up by the effects of an anti-depression drug.
Other popular and potentially effective Prozac alternative medicines include: anxiety or depression relieving supplements and vitamins such as valerian and St. John’s Wort, and serotonin producing amino acids such as L-tryptophan. Any positive effects of this drug can be easily recreated with natural medicines and healing therapies, there is no reason to suffer from side effects or ineffectiveness when equally effective and side-effect free Prozac alternatives therapy is available.
People are often given an antidepressant prescription without any prior investigations into what might be causing their depression. Low Serotonin is frequently blamed as the cause for depression but what about food allergies which slow metabolism, environmental neurotoxins like heavy metals that ruin our energy metabolism, or a low thyroid? The depressed individual may have a diet that is so severely poor in nutrients, that they are not able to produce what is required for optimal brain health.
Or, a person may just be completely wrapped up in an unsatisfying life and they need a supportive and stable environment to make changes. Any of these issues could be underlying causes of depression. But instead of addressing these underlying problems, a person is usually given an antidepressant that brings on even more problems than were present before using the medication.
SSRI’s like Fluoxetine block Serotonin reuptake, they do not produce any Serotonin. Serotonin is made for reuptake, so it can be used again by the nerve cell. But, when the Serotonin is being forced out into nerve space (synapse), there is then no Serotonin available for reuptake and it will eventually degrade into its own metabolites. This is very similar to the process of Cocaine relieving depression for only a short time. Cocaine will use up all of the persons Dopamine, rather than producing any of it.
We find potential medical reasons for why an individual is depressed. Our program’s protocol uses lab testing, stabilization of the neurochemistry through using natural substances, cessation that removes environmentally accumulated toxins, withdrawal techniques, IV amino treatment, nutritional therapy, peer support, exercise, yoga, massage, and other therapies to successfully combat depression and create effective Prozac alternatives natural help plans.