Treating Depression: Update on Antidepressants

Depression. The Greeks were on the right track when they called it “melancholia” and described it as disabling illness rather than a passing bout of sadness, dejection, or feeling down in the dumps. As anyone who has experienced it knows, depression settles in and takes over. It can rob us of sleep, the desire to eat, the ability to concentrate, and , perhaps worst of all, the capacity to take pleasure in anything, including family and friends. All over the world, this debilitating experience is more common in women than in men. In the United States, where more than 19 million adults suffer from some type of depression every year, the ratio is two to one.

Watch for bipolar depression

In some people, taking an antidepressant may kick off an episode of hypomania, an expansive mood characterized by mild elation, talkativeness, increased productivity, and sometimes risky behaviors. Irritability is another feature. Hypomania has its seductive side, but the downside is that, in people who have bipolar disorder, it can progress to mania, an over-the-top “high” that can degenerate into destructive behaviors and sometimes hospitalization.

People with bipolar disorder cycle through bouts of depression and manic behaviors, interspersed with normal moods. The depressive phases occur more often, tend to last longer, and are experienced more negatively than the manic ones. Consequently, an individual with bipolar disorder may not seek help until depressive symptoms hold sway. As a result, she or he may be misdiagnosed as having classic depression and be inappropriately treatments with antidepressants. Bipolar disorder requires a range of treatments, including mood-stabilizing drugs and therapy with a mental health professional. This is another reason why clinicians must keep close track of anyone for whom they’ve prescribed antidepressants, and likewise, why people taking these drugs should report any unusual symptoms or irritability.

Most depression can be treated effectively. For example, talk therapy can help a woman understand and address sources of depression, such as loss, trauma, and internal conflicts. Medications can treat some of the faulty neuro-chemistry, thought in many cases, to underlie some aspects of the disorder. Either approach is effective for mild to moderate depression; optimally, they should be used together.

According to a National Mental Health Association survey, many women believe depression is “normal” during certain stages of their lives and may mot seek help. But depression is not normal at any age. Given its enormous impact on the quality of life, no women should hesitate to ask for help from her primary care doctor or a psychologist, psychiatrist, pastoral counselor, or other qualified mental health professional. The range of therapies now available makes it possible to receive individually tailored treatment that can be adjusted as circumstances change.

This article is an update on antidepressant options and their use.

Choosing an antidepressant

Most antidepressants increase circulating levels of neuro-transmitters (chemicals that permit communication among nerve cells) in the brain. The targeted neurotransmitters are serotonin, norepinephrine, and dopamine. Antidepressants are not “uppers.” They improve mood only in people who are depressed, and the improvement is slow (it may take 4-6 weeks ) and can be quite subtle.

Depression is different in every woman. We don’t all respond to the same antidepressants, nor to the same doses of them. Any given antidepressant won’t work in 10%-30% of people who take it, so it may take several months to find the right medication and dose. If one medication doesn’t work, you may need a supplemental one, or a different drug altogether. The goal is compete relief of symptoms, which can include sleep problems, significant weight change, unrelieved sadness or tearfulness, trouble concentrating, and an overwhelming sense of worthlessness or guilt. Your clinician should follow you closely to make sure that treatment is working and to monitor for side effects or any other problems.

All have side effects

Tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), and several newer drugs all have different mechanisms and side effects (see “Medications for treating depression”). Reducing the dose, adding a counteracting drug, or switching to a different class of drug can overcome some side effects. For example, SSRIs very often reduce libido and interfere with the ability to reach orgasm. Wellbutrin and Remeron are less likely to cause these problems. Weight gain, a common complaint with TCAs and MAOIs , is less likely to occur with Effexor and Wellbutrin.

There are many ways to resolve side effects, so don’t hesitate to let your clinician know if you’re experiencing any.

About SSRIs

SSRIs were introduced in the 1980s, unseating tricyclic antidepressants (TCAs) as the first-line medications for treating depression, because they have slightly fewer side effects, are easier to use (no blood level monitoring is required), and are safer in case of an overdose. TCAs may work better, however, in certain situations, such as when pain or insomnia are involved. Prozac, the first SSRI developed for treating depression, has become particularly well known because of popular books, such as Peter D. Kramer’s Listening to Prozac (1997) and Lauren Slater’s Prozac Diary (1999). Prozac is now widely used for other psychiatric conditions, including anxiety, bulimia, and phobias, and is marketed to women as Sarafem to relieve premenstrual dysphoric disorder.

Prozac has also gained notoriety because of scattered reports associating it with an increased risk for suicide. The FDA has urged the manufacturers of Prozac and several other antidepressants to include stronger warnings that patients taking these drugs should be monitored for suicidal thoughts, especially early in treatment or when the dose is adjusted. As yet, there’s no clear evidence of a direct link between Prozac and suicide.

Not addicting, but avoid quick stops

If you’ve been prescribed an antidepressant, expect to stay on it for at least six months. Research suggests that longer may be better. But many people quit sooner, partly because of side effects.

Although antidepressants aren’t considered addictive, they can cause some uncomfortable withdrawal symptoms--known as discontinuation syndrome-- if they’re stopped too abruptly. Each of the major antidepressant classes has its own typical discontinuation syndrome. People who suddenly quit taking SSRIs or skip several doses may experience dizziness, trouble with balance or coordination, tingling, electric-shock-like sensations, and flulike symptoms. Drugs that take longer to clear the body, such as Prozac, produce fewer and milder symptoms. The riskiest symptoms follow abrupt withdrawal from MAOI’s which can cause agitation, sleeplessness, and sometimes psychosis with hallucinations or paranoia. (This class of medications is rarely used.)

The solution to discontinuation syndrome is to taper very gradually, and if symptoms appear, to resume taking the usual dose and taper more slowly from there.

For more information contact:

The Alliance for the Mentally Ill

NAMI of Greater Chicago

1536 West Chicago Avenue

Chicago, IL 60622

(312) 563-0445

Fax (312) 563-0467

namigc@aol.com

www.namigc.org

Medications for treating depression
Class/medications How they work Side effects/comments
Selective serotonin reuptake inhibitors(SSRIs) citalopram (Celexa) fluoxetine (Prozac) fluvoxamine (Luvox) escitalopram (Lexapro) paroxetine (Paxil) sertraline (Zoloft)	SSRIs primarily block the reuptake of serotonin, making more of it available in the brain.	Common side effects include dry mouth, drowsiness, dizziness, decreased sexual interest and problems achieving orgasm, nausea, headache, jitteriness, sweating, diarrhea or constipation, and insomnia. May cause weight gain. Many side effects fade over time. May interact with warfarin (Coumadin), TCAs, and any drug that increases serotonin concentrations. Should not be taken with MAOIs (see below). Prozac is available in a once-weekly, slow release form.
Tricyclic antidepressants (TCAs) amitriptyline (Elavil, Endep) clomipramine (Anafranil) desipramine (Norpramin, Pertofrane) doxepin (Adapin, Sinequan) * imipramine (Tofranil) nortriptyline (Aventyl, Pamelor) protriptyline (Vivactil) *trimipramine (Surmontil)	TCAs block the reuptake of norepinephrine, serotonin, or both.	Common side effects include dry mouth, dizziness, drowsiness, constipation, incomplete urination, weight gain, sun sensitivity, sweating, faintness upon standing, increased heart rate, and sexual side effects. Rarely, TCAs cause confusion, numbness, tingling, and tremors. Doxepin can cause drowsiness in breast-fed infants of women taking the drug. About one-third of people taking TCAs discontinue because of weight gain and other side effects. TCAs are considered safe to take during pregnancy. May be the best choice for people with major depressive disorder. Overdose is very serious and may be fatal. Blood levels must be monitored.
Monoamine oxidase inhibitors (MAOIs) isocarboxazid (Marplan) phenelzine (Nardil) *tranylcypromine (Parnate)	MAOIs block monoamine oxidase, which breaks down norepinephrine and serotonin.	Side effects include dry mouth, faintness upon standing, headache, insomnia, constipation, and weight gain. Can cause a severe blood pressure crisis if ingested with certain drugs, such as diet pills, cold remedies, or other stimulants, or foods containing tyramine (e.g., red wines, aged cheeses, smoked meats). May increase the risk of birth defects if taken in the first three months of pregnancy. Shouldn’t be taken with other antidepressants, Interacts with many drugs.
Serotonin-norepinephrine reuptake inhibitors (SNRIs) *venlafaxine (Effexor XR)	Works like an SSRI at low doses and a TCA at higher doses.	Side effects include nausea, headache, insomnia, dry mouth, dizziness, constipation, increases in blood pressure, and loss of appetite. Venlafaxine can reduce hot flashes in some women.
Other antidepressants bupropion (Wellbutrin) mirtazapine (Remeron) *nefazodone (Serzone)	Activity unique to each drug. Bupropion increases dopamine and norepinephrine. Remeron affects serotonin and norepinephrine. Serzone acts mostly on serotonin reuptake.	Bupropion may cause agitation, dry mouth, sweating, sleep problems, and loss of appetite; it does not have sexual side effects. It should not be used by people at risk for seizures. Remeron can cause drowsiness, dry mouth, constipation, and weight gain; it rarely causes sexual side effects. Serzone may cause dry mouth, dizziness, constipation, and drowsiness. It does not cause weight gain and is less likely than SSRIs to have sexual side effects. Serzone carries an FDA “black box” warning on the label about rare cases of liver failure. The drug is no longer used in Canada and several other countries.