Antidepressants: Medications for Depression

The effectiveness of antidepressants

If you're suffering from depression, the idea of a “happy pill” that will cure your symptoms might sound very appealing. But while there are a variety of drugs for treating depression, these antidepressant medications are not miracle cures. Many people respond only partially to antidepressants. Others are unable to tolerate the side effects. So while drug treatment can be beneficial, it’s by no means the only answer. There are other effective treatment approaches that can be taken in addition to or instead of medications. It's up to you to evaluate your options and decide what's best for you.

Antidepressants reduce symptoms in approximately 70 percent of people. This leaves nearly 1 out of 3 people who don't get relief. Even in those who respond to medication, complete remission is rare. More commonly, their symptoms are reduced but not cured. This is important because unless a full remission is achieved, depression is very likely to recur.

How antidepressants work

People suffering from depression are thought to have lower levels of some of the chemical messengers in the brain, called neurotransmitters. The three neurotransmitters believed to be involved in depression are serotonin, dopamine, and norepinephrine. Neurons in the brain constantly produce, release, and reabsorb these brain chemicals. Antidepressants increase the levels of these neurotransmitters in the brain by blocking their reabsorption.

While this has led to the popular belief that depression is the result of a chemical imbalance in the brain that can be corrected with drugs, the reality is more complex. It is not yet known whether low levels of neurotransmitters cause depression, or whether depression causes this imbalance in brain chemistry.

Medication vs. therapy

While antidepressants may improve mood by boosting the “feel-good” chemicals in your brain, they don't treat the actual cause of the depression. Because of this, relapse rates are high once drug treatment is stopped. In contrast, the emotional insights and coping skills acquired during therapy can have a more lasting effect on depression. A University of Pennsylvania study backs up this claim. It found that cognitive therapy works just as well as antidepressants and is more effective than medication in preventing relapse once treatment ends.

In a moderate to severe depression, medications may be useful in the short term, but should be accompanied by therapy to address underlying issues. Sometimes the heaviness of a depression serves to mask painful emotions, which may then come to the surface when medications are taken. The result can be an unexpected sadness – yet another reason that psychotherapy is so important when using antidepressants.

Antidepressants and suicide

There is a risk that antidepressant treatment will cause an increase, rather than a decrease, in depression. In fact, all depression medications are required by the FDA to carry a warning about the increased risk of suicide, hostility, and agitation. The FDA advises that all individuals on antidepressants be closely watched for increases in suicidal thoughts and behaviors.

Monitoring is especially important if this is the person’s first time on depression medication or if the dose has recently been changed. If the depression appears to be getting worse, an evaluation by a mental health professional should be scheduled as soon as possible. New problems with anxiety, insomnia, aggressiveness, irritability, impulsivity, and restlessness—particularly if the symptoms are severe or appeared abruptly—are red flags as well, and should be evaluated immediately.

Deciding if medication is right for you

If you’re considering antidepressants as a treatment option, make sure you weight all the pros and cons and talk to your healthcare provider about any side effects or treatment guidelines you will need to follow. The following questions may help you make your decision.

Questions to ask yourself and a mental health professional

• Is my depression severe enough to justify drug treatment?
• Is medication the best option for treating my depression?
• Am I willing to tolerate unwanted side effects?
• What non-drug treatments might help my depression?
• Do I have the time and motivation to pursue other treatments such as psychotherapy and exercise?
• What self-help strategies might help reduce my depression?
• If I decide to take medication, should I pursue psychotherapy as well?

Questions to ask your doctor

• Are there any medical conditions that could be causing my depression?
• What are the side effects and risks of the antidepressant you are recommending?
• Are there any foods or other substances I will need to avoid?
• How will this drug interact with my other prescriptions?
• How long will I have to take this medication?
• Will withdrawing from the drug be difficult?
• Will my depression return when I stop taking medication?

Non-drug treatment alternatives

There are a variety of effective treatments for depression that don't involve medication, including talk therapy, exercise, or meditation. While these treatments require more time and effort than it takes to pop a pill, their advantage is that they can be just as effective in reducing depression, they do so without side effects, and they help address some of the causes, rather than only the symptoms of depression. However, if your depression is so severe that you don't have the energy to pursue treatment, a brief trial of antidepressants may boost your mood to a level where you can focus on therapy.

 

Taking antidepressants safely

If you decide that treating your depression with medication is the right option, you will need to see a doctor. The first guideline is to consult with a psychiatrist, rather than your family physician. Although any medical doctor can prescribe medications, psychiatrists are doctors who specialize in mental health treatment. They are more likely to be familiar with the newest research on antidepressant medication and to know about specific safety concerns. Your health and well-being depend on your doctor's expertise, so it's important to choose the physician who is best qualified.

You should also educate yourself about your drug. Make sure you know about its common side effects and any special warnings.

Here are some other guidelines for taking your antidepressant medication safely:

• Be patient – Finding the right drug and dosage is a trial and error process. It takes approximately 4 to 6 weeks for antidepressant medications to reach their full therapeutic effect. Many people try several medications before finding one that works for them.
• Follow instructions – Be sure to take your antidepressant according to the doctor's instructions. Don't skip or alter your dose, and don't stop taking your pills as soon as you begin to feel better. Stopping treatment prematurely is associated with high relapse rates.
• Monitor side effects – Keep track of any physical and emotional changes you’re experiencing and talk to your doctor about them. Contact your doctor or therapist immediately if your depression gets worse or you experience an increase in suicidal thoughts,
• Go to therapy – Medication can reduce the symptoms of depression, but it doesn’t treat the underlying problems. Psychotherapy can help you get to the root of your problems, change negative thinking patterns, and learn new ways of coping.

Antidepressant withdrawal

If you abruptly stop taking your antidepressant medication, you may experience a number of unpleasant withdrawal symptoms such as dizziness, nausea, lethargy, and headache. This is known as Antidepressant Discontinuation Syndrome. Antidepressant discontinuation syndrome is especially common when you stop taking Paxil or Zoloft. However, all medications for depression can cause withdrawal symptoms.

Depression and anxiety are also common symptoms when withdrawing from antidepressants. When depression is a withdrawal symptom, it is often more severe than the original depression that led to drug treatment in the first place. Unfortunately, many people mistake this withdrawal symptom for a return of their depressive illness and resume medication, creating a vicious circle.

Antidepressant Withdrawal Symptoms
Emotional symptoms	Sensory disturbances	Flu-like symptoms
Crying spells Irritability or aggression Anxiety Agitation	Numbness Blurred vision Tingling sensation Electric shock sensations	Fatigue Headache Muscle aches Sweating
Gastrointestinal symptoms	Movement & balance	Sleep disturbances
Nausea and vomiting Abdominal pain or cramping Loss of appetite Diarrhea	Tremor Muscle twitches and jerks Loss of coordination Dizziness	Insomnia Nightmares Night sweats Vivid dreams

In order to avoid antidepressant withdrawal symptoms, never stop your medication “cold turkey.” Instead, gradually taper your dose, allowing for at least 1-2 weeks between each dosage reduction. This tapering process may take up to several months, and should be monitored under a doctor's supervision.

Types of antidepressants and their side effects

Antidepressant medications prescribed for depression fall into four different classes of drugs: the widely used serotonin reuptake inhibitors (SSRIs), the tricyclic antidepressants, the monoamine oxidase inhibitors (MAOIs), and the newer atypical antidepressants.

SSRIs (selective serotonin reuptake inhibitors)

The SSRIs are the most commonly prescribed class of antidepressants. They act on a chemical in the brain called serotonin. The SSRIs include drugs such as Prozac, Zoloft, and Paxil.

The SSRIs are preferred over older classes of antidepressants such as tricyclic antidepressants and MAOIs because their adverse effects are less severe.

Like all antidepressants, SSRIs can cause an increase in suicidal thoughts and behaviors. They also carry a risk for increased hostility, agitation, and anxiety. In adults 65 and older, SSRIs increase the risk for falls, fractures, and bone loss. The SSRIs can also cause serious withdrawal symptoms if you stop taking them abruptly.

Common side effects of SSRIs include:

Nausea Insomnia Anxiety and restlessness Decreased sex drive Dizziness Weight gain or loss

Tremors Sweating Drowsiness or fatigue Dry mouth Diarrhea or constipation Headaches

Atypical antidepressants

There are a variety of newer atypical antidepressants which target other neurotransmitters either alone or in addition to serotonin. Some of the brain chemicals they affect include norepinephrine and dopamine.

The side effects vary according to the specific drug. However, many of the atypical antidepressants can cause nausea, fatigue, weight gain, sleepiness, nervousness, dry mouth, and blurred vision.

The atypical medication buproprion, also known by the brand name Wellbutrin, is less likely than the SSRIs to cause sexual dysfunction. It is often prescribed either alone or in addition to an SSRI medication when sexual side effects occur.

Tricyclic antidepressants

Tricyclics are among the oldest antidepressants. They work by inhibiting the brain’s reuptake or serotonin and norepinephrine. They also partially inhibit the reabsorption of dopamine. Because the tricyclics have such a broad mechanism of action, they tend to cause more side effects than the other antidepressants. For this reason, the SSRIs and the atypical antidepressants are usually prescribed first.

Tricyclic antidepressants typically take around two weeks to provide symptom relief. Drowsiness is a highly common side effect, particularly in the first few weeks after starting the medication. The tricyclics also cause many withdrawal symptoms when discontinued abruptly.

MAOIs (Monoamine oxidase inhibitors)

MAOIs are the oldest class of antidepressants. MAOIs have severe interactions with certain foods, drinks, and medications. Combining MAO inhibitors with foods or drinks containing tyramine can result in dangerously high blood pressure, which can lead to a stroke or heart attack. Because of this danger, MAOIs are not typically chosen as a first-line depression treatment.

If your doctor prescribes an MAOI, you will have to carefully monitor what you eat and what drugs you take. Items that are restricted include many cheeses, chocolate, wine, and beer.

Other common side effects of MAOIs include:

Dizziness Insomnia Weight gain

Headaches Sexual problems Daytime sleepiness

If you have previously taken an SSRI, you should wait at least five weeks before taking an MAOI. Combining SSRIs and MAOIs can lead to a life-threatening condition called serotonin syndrome.

Related links for antidepressant medication

General information about antidepressants

How to Take an Antidepressant – A guide to depression drugs that includes a discussion on the two “especially bothersome” side effects: sexual dysfunction and weight gain. (Psychology Today)

Some Drugs Work to Treat Depression, But It Isn't Clear How – Reviews the lack of evidence for the chemical imbalance theory of depression. Includes new theories on how antidepressants work. (Wall Street Journal)

Antidepressant side effects and risks

Suicidality in Children and Adolescents Being Treated With Antidepressant Medications – FDA Public Health Advisory on the increased suicide risk in children and adolescents taking antidepressants. (U.S. Food and Drug Administration)

Sexual Problems and Depression – Learn about the sexual side effects of antidepressants and how to treat the problem. (Cleveland Clinic)

Antidepressant Use Linked to Bone Loss – Covers two Archives of Internal Medicine studies on the connection between SSRI use in adults over 65 and abnormal bone loss. (National Institutes of Health)

Study: Antidepressants Boost Fracture Risk – Reviews a Canadian study, published in the Archives of Internal Medicine, and the link it found between SSRI use and bone fractures in the elderly. (CBS News)

Antidepressant treatment guidelines

Antidepressants: Selecting One That's Right for You – Introduction to the various types of antidepressants and how to find the right one for you. (Mayo Clinic)

How To Think About Medication – Tips on recognizing when antidepressants are appropriate and how to take charge of your health and drug treatment. (Psychology Today)

Why Settle for Silver, When You Can Go for Gold? Response vs. Recovery as the Goal of Antidepressant Therapy – Emphasizes the importance of attaining full remission when treating depression, rather than just a reduction in symptoms. (Brainstorms)

Types of antidepressants

Selective Serotonin Reuptake Inhibitors (SSRIs) -Overview of the SSRI class of antidepressants. Covers types, doses, side effects, and warnings. (Intelihealth)

Tricyclic Antidepressants, Tricyclic (TCAs) and Heterocyclic Antidepressants For Depression – Guide to the tricyclic antidepressants, including how they work and common side effects. (HealthyPlace)

How Newer Antidepressants Work – Describes how the newer atypical antidepressants or “designer” antidepressants such as Wellbutrin work. (Slate Magazine)

Monoamine oxidase inhibitors, MAOIs and Diet – Article on how to avoid serious side effects while taking MAOIs by restricting foods containing tyramine. (Mayo Clinic)

Antidepressant withdrawal

Getting Off Antidepressants: Antidepressant Discontinuation Syndrome – Learn about antidepressant withdrawal and how to stop taking an SSRI drug safely. (HealthyPlace)

Dependence on Antidepressants & Halting SSRIs – Advice from a doctor on how to withdraw from SSRI medication without experiencing adverse symptoms. (Benzodiazepine Addiction, Withdrawal & Recovery)

Antidepressant Discontinuation Syndrome – Written for doctors, this journal article covers the withdrawal symptoms of abrupt SSRI discontinuation. (American Family Physician)

Delving deeper into antidepressant medications

Do Antidepressants Cure or Create Abnormal Brain States? - Article asserts that instead of correcting a biochemical abnormality in the brain, antidepressants create abnormal states that may coincidentally relieve symptoms. (Public Library of Science)

Psychiatry by Prescription – Article on the growing use of psychotropic medications for relatively mild conditions. (Harvard Magazine)

Distance Sought Between Doctors and Drug Industry – Article on the influence of drug industry money on  doctor's treatment decisions. Includes information about a medical panel's recommendations for reducing this conflict of interest. (Washington Post)

Melinda Smith, M.A., Jaelline Jaffe, Ph.D., and Jeanne Segal, Ph.D., contributed to this article. Last modified on: 12/14/07.