Antidepressant Treatment

Antidepressants (ATD) are the first line of therapy available for clinical depression. They do not “cure” depression but alleviate its symptoms, and you may have to try two or three until you find the one that works for you. The right ATD will be the one that reduces the symptoms and has tolerable side effects. For this reason, patients may be prescribed different ones at different doses.

What is the right antidepressant for you?

Before prescribing them, your doctor will have to consider a number of factors:

Main symptoms. For example, if you suffer from persistent anxiety, sertraline (Zoloft) can be considered. Mirtazapine (Remeron) and trazodone are usually prescribed for insomnia in UK.

Side effects. Some produce dry mouth, weight gain or have undesirable effects on sexual life. Tricyclic ATD (imipramine, amitriptyline, clomipramine) are very effective but produce side effects. Selective serotonin reuptake inhibitors (SSRIs) are very popular but some patients cannot tolerate their side effects.

Interaction with other medications. You may be taking other medications for diabetes, hypertension, or other medical conditions that could be a contraindication for some ATD. For example, SSRIs can produce serious reactions when prescribed alongside non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, diclofenac or naproxen.

Pregnancy and breastfeeding. In general, they are not contraindicated during pregnancy and breastfeeding, but some like paroxetine for example, should be avoided.

Genetic factors. It is important to establish what ATD has worked for your family before, because genetic factors can play an important role in a positive response to ATD treatment.

Other medical conditions. Some could help to deal with more than one condition. For example, venlafaxine (Effexor XR) is helpful for symptoms of anxiety disorders, whilst bupropion can be prescribed for smoking cessation as well. Duloxetine (Cymbalta) is prescribed to reduce pain or fibromyalgia and amitriptyline to manage migraines.

Types of Antidepressants

ATD are classified depending on the particular way they work in the neural pathways, exerting their effects on specific neurotransmitters or neural messengers (chemical molecules involved in neural interactions).

SSRIs (Selective Serotonin Reuptake Inhibitors). These are usually the first choice for starting antidepressant treatment, because they are safe and have less side effects. SSRIs include: escitalopram, citalopram, fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil).

SNRIs (Serotonin and Norepinephrine Reuptake Inhibitors). Due to their dual mechanism of action, doctors prescribe SNRIs when they want to treat symptoms resulting from alterations in both neurotransmitters. These include duloxetine (Cymbalta), venlafaxine (Effexor XR), desvenlafaxine and levomilnacipran.

Tricyclic antidepressants. These are the first ones to be discovered more than 50 years ago. They are effective in reducing depression symptoms but have more side effects than SSRIs. Imipramine (Tofranil), nortriptyline, amitriptyline, doxepin and desipramine. They are not prescribed unless you have failed or are intolerant to any other ATD.

MAOIs (Monoamine Oxidase Inhibitors). These have a mild effect on depressive symptoms and because of the many side effects, negative interactions with other ATD like SSRIs and certain foods like some cheeses, pickles and wines. MAOIs include: tranylcypromine (Parnate), phenelzine (Nardil) and isocarboxazid (Marplan).

Atypical antidepressants. This is a mix of ATD that do not fit neatly into any other categories. These include: trazodone, mirtazapine (Remeron), vilazodone and bupropion (Wellbutrin SR, Wellbutrin XL, others).

Other. Your doctor can prescribe you other medications for more complex types of major depression. For example, nasal spray esketamine (Spravato) for Treatment Resistant Depression or mood stabilizers like lithium, valproate, carbamazepine or lamotrigine.