Antidepressant Medications by Mitchell L Glaser, MD.




Depression treatment often, but not always, includes medication. Talk therapy should always be a part of medication treatment. In children, the risks versus benefits of medication are not as clear as in adults. So medication is not as often prescribed for depressed children, but sometimes it is needed and is helpful. Generally speaking, most medications for depression are also first line treatment for anxiety. 






The neuro-chemicals, and nerve cells involved in depression and anxiety are very similar. This report will describe when antidepressant medications (abbreviated ADmeds) are required for successful treatment of depression and list how the ADmeds (antidepressant medications) work and their side effects. Antidepressant meds (ADmeds) treat depression, anxiety, panic attacks, obsessive compulsive disorder, chronic pain and fibromyalgia, migraine head aches, and bed wetting. 






Why bother treating depression? Depression is a serious neurologic condition. Depression is not healthy for the brain itself. Depression and anxiety both lead to nerve cell deterioration and eventual nerve cell death. This means, the depressed or anxious brain shrinks or atrophies as we say in the medical field. The longer a person is depressed, or the more episodes of depression a person has, the more the brain shrinks. Additionally, the longer a person is depressed, and the more episodes of depression a person has, the harder the depression is to treat and also there is less robust a recovery. Therefore, a person should treat their depression sooner rather than later, and prevent further episodes of depression from occurring. Reversing the depression leads to nerve cell re- growth. That is why medication takes weeks to work. The medication stimulates the nerve cells to re-grow and reverse the depression. The medication also seems to prevent nerve cell death, thus preventing the return of depressive symptoms. 






What about the risk of suicide with antidepressant medications (ADmeds)? There has been much in the news about suicide being linked to ADmed treatment. This has lead to less ADmeds being prescribed to children. While the number of prescriptions to children has gone down, the rate of suicide attempts has gone up. This may or may not be coincidence. My own clinical experience is that as long as we guard against bipolar disorder (manic depression), then the risk of suicide worsening with ADmeds is very very very low. I have yet to see this occur in all my years of practice and training. ADmeds can worsen mania in a bipolar patient, causing a loss of rational thinking. Thus, one must screen for bipolar disorder in all patients presenting with depression. There is a much greater risk of suicide in an untreated depressed patient than in one treated with meds in my clinical opinion. However, in children the benefits of medication for depression are not clear cut and therefore more rigid guidelines are used in deciding whether or not to prescribe ADmeds for kids. 






Who needs medication? Any adult diagnosed with major depression can benefit from ADmeds. Many adults and children with depression can get well with talk therapy alone. Here are the factors I have determined, after review of the literature and my clinical experience, that necessitate medication treatment. 1. More than one episode of major depression 2. Strong family history of depression or anxiety or panic or other serious psychiatric illness. 3. Failure to get better after 3 months of talk therapy. Each of these criteria indicate a need for medication treatment. 






How long do I take antidepressant medications (ADmeds)? ADmeds should be taken for at least one year or longer. If multiple family members suffer from depression, or if you have tried to stop taking medication but symptoms of depression have returned, than that is a sign that ADmeds will be needed for many years, possibly life long. Some people look at taking medications as a crutch and are afraid that if they start taking ADmeds, then they will become dependent on meds forever. I look at this reasoning as similar to treatment of high blood pressure. Some people with high blood pressure can indeed cure their disease with diet and exercise. Some people with depression can cure their disease with talk therapy and life style changes. If you can do that then fine, but if you can't , and you let your symptoms become chronic, then successful treatment with medication will become less likely the longer you wait to take medication. If you have had more than one episode of depression, the odds are that you will experience more episodes, and each episode will become longer, more severe, and less treatable. Therefore, taking ADmeds even after symptoms have resolved is important at preventing a recurrence. To prevent recurrence, you may need to take ADmeds for a lifetime. Just like someone with high blood pressure must take medication to prevent strokes and heart disease. People with high blood pressure who take their meds do well, people with major depression who take their meds do well too. 






How many medications will I need to take? Most patients who need to see a psychiatrist to treat their depression take more than one medication to treat their depression. So if you require 2 or 3 or 4 meds to treat your symptoms, you are not alone. 






What medications are used to treat depression? The most common are the antidepressant medications. These medications also treat anxiety so are also called anxiolytics as well as antidepressants. Other medications used to treat depression are antipsychotics (abilify, zyprexa, seroquel), lithium (used to treat bipolar disorder also), synthetic thyroid hormone called cytomel or levothyroxine, lamictal, testosterone, estrogen, fish oils (omega 3,6,9), and folic acid. Antidepressants are divided into the following categories based on how they work. Antidepressant meds (ADmeds) increase various chemicals in the brain. These chemicals are called neurotransmitters. They transmit a signal from one neuron to the next neuron. A neuron is the name of the cells that make up most of the brain. Neurons are responsible for your thoughts, feelings, and actions. 






The following mechanisms of action are theories as to how the meds work, no one really knows for sure 100%, but we have a pretty good understanding of them. The chemicals involved in depression are serotonin, norepinephrine and epinephrine, and dopamine. Other chemicals may also be involved that have yet to be discovered. It seems, that ADmeds work by increasing the amount of these chemicals present in the brain in specific areas of the brain. By increasing these chemicals, it stimulates the nerve cells to grow. The growth of the neurons (nerve cells) leads to decrease in depression. Furthermore, the ADmeds seem to protect against neuron loss or atrophy (shrinkage) of the brain. The medications for depression take time to work. We give the first dose 4 weeks before we assess the need for an increase in strength. Then we must wait 2 to 4 weeks on each dosage adjustment if it is needed. 






ADmeds must be taken every day, all year round for them to work except for premenstrual dysphoric disorder, and seasonal affective disorder. Taking medication is a serious decision not to be taken lightly. Any medication can kill you, even tylenol. One must weigh the pros and the cons before starting any medication regimen. Side effects from antidepressant meds (ADmeds) are very very rare, but they can happen. 






The most well known of ADmed categories is the selective serotonin reuptake inhibitors, SSRI for short. These meds include Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline), Celexa and lexapro, and Luvox. These meds differ only slightly from each other. Most of the differences pertain to drug/drug interactions. So if you are on multiple medications, one med may be better for you than the other. Zoloft and Lexapro seem to have the least interactions with other meds, while Prozac and Luvox seem to have the most. SSRI medications also work very well for obsessive compulsive disorder but usually require higher doses than for depression or anxiety. 






The advantages of SSRI's is they are usually taken once daily, and are very well tolerated, and have little serious side effects. Side effects may include small weight gain of 2-5 pounds over one year. Some patients can experience daytime tiredness, lack of enthusiasm (zombie effect), and difficulty in achieving orgasm (cumming) during sex or masturbation. Some men are prescribed Zoloft for premature ejaculation. Prozac is the most studied for children so it is considered first line for pediatric depression. Prozac also stays in your system the longest-3 to 5 days, and comes in a weekly pill dosage form. Some drug companies have developed long acting pills to replace the generic form of their medications that have had their patents expire. Generally speaking, long acting versus short acting makes no difference as long as you take the medication as prescribed. Their may be slight differences in side effects but no study, that I am aware of, convincingly proves any benefit for the higher priced long acting varieties. SSRI's generally are very safe for the heart but if one has a pre-existing heart condition, SSRIs can aggravate it. The heart condition that is a factor in prescribing ADmeds is called a cardiac conduction delay. SSRI effects on the heart are so small, that we generally do not check the heart before prescribing these meds. A very very very rare side effect of SSRI's is syndrome of inappropriate antidiuretic hormone. This causes a person to stop making urine. This is a reversible side effect once the med is stopped.






 The antidepressant I prefer to prescribe first is Wellbutrin (buproprion). Wellbutrin comes in 3 forms: regular (three times a day), SR (twice a day), and XL (once a day). All three are generic at this time. Wellbutrin probably works by increasing dopamine and serotonin in the brain. It helps depression, and anxiety. Wellbutrin also helps attention deficit disorder. So I particularly like it for adults and children with combination of depression and inattention problems. Wellbutrin has the highest risk of causing a temporary seizure. If one gets a seizure while on wellbutrin, wellbutrin should be stopped. The seizure is not permanent. Wellbutrin is thought to be the safest of ADmeds as far as heart issues are concerned. Wellbutrin also does not cause daytime tiredness, nor weight gain, nor does it have sexual side effects.






 Remeron is another antidepressant in its own category. It works very well for depression and insomnia, but causes severe weight gain. 






The next category of antidepressants are the combination serotonin/norepinephrine reuptake inhibitors. This includes Cymbalta and Effexor. Many studies show effexor to be superior for treatment resistant depression and anxiety. All antidepressants can increase blood pressure, but effexor seems to do this more than the others. The makers of cymbalta have a study that shows that it does not increase weight nor have sexual side effects, but that particular manufacturer has medium credibility in my opinion for making extra ordinary claims that do not prove to be true over time. However, so far, the times I have prescribed it, it has been well tolerated by my patients and worked well. Effexor can cause a person to feel hot and on edge more so than other antidepressant meds. This may be due to its slightly stronger action. Effexor can cause tiredness, weight gain and delayed orgasm. 






Another category is the tricyclic antidepressants. This is the oldest and original category of antidepressant meds. This category includes about 8 different meds. They seem to work the best but have serious side effects so are prescribed as second line. Usually, these meds are added to an SSRI or Wellbutrin if those meds only partially work. The most common in this category are Elavil (amitriptaline), imipramine, clomiparamine, and anafranil. Anafanil is often used for obsessive compulsive disorder. Imipramine is often used for bedwetting in children. These meds offer some help of attention deficit hyperactivity disorder as well. These meds tend to be very sedating so are taken at night and help with sleep. They have anticholinergic side effects. These side effects include constipation, difficulty urinating (micturating), blurry vision, dry eyes and mouth, and weight gain. One should not take these meds if you have closed or narrow angle glaucoma. This category of meds is highly cardiotoxic. That means you must have a healthy heart prior to taking these meds and a normal EKG is required prior to starting these meds. An overdose of this catagorie of meds will likely kill you due to a heart attack. This category seems to work the best for treatment of chronic pain, migraine head aches, and fibromyalgia. Trazadone is often used to treat insomnia. 






The last category is the mono-amine oxidase inhibitors (MAOI). Mono amine oxidase is an enzyme in your body and brain that breaks down serotonin, epinephrine, and norepinephrine. So by inhibiting this enzyme, those chemicals are increased in the brain. MAOI?s are the least prescribed antidepressants because they are more difficult to take. One must not take certain other medications including some cold medications, stimulants, and other antidepressants or a severe increase in blood pressure could result, leading to a stroke or heart attack. Some MAOIs require a special diet that does not contain tyramine. One MAOI called Emsam, a skin patch changed daily often may not require a special diet Aged meats and aged cheeses and chianti are particularly high in tyramine. especially at the lower doses but at the higher doses not as clear cut. 






  Second line medication for depression include lithium, abilify, and seroquel. They are described in detail under bipolar disorder treatment. Abilify, Seroquel XR, Rexulti are all medications that are effective for depression and FDA approved to treat depression that does not completely resolve with the standard antidepressants. Its the go of treatment to achieve complete resolution of symptoms These medications are used for depression quite often.  







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