Depression Medications By M. 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
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
What about the risk of suicide with antidepressant
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
How long do I take antidepressant medications
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
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. Aged
meats and aged cheeses and chianti are
particularly high in tyramine.
Second line medication for depression include
lithium, abilify, and seroquel. They are described
in detail under bipolar disorder treatment. Thyroid
hormone supplements help depression even if you
have a normal thyroid. Thyroid hormone regulates
metabolism, body heat, and energy level in the
In conclusion, one does not have to suffer from
depression. Combination medication plus talk
therapy is very effective. One should not delay in
starting treatment. Often, more than one
medication is needed. Once the symptoms
resolve, do not stop taking the medications!
Mitchell L. Glaser, MD.