Treat the underlying cause. Sometimes, there is a medical problem causing or worsening the depression. If so, the obvious first step is to treat that underlying condition.
St. Johns Wort is a widely marketed herbal antidepressant. Scientific studies so far have yielded mixed results as to whether or not this herb really works, but it is probably helpful for at least some patients with mild to moderate depression. The most common side effect is sun sensitivity.
Selective serotonin reuptake inhibitors (SSRIs). Serotonin is a neurotransmitter--a chemical that carries messages from one nerve to another. Patients with depression often have low levels of serotonin in their brains, and SSRIs work by improving that chemical imbalance. Examples include Fluoxetine (Prozac®), sertraline (Zoloft®), paroxetine (Paxil®), citalopram (Celexa®), escitalopram (Lexapro®), and fluvoxamine (Luvox®). This is probably the most commonly used class of antidepressants today.
The most common side effects of SSRIs are increased appetite (leading to weight gain) and sexual dysfunction (reduced libido, erectile dysfunction, difficulty achieving orgasm). Bear in mind that all of these symptoms are also common in depressed patients who aren't taking medication. Also, many people have no side effects (or only mild ones), so an SSRI might actually improve some of these symptoms for you.
Some SSRIs, especially paroxetine, tend to cause a little sedation—which can help those with insomnia. Others, like sertraline and fluoxetine, tend to increase levels of energy—which is helpful for people battling fatigue or "brain fog." Citalopram and escitalopram tend not to cause either effect. For some patients, it makes sense to take a sedating medication in the evening or a stimulating one in the morning. Be aware that these are general tendencies and you will need to determine for yourself what effect any one of them has on you.
Serotonin/norepinephrine reuptake inhibitors (SNRIs). These medicines are similar to SSRIs, but they also increase brain levels of norepinephrine, another neurotransmitter that tends to be low in the brains of depressed patients. Examples include venlafaxine (Effexor®), desvenlafaxine (Pristiq®), and duloxetine (Cymbalta®). Their side effect profiles are similar to the SSRIs, except that all of the SNRIs tend to cause stimulation rather than sedation. Venlafaxine may also raise the blood pressure by about 5-10 points, which may be useful for people with low blood pressure, but a problem for those with hypertension. Duloxetine does not affect blood pressure. Desvenlafaxine is relatively new, and it is not clear if it has any effect on blood pressure or not. In addition to treating depression, the SNRIs are often helpful in controlling nerve pain.
Bupropion (Wellbutrin®, Budeprion®). This antidepressant has a mechanism of action that is completely different from the SSRIs and SNRIs, and it also has a very different side effect profile. Bupropion is one of the few antidepressants that don't tend to cause sexual dysfunction. In addition, it does not increase the appetite—it may even help people lose weight—and has been shown to help people quit smoking.
The most common side effect of this medication is a feeling of overstimulation, which often improves after the first couple of weeks of therapy. The most serious risk with bupropion is that it increases the chance of developing a seizure. The good news is that seizures are very rare in patients taking bupropion, and can usually be prevented by following a few simple guidelines. Patients with a prior history of head injury or seizure disorder should not take bupropion. Combining bupropion with alcohol also increases the seizure risk, so you should not drink alcohol while on this medication. Of course, alcohol worsens depression, so depressed patients are well advised to go alcohol-free, anyway. Finally, I always prescribe the most extended-release forms of bupropion (Wellbutrin XL®; Budeprion XL®), which reduce the seizure risk by avoiding the high blood levels of the drug that can occur with the rapidly absorbed dosage forms.
Tricyclic antidepressants (TCAs). This is one of the oldest classes of antidepressant medications. There are at least a dozen drugs in this category. Some examples include amitriptyline (Elavil®), nortriptyline (Pamelor®), and imipramine (Tofranil®). Trazodone (Desyrel) is a closely related medication that can be thought of in the same class with the TCAs. These drugs are not often used as primary treatment for depression anymore, because the newer medications discussed above usually have fewer side effects. However, some patients still respond better to the TCAs than any other type of antidepressant. Low-dose TCAs are often very powerful when used in combination with one of the newer drugs to boost the overall antidepressant effect.
Like most other antidepressants, the TCAs may cause increased appetite and sexual dysfunction. Other common side effects include dry mouth, constipation, and difficulty urinating, but these are usually less severe with lower doses. All of the TCAs are sedating, and depressed patients with insomnia often benefit from adding an evening low-dose TCA to their other antidepressant medication(s). Palpitations and slow or rapid heartbeats can also occur, but those are rare when lower doses are used. Patients with known (or a predisposition to) irregular heartbeat may need to avoid TCAs.
In addition to treating depression and insomnia, the TCAs can also help to prevent migraines and control nerve pain.
All of these antidepressants are generally effective and safe, but individual results vary widely, and you may need to try various doses of several different medications before finding the right one for you.
St. Johns Wort is a widely marketed herbal antidepressant. Scientific studies so far have yielded mixed results as to whether or not this herb really works, but it is probably helpful for at least some patients with mild to moderate depression. The most common side effect is sun sensitivity.
Selective serotonin reuptake inhibitors (SSRIs). Serotonin is a neurotransmitter--a chemical that carries messages from one nerve to another. Patients with depression often have low levels of serotonin in their brains, and SSRIs work by improving that chemical imbalance. Examples include Fluoxetine (Prozac®), sertraline (Zoloft®), paroxetine (Paxil®), citalopram (Celexa®), escitalopram (Lexapro®), and fluvoxamine (Luvox®). This is probably the most commonly used class of antidepressants today.
The most common side effects of SSRIs are increased appetite (leading to weight gain) and sexual dysfunction (reduced libido, erectile dysfunction, difficulty achieving orgasm). Bear in mind that all of these symptoms are also common in depressed patients who aren't taking medication. Also, many people have no side effects (or only mild ones), so an SSRI might actually improve some of these symptoms for you.
Some SSRIs, especially paroxetine, tend to cause a little sedation—which can help those with insomnia. Others, like sertraline and fluoxetine, tend to increase levels of energy—which is helpful for people battling fatigue or "brain fog." Citalopram and escitalopram tend not to cause either effect. For some patients, it makes sense to take a sedating medication in the evening or a stimulating one in the morning. Be aware that these are general tendencies and you will need to determine for yourself what effect any one of them has on you.
Serotonin/norepinephrine reuptake inhibitors (SNRIs). These medicines are similar to SSRIs, but they also increase brain levels of norepinephrine, another neurotransmitter that tends to be low in the brains of depressed patients. Examples include venlafaxine (Effexor®), desvenlafaxine (Pristiq®), and duloxetine (Cymbalta®). Their side effect profiles are similar to the SSRIs, except that all of the SNRIs tend to cause stimulation rather than sedation. Venlafaxine may also raise the blood pressure by about 5-10 points, which may be useful for people with low blood pressure, but a problem for those with hypertension. Duloxetine does not affect blood pressure. Desvenlafaxine is relatively new, and it is not clear if it has any effect on blood pressure or not. In addition to treating depression, the SNRIs are often helpful in controlling nerve pain.
Bupropion (Wellbutrin®, Budeprion®). This antidepressant has a mechanism of action that is completely different from the SSRIs and SNRIs, and it also has a very different side effect profile. Bupropion is one of the few antidepressants that don't tend to cause sexual dysfunction. In addition, it does not increase the appetite—it may even help people lose weight—and has been shown to help people quit smoking.
The most common side effect of this medication is a feeling of overstimulation, which often improves after the first couple of weeks of therapy. The most serious risk with bupropion is that it increases the chance of developing a seizure. The good news is that seizures are very rare in patients taking bupropion, and can usually be prevented by following a few simple guidelines. Patients with a prior history of head injury or seizure disorder should not take bupropion. Combining bupropion with alcohol also increases the seizure risk, so you should not drink alcohol while on this medication. Of course, alcohol worsens depression, so depressed patients are well advised to go alcohol-free, anyway. Finally, I always prescribe the most extended-release forms of bupropion (Wellbutrin XL®; Budeprion XL®), which reduce the seizure risk by avoiding the high blood levels of the drug that can occur with the rapidly absorbed dosage forms.
Tricyclic antidepressants (TCAs). This is one of the oldest classes of antidepressant medications. There are at least a dozen drugs in this category. Some examples include amitriptyline (Elavil®), nortriptyline (Pamelor®), and imipramine (Tofranil®). Trazodone (Desyrel) is a closely related medication that can be thought of in the same class with the TCAs. These drugs are not often used as primary treatment for depression anymore, because the newer medications discussed above usually have fewer side effects. However, some patients still respond better to the TCAs than any other type of antidepressant. Low-dose TCAs are often very powerful when used in combination with one of the newer drugs to boost the overall antidepressant effect.
Like most other antidepressants, the TCAs may cause increased appetite and sexual dysfunction. Other common side effects include dry mouth, constipation, and difficulty urinating, but these are usually less severe with lower doses. All of the TCAs are sedating, and depressed patients with insomnia often benefit from adding an evening low-dose TCA to their other antidepressant medication(s). Palpitations and slow or rapid heartbeats can also occur, but those are rare when lower doses are used. Patients with known (or a predisposition to) irregular heartbeat may need to avoid TCAs.
In addition to treating depression and insomnia, the TCAs can also help to prevent migraines and control nerve pain.
All of these antidepressants are generally effective and safe, but individual results vary widely, and you may need to try various doses of several different medications before finding the right one for you.
