Many antidepressants work in a multitude of different ways and target different neurotransmitters such as serotonin, norepinephrine and dopamine. When prescribing a medication for depression a psychiatrist may consider:
- Symptoms. Symptoms of depression can vary from one person to another and even in the same individual at different time periods of their depression episodes. One week they may cry more, the next month may be more irritability. One antidepressant may relieve certain symptoms better than another. For example, if someone cannot fall asleep an antidepressant that’s sedating may become a viable option. Even within one class of medicines that has six options, the art in this field of medicine is that they are all not created equal. There is no “one size fits all”
- A medicine worked for a close relative. How a medication worked for a first-degree relative (parent, brother or sister) can indicate that it might work for you. A psychiatrist should always consider genetics. In parallel if an antidepressant has been effective for your depression in the past, it has a high likelihood to work again.
- Pregnancy or breast-feeding. A decision to use antidepressants during pregnancy and breast-feeding is evaluated based on the risks and benefits. The risk or incidence of birth defects and other problems for babies of mothers who take antidepressants during pregnancy is low. This decision is always up to the expecting mother with guidance by your psychiatrist.
- Other health conditions. Some antidepressants may exacerbate certain mental or physical health conditions. One common concern is weight gain or sexual side effects. On the contrary certain antidepressants can help treat both physical symptoms and depression. For example, venlafaxine (Effexor XR) may relieve symptoms of anxiety disorders or menopausal symptoms and bupropion can help with smoking cessation. Duloxetine (Cymbalta) a common antidepressant is well known to reduce neuropathic pain or fibromyalgia.
- Cost and health insurance coverage. Unfortunately in modern medicine we always have to think of cost, will insurance pay for the medicine if for example there is no generic, ease of taking the medicine (one time a day vs three) alongside a myriad of other factors
Types of Antidepressants
Certain chemicals in the brain called neurotransmitters are associated with depression. These three neurotransmitters are serotonin, norepinephrine and dopamine. Most antidepressants relieve depression by affecting one or two of these neurotransmitters, sometimes called chemical messengers, which aid in communication between brain cells. Each class of antidepressant work on these neurotransmitters in slightly different ways.
Many types of antidepressant medications are available to treat depression, including:
- Selective serotonin reuptake inhibitors (SSRIs): Doctors often start by prescribing an SSRI. These medications in general cause fewer side effects and are less likely to cause problems at higher therapeutic doses than other types of antidepressants are. They are very safe and also indicated for Anxiety disorder as well. SSRIs include fluoxetine (Prozac), paroxetine (Paxil), Fluvoxamine (luvox), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro)
- Serotonin and norepinephrine reuptake inhibitors (SNRIs): SNRI medications include duloxetine (Cymbalta), venlafaxine (Effexor XR) and desvenlafaxine (Pristiq)
- Atypical antidepressants: Atypical antidepressants are medications that don’t into a particular category by mechanism alone. Antidepressants in this category include mirtazapine (Remeron), vortioxetine (Trintellix), vilazodone (Viibryd), trazodone and bupropion (Wellbutrin XL). Bupropion is one of the few antidepressants not associated with sexual side effects as it does not target serotonin.
- Tricyclic antidepressants: Tricyclic antidepressants include imipramine (Tofranil), nortriptyline (Pamelor), amitriptyline, doxepin and desipramine. They tend to cause more side effects than newer antidepressants including sedation and blurry vision. Tricyclic antidepressants usually aren’t prescribed unless the SSRIS have failed
- Monoamine oxidase inhibitors (MAOI): MAOIs such as tranylcypromine (Parnate) and Phenelzine (Nardil) may be prescribed, but often when a multitude of other medications have failed. This can be due to serious side effects and the absolute utilization of a strict diet because of dangerous interactions with certain foods. These medications cannot be combined with SSRIs.
- Other medications: A psychiatrist may recommend combining two antidepressants with two different mechanisms to enhance antidepressant effects.