Patient education: Medicines for depression (The Basics)

What do medicines for depression do? — Medicines for depression, also called "antidepressants," can:

●Help you feel better and more able to do everyday tasks

●Reduce the symptoms of depression

●Relieve anxiety

Each of the antidepressants works in a different way. But in general, they all change the chemistry of the brain (figure 1).

Which medicine might I need? — Your doctor will decide which medicine is best for you. They might ask if any of your family members have had good results with a particular antidepressant. If so, that might be a good place for you to start. The section at the end lists the most common antidepressant choices. Most people take just 1 antidepressant, but some people take 2 of the medicines together.

The first medicine you try might not help enough. If that happens, tell your doctor or nurse, and don't give up. People sometimes need to try a few different medicines or combinations of medicines before they find the treatment that works for them. Your doctor will give you instructions on how to safely switch to a new medicine if the first one is not helping you to feel better.

The section at the end includes some basic information on the main medicines used in depression. For more detailed information about your medicines, ask your doctor or nurse for the patient hand-out from Lexicomp available through UpToDate. It explains how to use each medicine, describes its possible side effects, and lists other medicines or foods that can affect how it works.

How long before I feel better? — Most antidepressants start to help within 2 weeks of when you start taking them. But it usually takes at least 4 to 6 weeks before you get the full effect, and might take as long as 12 weeks. If you don't feel any better after 2 to 4 weeks, ask your doctor or nurse what you can do. They might suggest continuing to wait and see if things change, or they might increase your dose, prescribe a second medicine, or offer another solution.

How long do I keep taking the medicines? — Most people who get better stay on antidepressants for at least 6 to 9 months. If you have severe depression or have had lots of episodes of depression, it might make sense to stay on your antidepressant for a year or longer. People with depression who recover and then go off their medicines often get depressed again.

If and when you do go off your medicine, do it with the help of your doctor or nurse. You will need to slowly decrease your dose over a few weeks or longer. Stopping most antidepressants all of a sudden can make you feel ill.

What if I have side effects? — If you have minor side effects when you start taking an antidepressant, try staying on the medicine for a few weeks. Minor side effects often go away after your body gets used to the new medicine. If side effects do not go away or worry you, mention your problems to your doctor or nurse. They might have suggestions for how to reduce or deal with your side effects. They can also help you switch your medicine safely if it isn't the right one for you.

Each of the medicines is different. In general, side effects from the most commonly used antidepressants can include:

●Feeling anxious, jittery, or restless

●Having trouble sleeping

●Feeling tired

●Headaches

●Nausea, diarrhea, or constipation

●Dry mouth

●Problems with sex

●Weight gain

What are the different antidepressants? — Below is some general information about the different types of medicine used to treat depression:

●SSRIs (selective serotonin reuptake inhibitors) – SSRIs are usually the first medicines doctors prescribe when they are treating someone with depression. SSRIs often work well, are safe, and have fewer side effects than many of the other medicines. Some examples of SSRIs include citalopram (brand name: Celexa), fluoxetine (brand name: Prozac), and sertraline (brand name: Zoloft).

●SNRIs (serotonin-norepinephrine reuptake inhibitors) – SNRIs work in a similar way to SSRIs, but they also have other effects. Doctors sometimes suggest these medicines when SSRIs do not help enough. Examples of SNRIs include duloxetine (brand name: Cymbalta), venlafaxine (brand name: Effexor), and desvenlafaxine (brand name: Pristiq). SNRIs can increase your blood pressure. Talk to your doctor if you have high blood pressure.

●Atypical antidepressants – Atypical antidepressants include bupropion (brand name: Wellbutrin) and mirtazapine (brand name: Remeron). These medicines do not tend to cause sex-related side effects, so doctors sometimes give them to people who have those side effects with other antidepressants. Bupropion does not cause weight gain, and it can be especially helpful to people who lack energy or smoke, but it can cause jitteriness. Mirtazapine increases appetite and can cause weight gain, so doctors sometimes give it to people with low appetite.

●Serotonin modulators – Serotonin modulators include trazodone, vilazodone (brand name: Viibryd), and vortioxetine (brand name: Trintellix). Trazodone is often used to improve sleep, so doctors sometimes prescribe it to people who have trouble sleeping. Vilazodone is more likely than other antidepressants to cause nausea, vomiting, and diarrhea.

●TCAs (tricyclic and tetracyclic antidepressants) – TCAs are not used as much as SSRIs, SNRIs, and atypical antidepressants. That's because TCAs can cause more side effects, such as constipation and drowsiness. In addition, TCAs can disrupt the heart's rhythm and cause other serious problems. In older people, these medicines can also cause falls, confusion, and memory problems. Even so, TCAs can help some people with depression, especially if they do not get better with SSRIs, SNRIs, or atypical antidepressants. Some examples of TCAs include nortriptyline (brand name: Pamelor) and desipramine (brand name: Norpramin).

●MAOIs (monoamine oxidase inhibitors) – MAOIs are not used very often because they can cause a lot of side effects, and because people who take them must avoid certain foods and medicines. Still, MAOIs can help people who have depression along with other problems or who do not get better with other medicines. Examples of MAOIs include isocarboxazid (brand name: Marplan), moclobemide (brand name: Manerix), phenelzine (brand name: Nardil), selegiline (sample brand name: Emsam patch), and tranylcypromine (brand name: Parnate). If you need to follow a special diet, your doctor or nurse can give you list of foods that are safe to eat.

The tables list the generic and US brand names of several antidepressants and how likely each medicine is to cause certain side effects (table 1 and table 2). The right medicine for you depends on several different things, including your health, other medicines you take, and your preferences about possible side effects. There are more safety concerns about TCAs and MAOIs compared to the other types, but they might be an option if you don't get well with other medicines.

Cutting back on alcohol and getting regular exercise can lower the chance of side effects. These things can also help you feel better.

What can I do to stay safe? — Take your medicines exactly as your doctor tells you, so you get the correct amount of each medicine. Some people find it helpful to use reminders or a weekly pill box (picture 1).

Antidepressants can cause serious problems if taken with certain other medicines. Your doctor and pharmacist need to know all of the medicines you take to help avoid this. This includes any over-the-counter medicines, vitamins, and herbs. Bring a list of the names and doses of all your medicines each time you visit any doctor. You can find an example of this kind of list at the following website: www.fda.gov/drugs/resources-you-drugs/my-medicine-record.

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