Antidepressants—A Better Understanding Before You Talk With Your Doctor A. Denae Brake, Pharm.D. Clinical Pharmacist Catalyst Rx Sir Francis Bacon once said, “Knowledge is power”. But being depressed can make you feel like your power has been taken away from you. Taking antidepressants can help improve your mood and the other physical and mental symptoms of depression, but th ey can also be associated with side effects. Understanding how antidepressants work, what they treat and some of the associated side effects can give you the power to make wise decisions when talking to your provider about being treated for depression. Antidepressants were first developed in the 1950s. There are now over 30 different kinds from five major classes. The classes are: Tricyclics MAOIs (Monoamine oxidase inhibitors) SSRIs (Selective Serotonin Reuptake Inhibitors) SNRIs (Serotonin and Norepinephrine Reuptake Inhibitors) Others Antidepressants generally work by increasing neurotransmitter activity in the brain. Neurotransmitters are chemical messengers that help nerve cells communicate with one another. Antidepressants increase the number of neurotransmitters by stimulating their production or by blocking them from going back into storage after they have been secreted. Neurotransmitters are involved in controlling many aspects of our well being, such as our mood, sleep, eating, pain and thinking. The neurotransmitters believed to be responsible for balancing our physical and mental health are serotonin, norepinephrine and dopamine. As with other drugs, antidepressants may be used to treat other conditions. For example, antidepressants may be used to treat: ADHD (Attention-deficit hyperactivity disorder) OCD (Obsessive compulsive disorder) Moderate to severe depressive disorder Eating disorders Chronic pain PTSD (Post-traumatic stress disorder) Severe anxiety and panic disorder Smoking Cessation If you and your doctor decide that you should start an antidepressant, please rest assured that they are not addictive. Some drugs, like tranquilizers, certain sleep aids, alcohol and nicotine can be habit forming. Antidepressants are not. There is some controversy because many people who stop these medications suddenly experience symptoms, such as stomach upset, headache, dizziness, anxiety, agitation or irritability. But these symptoms are due to your body’s response to the sudden withdrawal of the medication. It is very important to taper off antidepressants when discontinuing their use in order to minimize these effects. You should only stop an antidepressant on your doctor’s advice, and you should follow his/her directions regarding the gradual reduction of the dosag e over a period of at least several weeks. As with many medications, certain side effects have been associated with the use of antidepressants. The table below lists some of the most common side effects associated with each of the families of antidepressants. Not all possible side effects are listed, and not every patient experience side effects to the same degree. Please be sure to speak with your doctor and/or your pharmacist if you have any questions about any side effects that you may be experiencing, or if you have any other questions about your medications. You may also want to ask your doctor if there is an alternative, other than medications, that may be appropriate for you to treat your symptoms of depression, stress and/or anxiety. Some alternatives are counseling and/or finding someone to talk to, regular exercise, avoiding alcohol or street drugs, eating healthy foods such as fruits, vegetables and whole grains, getting plenty of sleep, taking time to relax and participating in activities you enjoy. If you and your provider find that a medication is the best choice for you, take the time to talk with him/her about the pros and cons of each medication. When the right medication is taken at the right dose, antidepressants can be very effective in the treatment of depression. Class Drug Use/Comments How they work Possible Side Effects Tricyclics Amitriptyline These agents were developed for Increase levels of serotonin Major side effects include: dry mouth , (Elavil®) depression, but are also used for and norepinephrine but also blurred vision, constipation difficulty amoxapine chronic pain, migraines, as creates less serotonin with urination. clomipramine hypnotics, ADHD, some anxiety receptors for the (Anafranil®) disorders. neurotransmitters to work. Other side effects include: arrhythmias, desipramine rash, anxiety agitation, movement (Norpramin®) disorders, nausea, decreased libido, doxepin sexual dysfunction, and sweating. (Sinequan®, Doxepin is also used for itching Zonalon®) Not recommended for people with heart imipramine disease or uncontrolled blood pressure. (Tofranil®) Maprotiline Increased risk of toxicity with some of Nortriptyline these agents combined with grapefruit. (Pamelor®) Protriptyiline (Vivactil®) Class Drug Use/Comments How they work Possible Side Effects Timipramine (Sumontil®) SSRIs Citalopram Depression These medications block the Somnolence, insomnia, nausea, dry (Celexa®) reuptake of serotonin back mouth, sweating, weight gain Escitalopram Depression, Generalized Anxiety into storage, so there is more Headache, somnolence, insomnia, (Lexapro®) Disorder available in the brain. nausea, Fluoxetine Depression, panic disorder, OCD, Nausea, weight gain (Prozac®) Generalized Anxiety Disorder, PTSD, PMS, Bulimia fluvoxamine Depression Nausea, weight gain Paroxetine Depression, panic disorder, OCD, Drowsiness, Nausea, weight gain (Paxil®) Social Anxiety Disorder, Generalized Anxiety Disorder, PTSD Sertraline Depression, panic disorder, OCD, Nausea, weight gain, diahrrea (Zoloft®) Social Anxiety Disorder, PTSD Depresssion, pain Inhibitors of serotonin and norepinephrine reuptake and SNRIs Duloxetine weak inhibitors of dopamine Similar side effects as SSRIs (Cymbalta) reuptake. Venlafaxine Depression, anxiety disorder, social Similar side effects as SSRIs. Not (Effexor) anxiety disorder, panic disorder recommended for people with heart disease or uncontrolled blood pressure. MAOIs Isocarboxazid Depression Monoamine oxidase is an Dry mouth, constipation, blurred vision, (Marplan) enzyme system, which is & urinary retention; drowsiness, low Phenelzine responsible for the blood pressure, weight gain. Diet must (Nardil) metabolism of chemicals in be low in tyramine—wines, cheeses. Tranylcypromine the body; norepinephrine, Absolutely can not use with other (Parnate) epinephrine, dopamine, antidepressants. serotonin. Monoamine Class Drug Use/Comments How they work Possible Side Effects oxidase inhibitors (MAOIs) inhibit this enzyme system, causing an increase in the concentration of these endogenous chemicals Others Bupropion Depression, Smoking Cessation, Works completely different Agitation; Contraindicated with (Wellbutrin) than other antidepressants its seizures, bulimia, and anorexia actions are thought to be noradrenergic and/or dopaminergic. Trazodone Depression, Insomnia It is thought to selectively Nightmares, Somnolence, dry mouth, (Desyrel) inhibits serotonin uptake by blurred vision, dizziness, confusion the brain Mirtazapine Depression It works at receptors in the Sedation, Weight gain, increased (Remeron, central nervous system to cholesterol, constipation, dry mouth, SolTab) release more norepinephrine increased appetite, weakness, muscle and serotonin. aches .