Selecting the antidepressant that is right for you is often not a simple task. OriginalBlog compiled a brief guide to help you - together with your doctor - to choose the depression medications among those currently available. Our guide explains the similarities and differences of common antidepressants to consider when selecting the one that will work for you best.

What is the same?

Overall benefits

All antidepressants are effective in acute and long-term treatment of depression.

Generally, after 3 months of treatment, the proportions of people with depression who will be much improved are: 50-65% if given an antidepressant compared with 25 – 30% if given an inactive “dummy” pill, or placebo.

It may seem surprising that people given placebo tablets improve, but this happens with all tablets that affect how we feel – the effect is similar with painkillers. Antidepressants are helpful but, like many other medicines, some of the benefit is due to the placebo effect.

The older medications (tricyclics) are just as effective as the newer ones (SSRIs or SNRIs). Chances of benefiting somewhat: 80%; significantly: 60-70%; completely: 50%.

Time to see benefits

Antidepressant medications are not a quick fix and take time to work. You may need to take the medicine as many as six to eight weeks until you notice the improvement.

Antidepressants aren’t just for depression

Antidepressants are not just for the treatment of depression. In addition to depression, these drugs may be useful in a range of other disorders:

• Anxiety (panic attacks, social anxiety, obsessive compulsive disorder, etc.)
• Chronic (neuropathic) pain syndromes
• Migraine prevention
• Sleep disturbances
• Agitation in people with dementia
• Childhood bedwetting
• Premenstrual dysphoria
• Fibromyalgia
• Chronic fatigue syndrome
• Eating disorders
• Personality disorders

Chance of stopping early

Chance of stopping early is >50% within 3 months.

You have a withdrawal, you don’t have a craving

Antidepressants are not technically addictive:

• You don’t need to keep increasing the dose to get the same effect
• You won’t find yourself craving them if you stop taking them

However, there is a debate about this. In spite of not having the symptoms of addiction, up to a third of people who stop SSRIs and SNRIs have withdrawal symptoms.

The Committee of Safety of Medicines in the UK reviewed the evidence in 2004 and concluded "There is no clear evidence that the SSRIs and related antidepressants have a significant dependence liability or show development of a dependence syndrome according to internationally accepted criteria."

Antidepressants & Alcohol

Most antidepressants (SSRIs, SNRIs, bupropion, desipramine) are not “sedatives” and do not substantially add to the impairing effects of alcohol when consumed responsibly.

However, most people with mood disorders (e.g., depression, anxiety) are vulnerable to alcohol's effect on mood stability.

What is different?

Individual response

There is evidence the tricyclic antidepressants (TCAs) are more effective for melancholic or severe depression than SSRIs5.

Unlike tricyclic antidepressants, SSRIs have very different molecular structures. Thus certain patients might benefit more from one SSRI than another.

Antidepressants with multiple neurotransmitter actions such as venlafaxine, mirtazapine, and duloxetine appear to have distinct advantages in terms of faster onset of action, higher rates of remission, and increased efficacy in relieving the physical or pain symptoms of depression3, 4.

Venlafaxine appears to more likely promote remission from depression than the SSRI medications 1.

In patients with moderate to severe depression, duloxetine appeared to help achieve remission at a statistically significant greater rate than SSRIs2.

Side effects

Antidepressants aren’t a silver bullet for depression, and they come with their own side effects and dangers. More than 60 percent of people taking antidepressants experience at least one side effect.

SSRIs affect fewer sites of action than TCAs, and as a result cause fewer types of side effects.

Weight Change

Tricyclics appear to slow metabolism and may promote carbohydrate cravings. Tertiary tricyclic antidepressants such as amitriptyline, imipramine, and doxepin are more likely to cause weight gain than secondary tricyclics such as desipramine and nortriptyline.

Mirtazapine (Remeron) may be placed between the SSRIs and the TCAs in terms of relative risk for weight gain. Weight gain is the most commonly reported side-effect of this antidepressant.

Of the SSRIs, paroxetine may be responsible for the highest amounts of weight gain6.

Venlafaxine (Effexor) appears to be a weight-neutral antidepressant.

Bupropion (Wellbutrin) is unlikely to cause weight gain, and is commonly associated with weight loss.

Sexual Dysfunction

Among SSRIs, paroxetine has the highest rates of sexual dysfunction7.

Bupropion (Wellbutrin) has the lowest risk for sexual problems8. Bupropion may be a more appropriate choice than SSRIs in patients for whom sexual dysfunction is a concern.

Cardiovascular side effects

Tricyclic antidepressants have significantly higher rate of serious cardiovascular side effects than SSRIs. Selective serotonin reuptake inhibitors as a class are less likely to affect cardiovascular parameters.

Nausea and vomiting

Venlafaxine (Effexor) is more likely to cause nausea and vomiting than SSRIs.

Sleepiness, sedation

With many tricyclics, the most troublesome effect with ongoing use is sedation.

Trazodone has a higher rate of sleepiness than SSRIs and SNRIs.

Discontinuation syndrome

Discontinuation syndrome is most common for people who abruptly discontinue paroxetine (Paxil) or venlafaxine (Effexor). Discontinuation syndrome is least common with fluoxetine (Prozac). It is generally best to taper off the dose of an antidepressant rather than stop it suddenly.

Safety issues

SSRIs have better safety than TCAs. A major advantage for the newer tablets is that they are not so dangerous if someone takes an overdose.

Venlafaxine (Effexor) is more toxic than SSRIs in overdose, with a fatal toxic dose closer to that of the tricyclic antidepressants than the SSRIs. Doses of 900 mg or more are likely to cause moderate toxicity10.

Paroxetine and venlafaxine should be avoided in children and teenagers < 18 years.

Onset of antidepressant effect

Mirtazapine (Remeron) has more rapid onset of action than selective serotonin reuptake inhibitors.

Escitalopram (Lexapro) is a fast-acting antidepressant with a more rapid onset of effect than the other SSRIs.

References

• 1. Nemeroff CB, Entsuah AR, Willard LB, Demitrack MA, Thase ME. Venlafaxine and SSRIs: pooled remission analysis. Program and abstracts of the American Psychiatric Association 156th Annual Meeting; May 17-22, 2003; San Francisco, California. New Research Abstract NR263.
• 2. Thase ME. Effectiveness of antidepressants: comparative remission rates. J Clin Psychiatry. 2003;64(suppl 2):3-7
• 3. Entsuah R. Venlafaxine vs SSRIS: comparison of somatic symptom resolution. World J Biol Psychiatry. 2004;5(suppl 1):92.
• 4. Wohlreich MM, Brannan SK, Mallinckrodt CH, et al. Onset of improvement in emotional and painful physical symptoms of depression with duloxetine treatment. World J Biol Psychiatry. 2004;5(suppl 1):91.
• 5. Boyce P, Judd F. The place for the tricyclic antidepressants in the treatment of depression. Aust N Z J Psychiatry. 1999 Jun;33(3):323-7. PubMed
• 6. Fergunson JM. SSRI antidepressant medications: adverse effects and tolerability. Primary Care Companion. J Clin Pschiatry. 2001;3:22Ц7.
• 7. Montejo-Gonza’lez AL, Llorca G, Izquierdo JA, Ledesma A, Bouson~o M, Calcedo A, Carrasco JL, Ciudad J, Daniel E, De la Gandara J, Derecho J, Franco M, Gomez MJ, Macias JA, Martin T, Perez V, Sanchez JM, Sanchez S, Vicens E. SSRI-induced sexual dysfunction: fluoxetine, paroxetine, sertraline, and fluvoxamine in a prospective, multicenter, and descriptive clinical study of 344 patients. J Sex Marital Ther. 1997 Fall;23(3):176-94. PubMed
• 8. Thase ME, Haight BR, Richard N, Rockett CB, Mitton M, Modell JG, VanMeter S, Harriett AE, Wang Y. Remission rates following antidepressant therapy with bupropion or selective serotonin reuptake inhibitors: a meta-analysis of original data from 7 randomized controlled trials. J Clin Psychiatry. 2005 Aug;66(8):974-81. PubMed
• 9. F R Mackay, N R Dunn, R M Martin, G L Pearce, S N Freemantle, R D Mann. Newer antidepressants: a comparison of tolerability in general practice. Br J Gen Pract. 1999 November; 49(448) PubMed
• 10. Thase ME. Effects of venlafaxine on blood pressure: a meta-analysis of original data from 3744 depressed patients. J Clin Psychiatry. 1998 Oct;59(10):502-8. PubMed