Antidepressants

Overview

Antidepressant medications are used to treat depression and other mood disorders.

There are different types of antidepressants. You may need to try different ones before finding one that works for you.

You may get side effects from antidepressants. Talk to your doctor if you get side effects that cause you problems.

You may get withdrawal symptoms when you stop taking antidepressant medication. Talk to your doctor before you stop taking them, even if you feel better. Your doctor may take you off your medication slowly if you have been taking them for a long time.

Antidepressant medication can affect other medications. Tell your doctor if you take any other medication.

WHAT ARE ANTIDEPRESSANTS AND HOW DO THEY WORK?

Antidepressants are a class of drugs that reduce symptoms of depressive disorders by correcting chemical imbalances of neurotransmitters in the brain. Chemical imbalances may be responsible for changes in mood and behavior.

Neurotransmitters are vital, as they are the communication link between nerve cells in the brain. Neurotransmitters reside within vesicles found in nerve cells, which are released by one nerve and taken up by other nerves. Neurotransmitters not taken up by other nerves are taken up by the same nerves that released them. This process is called “reuptake.” The prevalent neurotransmitters in the brain specific to depression are serotonin, dopamine and norepinephrine (also called noradrenaline).

In general, antidepressants work by inhibiting the reuptake of specific neurotransmitters, hence increasing their levels around the nerves within the brain, such as selective serotonin reuptake inhibitors (SSRIs), antidepressants that will affect serotonin levels in the brain.

FOR WHAT CONDITIONS ARE ANTIDEPRESSANTS USED?

Antidepressants are used to treat several conditions. They include, but are not limited to: depression, generalized anxiety disorder, agitation, obsessive compulsive disorders (OCD), manic-depressive disorders, childhood enuresis (bedwetting), major depressive disorder, diabetic peripheral neuropathic pain, neuropathic pain, social anxiety disorder, posttraumatic stress disorder (PTSD) etc.

Some off- label uses of antidepressants include, but are not limited to: fibromyalgia, chronic urticaria (hives), hot flashes, hyperhidrosis (drug-induced), pruritus (itching), premenstrual symptoms, bulimia nervosa, Tourette syndrome, binge eating disorder, etc.

Finding the right antidepressant

There are a number of antidepressants available that work in slightly different ways and have different side effects. When prescribing an antidepressant that’s likely to work well for you, your doctor may consider:

Your particular symptoms. Symptoms of depression can vary, and one antidepressant may relieve certain symptoms better than another. For example, if you have trouble sleeping, an antidepressant that’s slightly sedating may be a good option.

Possible side effects. Side effects of antidepressants vary from one medication to another and from person to person. Bothersome side effects, such as dry mouth, weight gain or sexual side effects, can make it difficult to stick with treatment. Discuss possible major side effects with your doctor or pharmacist.

Whether it worked for a close relative. How a medication worked for a first-degree relative, such as a parent or sibling, can indicate how well it might work for you. Also, if an antidepressant has been effective for your depression in the past, it may work well again.

Interaction with other medications. Some antidepressants can cause dangerous reactions when taken with other medications.

Pregnancy or breast-feeding. A decision to use antidepressants during pregnancy and breast-feeding is based on the balance between risks and benefits. Overall, the risk of birth defects and other problems for babies of mothers who take antidepressants during pregnancy is low. Still, certain antidepressants, such as paroxetine (Paxil, Pexeva), may be discouraged during pregnancy. Work with your doctor to find the best way to manage your depression when you’re expecting or planning on becoming pregnant.

Other health conditions. Some antidepressants may cause problems if you have certain mental or physical health conditions. On the other hand, certain antidepressants may help treat other physical or mental health conditions along with depression. For example, venlafaxine (Effexor XR) may relieve symptoms of anxiety disorders and bupropion may help you stop smoking. Other examples include using duloxetine (Cymbalta) to help with pain symptoms or fibromyalgia, or using amitriptyline to prevent migraines.

Cost and health insurance coverage. Some antidepressants can be expensive, so it’s important to ask if there’s a generic version available and discuss its effectiveness. Also find out whether your health insurance covers antidepressants and if there are any limitations on which ones are covered.

Types of antidepressants

Certain brain chemicals called neurotransmitters are associated with depression — particularly serotonin (ser-o-TOE-nin), norepinephrine (nor-ep-ih-NEF-rin) and dopamine (DOE-puh-meen). Most antidepressants relieve depression by affecting these neurotransmitters, sometimes called chemical messengers, which aid in communication between brain cells. Each type (class) of antidepressant affects 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 generally cause fewer bothersome side effects and are less likely to cause problems at higher therapeutic doses than other types of antidepressants are. SSRIs include fluoxetine (Prozac), paroxetine (Paxil, Pexeva), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro).

Serotonin and norepinephrine reuptake inhibitors (SNRIs). Examples of SNRI medications include duloxetine (Cymbalta), venlafaxine (Effexor XR), desvenlafaxine (Pristiq) and levomilnacipran (Fetzima).

Atypical antidepressants. These medications don’t fit neatly into any of the other antidepressant categories. More commonly prescribed antidepressants in this category include trazodone, mirtazapine (Remeron), vortioxetine (Trintellix), vilazodone (Viibryd) and bupropion (Wellbutrin SR, Wellbutrin XL, others). Bupropion is one of the few antidepressants not frequently associated with sexual side effects.

Tricyclic antidepressants. Tricyclic antidepressants — such as imipramine (Tofranil), nortriptyline (Pamelor), amitriptyline, doxepin and desipramine (Norpramin) — tend to cause more side effects than newer antidepressants. So tricyclic antidepressants generally aren’t prescribed unless you’ve tried other antidepressants first without improvement.

Monoamine oxidase inhibitors (MAOIs). MAOIs — such as tranylcypromine (Parnate), phenelzine (Nardil) and isocarboxazid (Marplan) — may be prescribed, often when other medications haven’t worked, because they can have serious side effects. Using an MAOI requires a strict diet because of dangerous (or even deadly) interactions with foods — such as certain cheeses, pickles and wines — and some medications, including pain medications, decongestants and certain herbal supplements. Selegiline (Emsam), an MAOI that you stick on your skin as a patch, may cause fewer side effects than other MAOIs. These medications can’t be combined with SSRIs.

Other medications. Your doctor may recommend combining two antidepressants, or other medications may be added to an antidepressant to enhance antidepressant effects.

What are the side effects of antidepressant medications?

The provider prescribing your medicine will discuss its potential side effects with you. He or she will try to prescribe drug(s) with the least number of side effects for your health condition. Sometimes, more than one medicine may be tried before the desired benefits are achieved.

You will be monitored closely so that your provider can detect the development of harmful side effects and make the necessary changes.

All medications – not just antidepressants – can cause side effects. Keep in mind that your provider prescribes the medication only if its expected benefits outweigh the risk of side effects.

Side effects, if they occur, are usually mild. Some side effects decrease after you have taken the drug for a while. However, if side effects don’t go away, they will once the drug is stopped. Be sure to discuss your concerns with your provider before taking any medicine.

Classes of antidepressant medications and common side effects

Selective serotonin reuptake inhibitors

SSRIs are among the most commonly prescribed medications. Some examples of SSRIs include sertraline (Zoloft®), paroxetine (Paxil®), fluoxetine (Prozac®) and citalopram (Celexa®). Side effects of selective serotonin reuptake inhibitors (SSRIs) include:

Agitation.

Nausea.

Diarrhea.

Sexual problems including low sex drive or inability to have an orgasm.

Dizziness.

Headaches.

Insomnia.

Increased anxiety.

Exhaustion.

Diarrhea.

Dry mouth.

Tremors.

Serotonin and noradrenaline reuptake inhibitors

SNRIs treat depression as well as long-term pain and anxiety. Some examples of SNRIs include venlafaxine (Effexor®), desvenlafaxine (Pristiq®) and duloxetine (Cymbalta®). Side effects of SNRIs include:

Headache.

Dizziness.

Nausea.

Heavy sweating.

Dry mouth.

Constipation.

Insomnia.

Sexual problems including low sex drive or inability to have an orgasm.

Tricyclic antidepressants

TCAs were among the first antidepressants approved. Because other, newer antidepressants are associated with fewer side effects, TCAs tend to be prescribed less often. Some examples of these drugs includes nortriptyline (Pamelor®), amitriptyline (Elavil®), and imipramine (Tofranil®). Side effects of tricyclic antidepressants include:

Dry mouth.

Blurred vision.

Increased fatigue and sleepiness.

Weight gain.

Tremors.

Constipation.

Bladder problems (retention of urine).

Dizziness.

Increased heart rate.

Monoamine oxidase inhibitors

MAOIs were the first antidepressants approved. Their use has largely been replaced by newer antidepressants, which are safer and have fewer side effects. Some examples of MAOIs include phenelzine (Nardil®), tranylcypromine (Parnate®) and isocarboxazid (Marplan®). Side effects of monoamine oxidase inhibitors (MAOIs) include:

Drowsiness.

Dry mouth.

Dizziness.

Headache.

Nausea.

Insomnia.

Diarrhea or constipation.

Weight gain.

Low blood pressure.

Tremors.

Increased sweating.

Sexual problems including low sex drive or inability to have an orgasm.

Bladder problems (difficulty starting urine flow).

Norepinephrine and dopamine reuptake inhibitors

NDRIs treat depression as well as seasonal affective disorder. It is often prescribed by doctors for many “off label” psychiatric uses including anxiety, bipolar disorder and attention deficit/hyperactivity disorder (ADHD). Bupropion (Wellbutrin®) is the only member of this drug class. Some of its known side effects include:

Headache.

Insomnia.

Dry mouth.

Constipation.

Nausea.

Tiredness.

Tremor.

Increased sweating.

Non-competitive N-methyl-D-aspartate receptor antagonists

Esketamine (Ketanest®, Spravato®) is a non-competitive N-methyl-D-aspartate receptor antagonist approved in 2019. This antidepressant is only available as a nasal spray and is to be used together with an oral antidepressant for adults whose depression hasn’t been able to be effectively treated with other drugs. Esketamine has the potential for abuse and misuse and is associated with an increased risk of suicidal thoughts and behaviors. It can only be administered in a certified medical office under the direct supervision of a healthcare provider. Esketamine isn’t available at pharmacies for at-home use. Some of its known side effects include:

Dizziness.

Nausea.

Sedation.

Anxiety.

Increased blood pressure.

Dissociation (distortion of time, space, illusions).

Vomiting.

Feeling drunk.

Lack of energy.

It’s important to remember that most patients taking antidepressants don’t develop side effects. However, all patients should be carefully monitored. Don’t drink alcoholic beverages while taking antidepressant medicines. Alcohol may interfere with their beneficial effects.

Can antidepressants give you suicidal thoughts?

In 2004, the FDA issued a black box label warning for suicidal ideation among 18- to 24-year-olds for common antidepressant drugs. This warning is the FDA’s strictest warning for labeling prescription drugs.

The effect of suicidal thoughts is most common with SSRIs, occurring in about 4% of people who take them. However, untreated depression is considered to be much more of a suicide risk than taking antidepressants.

Will you become addicted if you take antidepressants?

Antidepressant medicines aren’t addictive. They don’t make you “high,” have a tranquilizing effect or produce a craving for more. They aren’t “happy pills.”

How long will you have to take antidepressants?

Usually, these drugs must be taken regularly for at least 4 to 8 weeks before their full benefit takes effect. You are monitored closely during this time to detect the development of side effects and to determine the effectiveness of treatment.

In order to prevent a relapse of depression, medicines are generally prescribed for 6 to 12 months after a first-time depression. When you and your provider determine that you are better, you should expect to continue the medication for at least 4 to 6 additional months. After this, your provider may gradually taper you off your medicine.

If you feel better, can you stop taking antidepressants?

Once you and your provider have determined it is safe for you to stop taking your medicine altogether, you should continue to be monitored during periodic follow-up appointments (about every three months) to detect any signs of depression returning.

Long-term treatment with antidepressant medications may be recommended to prevent further episodes of depression in people who have already had two or more episodes of major depression. A history of depression in one’s family is another factor that supports long-term treatment.

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