Confused by the choice in antidepressants? With persistence, you and your doctor should find one that works so that you can enjoy life more fully again.

By Mayo Clinic Staff

Antidepressants are a popular treatment choice for those with depression. Although antidepressants may not cure depression, they can reduce your symptoms. The first antidepressant you try may work fine. But if it doesn't relieve your symptoms, or it causes side effects that bother you, you may need to try another.

But don't give up. A number of antidepressants are available, and chances are you'll be able to find one that works well for you.

There are a number of antidepressants available that work in slightly different ways and have different side effects. Most work equally well to relieve depression, so choosing the right one generally involves subtle differences. 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.
  • 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.
  • Interaction with other medications. Some antidepressants can cause dangerous reactions when taken with other medications.
  • Whether you're pregnant or breast-feeding. Many antidepressants may not be safe for your baby when taken during pregnancy or later when you're breast-feeding. 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, bupropion (Wellbutrin) may help relieve symptoms of both attention-deficit/hyperactivity disorder (ADHD) and depression. Other examples include using duloxetine (Cymbalta) to help with pain symptoms or fibromyalgia, or using amitriptyline to prevent migraine headaches.
  • Cost and health insurance coverage. Some antidepressants can be expensive, especially if there's no generic version available.

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. Each type (class) of antidepressant affects these neurotransmitters in slightly different ways.

Many types of antidepressant medications are available to treat depression, including those below. Discuss possible major side effects with your doctor or pharmacist.

  • Selective serotonin reuptake inhibitors (SSRIs). Doctors often start by prescribing an SSRI. These medications are safer and generally cause fewer bothersome side effects than other types of antidepressants. SSRIs include fluoxetine (Prozac, Selfemra), 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, Khedezla) and levomilnacipran (Fetzima).
  • Norepinephrine and dopamine reuptake inhibitors (NDRIs). Bupropion (Wellbutrin, Aplenzin, Forfivo XL) falls into this category. It's one of the few antidepressants not frequently associated with sexual side effects.
  • Atypical antidepressants. These medications don't fit neatly into any of the other antidepressant categories. They include trazodone (Oleptro), mirtazapine (Remeron) and vortioxetine (Brintellix). Both are sedating and usually taken in the evening. A newer medication called vilazodone (Viibryd) is thought to have a low risk of sexual side effects.
  • Tricyclic antidepressants. Tricyclic antidepressants — such as imipramine (Tofranil), nortriptyline (Pamelor), amitriptyline, doxepin, trimipramine (Surmontil), desipramine (Norpramin) and protriptyline (Vivactil) — tend to cause more side effects than newer antidepressants. So tricyclic antidepressants generally aren't prescribed unless you've tried an SSRI 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 birth control pills, decongestants and certain herbal supplements. Selegiline (Emsam), a newer 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. Other medications may be added to an antidepressant to enhance antidepressant effects. Your doctor may recommend combining two antidepressants or medications such as mood stabilizers or antipsychotics. Anti-anxiety and stimulant medications might also be added for short-term use.

Most antidepressants are generally safe, but the Food and Drug Administration requires that all antidepressants carry black box warnings, the strictest warnings for prescriptions. In some cases, children, teenagers and young adults under 25 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed.

Anyone taking an antidepressant should be watched closely for worsening depression or unusual behavior. If you or someone you know has suicidal thoughts when taking an antidepressant, immediately contact your doctor or get emergency help.

Keep in mind that antidepressants are more likely to reduce suicide risk in the long run by improving mood.

There are several steps you can take to get the best results:

  • Be patient. Once you and your doctor have selected an antidepressant, it may take six or more weeks for it to be fully effective. With some medications, you can take the full dosage immediately. With others, you may need to gradually increase your dose. Talk to your doctor or therapist about coping with depression symptoms as you wait for medications to take effect.
  • See if the side effects improve. Many antidepressants cause side effects that improve with time. For example, initial side effects when starting an SSRI can include dry mouth, nausea, loose bowel movements, headache and insomnia, but these symptoms usually go away as your body adjusts to the antidepressant.
  • If it doesn't work, try something else. If you have bothersome side effects or no significant improvement in your symptoms after six weeks, talk to your doctor about changing the dose, trying a different antidepressant (switching), or adding a second antidepressant or another medication (augmentation). A medication combination may work better for you than a single antidepressant.
  • Take your antidepressant consistently and at the correct dose. If your medication doesn't seem to be working or is causing bothersome side effects, call your doctor before making any changes.
  • Don't stop taking an antidepressant without talking to your doctor first. Some antidepressants can cause significant withdrawal-like symptoms unless you slowly taper off your dose. Quitting suddenly may cause a sudden worsening of depression.
  • Try psychotherapy. In many cases, combining an antidepressant with mental health counseling (psychotherapy) is more effective than taking an antidepressant alone. It can also help prevent your depression from returning once you're feeling better.
  • Avoid alcohol and illegal drugs. It may seem like alcohol or drugs lessen depression symptoms, but in the long run they generally worsen symptoms and make depression harder to treat. Talk with your doctor or therapist if you need help with alcohol or substance abuse.
Nov. 25, 2014