Confused by the choice in antidepressants? With persistence, you and your health care provider can find one that works so that you can enjoy life more fully again.By Mayo Clinic Staff
Antidepressants are a popular treatment choice for depression. Although antidepressants may not cure depression, they can reduce 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.
So don't give up. Many kinds of antidepressants are available, and chances are you'll be able to find one that works well for you. And sometimes a combination of medicines may be an option.
There are many types of antidepressants available that work in slightly different ways and have different side effects. When choosing an antidepressant that's likely to work well for you, your health care provider 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 causes some people to be calm or somewhat sleepy may be a good option.
- Possible side effects. Side effects of antidepressants vary from one medicine to another and from person to person. Bothersome side effects, such as dry mouth, nausea, weight gain or sexual side effects, can make it difficult to stick with treatment. Discuss possible major side effects with your health care provider or pharmacist.
- Whether it worked for a close relative. How a medicine worked for a blood 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 medicines. Some antidepressants can cause dangerous reactions when taken with other medicines.
- Pregnancy or breastfeeding. A decision to use antidepressants during pregnancy and breastfeeding is based on the balance between risks and benefits. Overall, the risk of birth defects and other problems for babies of people who take antidepressants during pregnancy is low. Still, certain antidepressants, such as paroxetine (Paxil, Pexeva), are discouraged during pregnancy. Work with your health care provider 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, many antidepressants may relieve symptoms of anxiety disorders. Bupropion may help you stop smoking. Other examples include using duloxetine (Cymbalta, Drizalma Sprinkle) to help with pain symptoms or fibromyalgia, or using amitriptyline to prevent migraines.
- Cost and health insurance coverage. Some antidepressants can be expensive, so 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.
Many mental health experts believe that 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 help relieve depression by affecting these neurotransmitters, sometimes called chemical messengers, which aid in communication between brain cells. Each type of antidepressant affects these neurotransmitters in slightly different ways.
Many types of antidepressants are available to treat depression, including:
- Selective serotonin reuptake inhibitors (SSRIs). Health care providers often start by prescribing an SSRI. These antidepressants generally cause fewer bothersome side effects and are less likely to cause problems at higher therapeutic doses than other types of antidepressants. SSRIs include fluoxetine (Prozac), paroxetine (Paxil, Pexeva), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro).
- Serotonin and norepinephrine reuptake inhibitors (SNRIs). Examples of SNRIs include duloxetine (Cymbalta, Drizalma Sprinkle), venlafaxine (Effexor XR), desvenlafaxine (Pristiq) and levomilnacipran (Fetzima).
- Atypical antidepressants. These antidepressants are called atypical because they 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 (Forfivo XL, Wellbutrin SR, others). Bupropion is one of the few antidepressants not frequently associated with sexual side effects.
- Tricyclic antidepressants. Tricyclic antidepressants — such as imipramine, 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 medicines haven't worked. This is because they can have serious side effects. Using an MAOI requires a strict diet because of dangerous (or even deadly) interactions with foods that contain tyramine — such as certain cheeses, pickles and wines — and some medicines, including pain medicines, 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 medicines can't be combined with SSRIs or other medicines that increase serotonin.
- Other medications. Your health care provider may recommend combining two antidepressants. Or your provider may add other medicines to improve antidepressant effects. This is called augmentation. Examples of antidepressant augmentation medicines include aripiprazole (Abilify), quetiapine (Seroquel) and lithium (Lithobid).
Most antidepressants are generally safe, but the U.S. Food and Drug Administration (FDA) 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 health care provider or get emergency help.
Keep in mind that antidepressants are more likely to reduce suicide risk in the long run by improving mood.
To get the best results from an antidepressant:
- Be patient. Once you and your health care provider have selected an antidepressant, you may start to see improvement in a few weeks, but it may take six or more weeks for it to be fully effective. With some antidepressants, you can take the full dose immediately. With others, you may need to gradually increase your dose. Talk to your provider or therapist about coping with depression symptoms as you wait for the antidepressant to take effect.
- Take your antidepressant consistently and at the correct dose. If your medicine doesn't seem to be working or is causing bothersome side effects, call your health care provider before making any changes.
- 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 side effects usually go away as your body adjusts to the antidepressant.
- Explore options if it doesn't work well. If you have bothersome side effects or no significant improvement in your symptoms after several weeks, talk to your health care provider about changing the dose, trying a different antidepressant, or adding a second antidepressant or another medicine. A medicine combination may work better for you than a single antidepressant.
- Try psychotherapy. In many cases, combining an antidepressant with talk therapy, called psychotherapy, is more effective than taking an antidepressant alone. It can also help prevent your depression from returning once you're feeling better.
- Don't stop taking an antidepressant without talking to your health care provider first. Some antidepressants can cause significant withdrawal-like symptoms unless you slowly taper off your dose. Quitting suddenly may cause a worsening of depression.
- Avoid alcohol and recreational drugs. It may seem as if alcohol or drugs lessen depression symptoms, but in the long run they generally worsen symptoms and make depression harder to treat. Talk with your health care provider or therapist if you need help with alcohol or drug problems.
Sept. 23, 2022
- Depression medicines. U.S. Food and Drug Administration. https://www.fda.gov/consumers/free-publications-women/depression-medicines. Accessed Aug. 17, 2022.
- Suicidality in children and adolescents being treated with antidepressant medications. U.S. Food and Drug Administration. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/suicidality-children-and-adolescents-being-treated-antidepressant-medications#:~:text=Antidepressants%20increase%20the%20risk%20of,suicidality%20with%20the%20clinical%20need. Accessed Aug. 17, 2022.
- Rush AJ. Unipolar major depression in adults: Choosing initial treatment. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
- Sabella D. Antidepressant medications. American Journal of Nursing. 2018; doi:10.1097/01.NAJ.0000544978.56301.F6.
- Depression. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/depression. Accessed Aug. 17, 2022.
- Ritter JM, et al. Antidepressant drugs. In: Rang & Dale's Pharmacology. 9th ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Aug. 17, 2022.
- Mental health medications. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/mental-health-medications. Accessed Aug. 17, 2022.
- Expert reaction to a review paper on the 'serotonin theory of depression.' Science Media Centre. https://www.sciencemediacentre.org/expert-reaction-to-a-review-paper-on-the-serotonin-theory-of-depression/. Accessed Aug. 18, 2022.
- Nunez NA, et al Augmentation strategies for treatment resistant major depression: A systematic review and network meta-analysis. Journal of Affective Disorders. 2022; doi:10.1016/j.jad.2021.12.134.
- Krieger CA (expert opinion). Mayo Clinic. Aug. 30, 2022.
- Kung S (expert opinion). Mayo Clinic. Aug. 30, 2022.