Guide To Antidepressants

OVERVIEW

This page is dedicated to helping establish a framework for how one can think about antidepressants. There are many options out there and we must be intentional in picking the right medication for our patients!

Given that we have so many choices at our disposal for antidepressant mediations, it is especially important to consider the options! (source)
Given that we have so many choices at our disposal for antidepressant mediations, it is especially important to consider the options! (source)
BROAD CATEGORIES OF MEDICATIONS: WHAT ARE OUR OPTIONS?

When trying to make this decision we must first be aware of what options we may have at our disposal. The major categories of antidepressants are explained more below:

Selective serotonin re-uptake inhibitors (SSRI): these medications (broadly) speaking are typically the first line options for monotherapy. Their efficacy and mild side effect profiles make them attractive options. Within this one medication class there are a number of options to pick from (Citalopram, Sertraline, Fluoxetine, and more)

Serotonin-norepinephrine reuptake inhibitors (SNRI): while not as popular as SSRIs, this drug class can sometimes also be a first-line treatment choice for patients. There are a few options to choose from (Duloxetine, Venlafaxine, and more).

Atypical antidepressants: this category includes medications that do not fit nicely into other categories (Bupropion, Mirtazapine)

Serotonin modulators: these medications modulate serotonin signaling (but not by inhibiting its re-uptake). Trazodone is a common example of this drug class.

Tricyclic antidepressants (TCA): a much older class of medication that is not used that commonly (for sole depression) anymore. Amitriptyline is a popular example.

Monoamine oxidase inhibitors (MAOI): a much older class of medication that really is not used that commonly (for sole depression) anymore. Tranylcypromine is an example.

OUR FIRST THOUGHTS: HAS ANYTHING WORKED IN THE PAST?

Often times the first time we see a patient in the clinic may not be the first time that they have been prescribed ever prescribed an antidepressant in the past. Perhaps our first thought for a patient we are trying to treat with antidepressants is if they have ever been treated in the past with any medications. Regardless of if the medications were successful or not, it is worth knowing this information! It will help us avoid giving ineffective medications, and then can also make our decision making much easier if we are able to start with a medication that we know has worked in the past.

OUR FIRST DECISION: SHOULD WE USE AN SSRI OR NOT?

Given how overwhelming the options for antidepressant medications may seem, it is useful to have a quick methodology for deciding what treatment path should be utilized for patients. Perhaps for the sake of efficiency we can make the general (but not absolute) claim that SSRI medications should be the default choice unless faced with a compelling reason to try other antidepressants.

While not everything can be binary in medicine, fundamentally (when choosing a single anti-depressant) it is advantageous to make the distinction early on between SSRI and non-SSRI options (source)
While not everything can be binary in medicine, fundamentally (when choosing a single anti-depressant) it is advantageous to make the distinction early on between SSRI and non-SSRI options (source)

The below reasons demonstrate some of the reasoning that causes one to decide against using SSRIs, and instead purse other options. 

The patient has bipolar disorder: a major contraindication for beginning SSRI therapy, patients should avoid this class of medication because it can precipitated manic episodes. Generally speaking most all patients with depressive disorders should be evaluated for bipolar disorder (simply to avoid prescribing this group of patients SSRI medications).

Sexual side effects are concerning to the patient: while the side effect profile of SSRI medications is comparatively mild, for some patients the possibility of having sexual dysfunction (one of the more common side effects of SSRIs) is a serious concern. This may be enough to justify exploring other options for the patient first.

The patient has another condition they need treated: SSRI medications are a great option for many patients, however sometimes patients have co-morbidities that are more effectively treated with a non-SSRI medication. Some examples of these other conditions include: 

  • Insomnia
  • Nicotine addiction
  • Overeating
  • Anorexia
  • Chronic pain
SSRI MEDICATIONS: WHAT ARE OUR OPTIONS? WHAT ELSE CAN WE TREAT WITH IT?

In the absence of a good reason to pursue other antidepressants, SSRIs are very commonly prescribed for depressive disorders. There are many options for patients even within this one class of medications. For this reason we must have some framework for tailoring specific SSRI medications to patients. Given that some SSRIs are approved for other reasons, we can use this as one means of deciding how to tailor treatment to our patients. When picking an SSRI option, the following aspects are worth considering to maximize the therapeutic impact of the medication.

Is the SSRI long or short acting?

Short acting SSRI medications can be useful if their is a lack of clarity regarding if the patient might have a mood disorder (such as bipolar disorder). This will enable a quick removal of the medication if mania is precipitated by the usage of the SSRI. Similarly, if patients are concerned about side effects using short acting medication will enable for a quick reversal of symptoms when the medication is discontinued. Examples include:

Long acting SSRI medications can be useful if their are concerns regarding medication compliance (i.e. in alcoholics that might miss doses of medications). Fluoxetine is one of the longer acting SSRI medications when compared to others.

Does the patient have other conditions that might benefit from an SSRI?

Post-traumatic stress disorder: Sertraline has been approved to treat PTSD as well.

Social anxiety: Paroxetine is the classic example of a SSRI that is used to manage social anxiety.

NON-SSRI MEDICATIONS: WHAT ARE OUR OPTIONS?

If we have excluded SSRI medications as an option, then we must have a good reason to do so. Let us elaborate more on how we can further tailor our pharmacological therapy based upon WHY exactly we are looking beyond SSRI antidepressants.

Treating insomnia (Trazadone, Mirtazapine): both of these medications have a sedating effect on patients, can can be used to also address insomnia in patients.

Treating nicotine addiction (Bupropion): this atypical antidepressant can help patients quite smoking.

Encouraging weight loss (Bupropion): this atypical antidepressant can help patients curb their appetite and lose weight.

Treating anorexia nervosa (Mirtazapine): this atypical antidepressant actually will increase the appetite of the patient.

Treating chronic pain (Amitriptyline): this TCA medication can help manage chronic pain that is experienced by patients.

FURTHER READING

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Page Updated: 08.18.2016