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There are several types of antidepressant medications used to treat depressive
disorders. These include newer medications, chiefly the selective
serotonin reuptake inhibitors (SSRIs), the tricyclics, and the
monoamine oxidase inhibitors (MAOIs). The SSRIs, and other newer
medications that affect neurotransmitters such as dopamine or
norepinephrine, generally have fewer side effects than tricyclics.
Sometimes your doctor will try a variety of antidepressants before
finding the medication or combination of medications most effective
for you. Sometimes the dosage must be increased to be effective.
Antidepressant medications must be taken regularly for as many
as 8 weeks before the full therapeutic effect occurs.
Patients often are tempted to stop medication too soon. They may feel better
and think they no longer need the medication. Or they may think the medication
isn't helping at all. It is important to keep taking medication until it has
a chance to work, though side effects may appear before antidepressant activity
does. Once the individual is feeling better, it is important to continue the
medication for 4 to 9 months to prevent a recurrence of the depression. Some
medications must be stopped gradually to give the body time to adjust. For individuals
with bipolar disorder or chronic major depression, medication may have to be
Antidepressant drugs are not habit-forming. However, as is the case with any
type of medication prescribed for more than a few days, antidepressants have
to be carefully monitored to see if the correct dosage is being given. The doctor
will check the dosage and its effectiveness regularly.
For the small number of people for whom MAO inhibitors are the best treatment,
it is necessary to avoid certain foods that contain high levels of tyramine,
such as many cheeses, wines, and pickles, as well as medications such as decongestants.
The interaction of tyramine with MAOIs can bring on a hypertensive crisis, a
sharp increase in blood pressure that can lead to a stroke. The doctor should
furnish a complete list of prohibited foods that the patient should carry at
all times. Other forms of antidepressants require no food restrictions.
Medications of any kind, prescribed, over-the counter, or borrowed, should
never be mixed without consulting the doctor. Other health professionals who
may prescribe a drug, such as a dentist or other medical specialist, should
be told that the patient is taking antidepressants. Some drugs, although safe
when taken alone can, if taken with others, cause severe and dangerous side
effects. Some drugs, like alcohol or street drugs, may reduce the effectiveness
of antidepressants and should be avoided. This includes wine, beer, and hard
liquor. Some people who have not had a problem with alcohol use may be permitted
by their doctor to use a modest amount of alcohol while taking one of the newer
Anti-anxiety drugs or sedatives are not antidepressants. They are sometimes
prescribed along with antidepressants; however, they are not effective
when taken alone for a depressive disorder. Stimulants, such as
amphetamines, are not first-line antidepressants and share the
habit-forming risks of antianxiety medications and sleeping pills.
Questions about any antidepressant prescribed, or problems that
may be related to the medication, should be discussed with the
Lithium has for many years been the treatment of choice for bipolar disorder,
as it can be effective in smoothing out the mood swings common
to this disorder. Its use must be carefully monitored, as the
range between an effective dose and a toxic one is small. If a
person has pre-existing thyroid, kidney, or heart disorders or
epilepsy, lithium may not be recommended. Fortunately, other medications
have been found to be of benefit in controlling mood swings. Among
these are two mood-stabilizing anticonvulsants, carbamazepine
(Tegretol®) and valproate (Depakote®). Both of these medications
have gained wide acceptance in clinical practice, and valproate
has been approved by the Food and Drug Administration for first-line
treatment of acute mania. Other anticonvulsants that are being
used now include lamotrigine (Lamictal®) and gabapentin (Neurontin®).
Most people who have bipolar disorder take more than one medication
including, along with lithium and/or an anticonvulsant, a medication
for accompanying agitation, anxiety, or insomnia. Finding the
best possible combination of these medications is of utmost importance
to the patient and requires close monitoring by the physician.
Existing antidepressant drugs are known to influence the functioning
of certain neurotransmitters in the brain, primarily serotonin
and norepinephrine, known as monoamines. Older medications
tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors
(MAOIs) affect the activity of both of these neurotransmitters
simultaneously. Their disadvantage is that they can be difficult
to tolerate due to side effects or, in the case of MAOIs, dietary
restrictions. Newer medications, such as the selective serotonin
reuptake inhibitors (SSRIs), have fewer side effects than the
older drugs, making it easier for patients to adhere to treatment.
Both generations of medications are effective in relieving depression,
although some people will respond to one type of drug, but not
Antidepressant medications take several weeks to be clinically effective even
though they begin to alter brain chemistry with the very first dose. Research
now indicates that antidepressant effects result from slow-onset adaptive changes
within the brain cells, or neurons. Further, it appears that activation of chemical
messenger pathways within neurons, and changes in the way that genes in brain
cells are expressed, are the critical events underlying long-term adaptations
in neuronal function relevant to antidepressant drug action. A current challenge
is to understand the mechanisms that mediate, within cells, the long-term changes
in neuronal function produced by antidepressants and other psychotropic drugs
and to understand how these mechanisms are altered in the presence of illness.
Knowing how and where in the brain antidepressants work can aid the development
of more targeted and potent medications that may help reduce the time between
first dose and clinical response. Further, clarifying the mechanisms of action
can reveal how different drugs produce side effects and can guide the design
of new, more tolerable, treatments.
As one route toward learning about the distinct biological processes that go
awry in different forms of depression, researchers are investigating the differential
effectiveness of various antidepressant medications in people with particular
subtypes of depression. For example, this research has revealed that people
with atypical depression, a subtype characterized by reactivity of mood (mood
brightens in response to positive events) and at least two other symptoms (weight
gain or increased appetite, oversleeping, intense fatigue, or rejection sensitivity),
respond better to treatment with MAOIs, and perhaps with SSRIs than with TCAs.
Many patients and clinicians find that combinations of different drugs work
most effectively for treating depression, either by enhancing the therapeutic
action or reducing side effects. Although combination strategies are used often
in clinical practice, there is little research evidence available to guide psychiatrists
in prescribing appropriate combination treatment.
Untreated depression often has an accelerating course, in which episodes become
more frequent and severe over time. Researchers are now considering whether
early intervention with medications and maintenance treatment during well periods
will prevent recurrence of episodes. To date, there is no evidence of any adverse
effects of long-term antidepressant use.
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