Considerations in Selecting an Antidepressant

If you have recently decided to seek treatment for depression, the good news is that there are many options available. Perhaps you yourself do not struggle with this illness, but you are concerned for a family member, close friend, or other loved one. Either way, being well-informed about antidepressant medications is essential. This article can serve as an initial guide; make sure any final decisions take place in conjunction with advice from a licensed professional physician or psychiatrist.

Make sure to get a proper diagnosis:

According to the National Institute of Mental Health (NIMH), an estimated 26.2% of Americans ages 18 and older -about one in four adults - suffer from a diagnosable mental disorder in any given year . While many of these people may not be necessarily be on medication, it’s clear that mental disorders are widespread and common.

What are the implications of these figures? There are several: First, you probably know someone who claims they are “feeling depressed” often. You may even be aware of the antidepressant treatment they are taking. While a frank and honest discussion of the problem is helpful, it is very important not to succumb to “crowd-think” or self-diagnosis. Joe or Jane may swear by Zoloft, for example, but choosing your best pharmacological option should never be a popularity contest.

What are your specific symptoms or the symptoms of the person in question? Currently, antidepressants are prescribed for a wide range of ailments. On the continuum of mental health and disease, there are several major “clusters” or categories of disorder. They can exist separately or in combination with each other and with other behavioral or physiological problems (such as substance abuse or obesity). This is called co-morbidity and again, can only be properly diagnosed by a professional.


The list below outlines the major illnesses for which antidepressants might be prescribed:

1. Mood Disorders:
- Major Depressive Disorder
- Dysthymic Disorder
- Bipolar Disorder
- Suicidal Ideation

2. Schizophrenia

3. Anxiety Disorders:
- Panic Disorder
- Obsessive-Compulsive Disorder (OCD)
- Post-Traumatic Stress Disorder (PTSD)
- Generalized Anxiety Disorder (GAD)
- Social Phobia
- Agoraphobia
- Specific Phobia

4. Eating Disorders

5. Attention Deficit Hyperactivity Disorder (ADHD)

6. Autism

7. Alzheimer's Disease

Be aware of pre-existing conditions:

In 2007, the U.S. Food and Drug Administration (FDA) recommended that makers of all antidepressant medications update the existing black box warning on their products' labeling to include warnings about increased risks of suicidal thinking and behavior, known as suicidality, in young adults ages 18 to 24 during initial treatment (generally the first one to two months). Because of the rapid and profound changes that normally take place in the growing teenager’s brain, extra caution should be used before giving antidepressants to anyone in this age group.

There are currently 36 drugs on the market with revised medication guides:

Anafranil (clomipramine); Asendin (amoxapine); Aventyl (nortriptyline); Celexa (citalopram hydrobromide); Cymbalta (duloxetine); Desyrel (trazodone HCl); Elavil (amitriptyline); Effexor (venlafaxine HCl); Emsam (selegiline); Etrafon (perphenazine/amitriptyline); Fluvoxamine maleate; Lexapro (escitalopram oxalate); Limbitrol (chlordiazepoxide/amitriptyline); Ludiomil (maprotiline); Marplan (isocarboxazid); Nardil (phenelzine sulfate); Nefazodone; HClNorpramin (desipramine HCl); Pamelor (nortriptyline); Parnate (tranylcypromine sulfate); Paxil (paroxetine HCl); Pexeva (paroxetine mesylate); Prozac (fluoxetine HCl); Remeron (mirtazapine); Sarafem (fluoxetine HCl); Seroquel (quetiapine); Sinequan (doxepin); Surmontil (trimipramine); Symbyax (olanzapine/fluoxetine); Tofranil (imipramine); Tofranil-PM (imipramine pamoate); Triavil (perphenazine/amitriptyline); Vivactil (protriptyline); Wellbutrin (bupropion HCl); Zoloft (sertraline HCl); and Zyban (bupropion HCl)

Besides children and teenagers, women who are pregnant or nursing should consult their primary-care physician about these drugs and the risks of possible side-effects.

In general, people with blood pressure problems (either too high or too low) should avoid the Monoamine Oxidase Inhibitors or MAOIs. These were some of the earliest medications developed to treat depression and have fallen out of favor today because of their many potential serious complications.

Another class of drugs, called Tricyclics, may aggravate pre-existing heart conditions. Patients with a history of seizures or head injury must also be cautious as these drugs may cause seizure.

The most popular antidepressants in use today:

On 28 January, 2009, The Lancet, which is the leading peer-reviewed medical journal in the United Kingdom, published a ground-breaking study titled "Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis." Authored by Dr. Andrea Cipriani PhD, Toshiaki A Furukawa MD, and Georgia Salanti PhD, this paper rates a dozen current drugs based on two primary criteria:

1) Efficacy, meaning how likely patients were to experience the desired effects of the drug.
2) Acceptability, which refers to the likelihood that a patient would continue using a drug for the duration of the study. The presumption is that if a high percentage of patients are dropping out because of the side-effects of a particular protocol, then that substance would be considered “less acceptable”.

Here is a summary of the report’s findings:

Efficacy:
1. Mirtazapine (Remeron)
2. Escitalopram (Lexapro)
3. Venlafaxine (Effexor)
4. Sertraline (Zoloft)
5. Citalopram (Celexa)
6. Buproprion (Wellbutrin)
7. Paroxetine (Paxil)
8. Milnacipran (Savella)
9. Fluoxetine (Prozac)
10. Duloxetine (Cymbalta)
11. Fluvoxamine (Luvox)
12. Reboxetine (Vestra)

Acceptability:
1. Sertraline (Zoloft)
2. Escitalopram (Lexapro)
3. Buproprion (Wellbutrin)
4. Citalopram (Celexa)
5. Fluoxetine (Prozac)
6. Milnacipran (Savella)
7. Mirtazapine (Remeron)
8. Venlafaxine (Effexor)
9. Paroxetine (Paxil)
10. Duloxetine (Cymbalta)
11. Fluvoxamine (Luvox)
12. Reboxetine (Vestra)

[Source: Cipriani et al, "Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis." Lancet (2009).]

This research is significant because it synthesizes the results of 117 previous studies and for the first time, ranks them in a hierarchy, from the patients’ point of view. Apparently, physicians all over the world were surprised that there would be marked differences by drugs in the same chemical family. Two SSRIs, for example, will not be perceived equally. Zoloft and Lexapro came in first for a combination of effectiveness and fewer side effects, followed by Prozac (fluoxetine), Paxil (paroxetine), Cymbalta, and Luvox among others.

The field of biochemistry is continually evolving. What was considered “state of the art” ten years ago is now known as out of date or even dangerous. Do not assume that your family physician is an expert on antidepressants. Doctors are busy people who sometimes are unable to keep up with pace of clinical trials. As a potential patient, or patient’s advocate, it is your responsibility to be aware of research like the above, and to share this knowledge with your doctor, if necessary.

Lifestyle changes and alternatives to antidepressants:

If you have done your homework, you may have realized that all antidepressants carry a risk of side-effects. If the symptoms in question are mild to moderate, you may benefit from trying some less chemically invasive therapies first. The suggestions that follow are among those most thoroughly tested and proven to be safe, effective, and beneficial for the widest range of people:

1. Exercise: It is what most Americans are lacking in. Thirty minutes of aerobic exercise three times a week will release endorphins, lower blood pressure, and relieve stress.

2. Nutritional supplements: B vitamins play a role in the production of certain neurotransmitters, which are important in regulating mood and other brain functions. Folic acid deficiency has been noted among people with depression. Vitamin B6, or pyridoxine, is the cofactor for enzymes that convert L-tryptophan to serotonin, so vitamin B6 deficiency might result in depression. There is some evidence that people with depression respond better to treatment if they have higher levels of vitamin B12. Also consider eliminating common allergens such as dairy, wheat, or soy.

3. St. John’s Wort: This is an herb available in tablets, capsules and liquid form from supermarkets and health food shops. Research suggests that it exerts its antidepressant action by inhibiting the reuptake of the neurotransmitters serotonin, norepinephrine, and dopamine.

4. Cognitive behavioral therapy (CBT): It seeks to help people change how they think about things. Unlike more traditional forms of therapy, it focuses on “here and now” problems and difficulties. Numerous clinical studies throughout the world have consistently demonstrated that cognitive behavioral therapy is as effective as antidepressant medication. Within 20 sessions of individual therapy, approximately 75% of patients experience a significant decrease in their symptoms.

The challenges of dealing with a major mood disorder can be daunting. Please take your time with this material; you may want to print out this article and keep it handy for reference. Selecting the right antidepressant is a crucial step on the road to wellness. Though the process may be difficult, at least now you can be an informed “consumer” of the medical buffet. Best wishes on your journey.

References:
1. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.
2. U.S. Census Bureau Population Estimates by Demographic Characteristics. Table 2: Annual Estimates of the Population by Selected Age Groups and Sex for the United States: April 1, 2000 to July 1, 2004 (NC-EST2004-02) Source: Population Division, U.S. Census Bureau Release Date: June 9, 2005. http://www.census.gov/popest/national/asrh/
3. For more information on some of these drugs, please see the FDA’s Index to Drug-Specific Information.
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm111085.htm
4. Dr Joseph Mercola; 10 Antidepressant Alternatives Proven to Work Original Drugs January 9, 2009