Help with Depression

What antidepressants are available?

There are various medications for the treatment of depression. They can be split up into
different groups. The most commonly used antidepressants:

• Tricyclic antidepressants (TCAs)
• Selective serotonin re-uptake inhibitors (SSRIs)
• Selective serotonin noradrenaline re-uptake inhibitors (SNRIs)

Tricyclic antidepressants have been on the market the longest. They are considered to be first-generation antidepressants. SSRIs and SNRIs are second-generation antidepressants.

The following are prescribed less often:

• Adrenergic alpha-2 receptor antagonists
• Monoamine oxidase (MAO) inhibitors
• Selective noradrenaline re-uptake inhibitors
• Selective noradrenaline/dopamine re-uptake inhibitors
• Melatonin receptor agonists and serotonin 5-HT2C receptor antagonists

There are also medications (like trazodone and lithium) that don’t belong to any group, as well as herbal products such as St. John’s wort.

How do antidepressants work?

The nerve cells in our brain use various chemicals to pass on signals. Even though not all details are known, experts believe that depression is caused by an imbalance of certain chemical messengers (neurotransmitters) like serotonin, which means that signals can’t be passed along the nerves properly. Antidepressants aim to increase the availability of these chemicals. The various drugs do that in different ways.

What does the treatment involve?

Antidepressants are usually taken daily. The goal in the first few weeks and months is to relieve the symptoms and, where possible, make the depression go away. Once that has been achieved, the treatment is continued for at least four to nine months. This continuation therapy is necessary to stop the symptoms from coming back. The medication is sometimes taken for longer to prevent relapses. The duration of treatment also depends on how the symptoms continue to develop over time and whether the depression is likely to return. Some people take antidepressants over many years.

Towards the end of the treatment, the dose is gradually reduced over the course of several weeks. You may experience temporary sleep problems, nausea or restlessness when coming off antidepressants. These symptoms are especially likely if you suddenly stop taking antidepressants. Sometimes people stop taking their medication as soon as they start feeling better, but that increases the risk of the depression coming back. Unlike many sleeping pills and sedatives, antidepressants don’t cause physical dependence or addiction.

How effectively do antidepressants relieve the symptoms?

There are a lot of different medications for treating depression. But it’s difficult to predict how well a particular medication will help an individual. Often healthcare professionals first suggest taking a drug that they consider to be effective and relatively well tolerated. If it doesn’t help as much as expected, it’s possible to switch to a different medication. Sometimes a number of different drugs have to be tried before you find one that works.

Studies show that the benefit generally depends on the severity of the depression: The more severe the depression, the greater the benefits will be. In other words, antidepressants are effective against chronic, moderate and severe depression. They don’t help in mild depression.

The various antidepressants have been compared in many studies. Overall, the commonly used antidepressants (SSRIs and SNRIs) were found to be equally effective. The Cipriani study compared antidepressants and included 500 studies and 100,000 people showed all antidepressants are superior to placebo.

Antidepressants can also relieve long-term symptoms of chronic depressive disorder (dysthymia) and chronic depression, and help make them go away completely.

An antidepressant can already have an effect within one or two weeks. But it may take longer for the symptoms to improve.

How well can antidepressants prevent relapses?

Antidepressants are usually taken for one to two years, and sometimes longer, to prevent
relapses. Relapse prevention may be a good idea for people who

• have already had several relapses,
• absolutely want to avoid a relapse, or
• have chronic depression.

It has been found taking an antidepressant over a long period of time helps prevent a relapse in an average of 27 out of 100 people.

What are the side effects of antidepressants?

Like all medications, antidepressants can have side effects. Over half of all people who take antidepressants have side effects. They usually occur during the first few weeks of treatment and are less common later on.

Some of these side effects are believed to be a direct consequence of the medication’s effect on the brain and are relatively similar among various drugs within the same group. Examples include a dry mouth, headaches, dizziness, restlessness and sexual problems. These kinds of problems are often perceived to be side effects of the medications. But some of them may be caused by the depression itself.

Whether or not someone has side effects, which side effects they have, and how frequent they are will depend on the drug, the dose used, and whether they have just started taking it or have been taking it for some time. And everyone reacts slightly differently to drugs too. The risk of side effects increases if you are also taking other medication. One of the drugs may make the side effects of the other worse. These kinds of drug interactions are common in older people and people with chronic illnesses who are taking several different kinds of medication.

For this reason, it’s important to thoroughly discuss the pros and cons of the various medications with your doctor.

Some side effects are more common with particular drugs:

• SSRIs are more likely than tricyclic antidepressants to cause diarrhoea, headaches, sleep problems and nausea.
• Compared to SSRIs, tricyclic antidepressants are more likely to cause vision problems, constipation, dizziness, a dry mouth, trembling and difficulty urinating (peeing).

The side effects of tricyclic antidepressants are often worse than those of SSRIs and SNRIs. More people tend to stop taking tricyclic antidepressants because of this: Studies found that about 15 out of 100 people who were taking tricyclic antidepressants did so, compared to around 10 out of 100 people who were taking SSRIs. There’s also a greater risk of severe side effects if an overdose of tricyclic antidepressants is taken.

Severe side effects

Antidepressants can cause dizziness and unsteadiness, increasing the risk of falls and bone fractures, especially in older people. Interactions with other medications can increase this risk.

A very small number of people have had heart problems, epileptic fits or liver damage while taking antidepressants. It is believed that these were rare side effects of antidepressants. Various studies suggest that teenagers are more likely to think about killing themselves (committing suicide) when taking SSRIs or SNRIs, and also actually attempt to take their own lives more often. Because of this, teenagers should see their doctor or therapist more regularly at the beginning of treatment so that any risk of suicide can be identified early on.

What should you consider when deciding whether or not to take antidepressants?

Whether antidepressants are an option will depend on things like the severity of the
symptoms. Other aspects can also play a role in the decision:

• Are you going to psychotherapy or are you planning to?
• Have you taken antidepressants before and did they help?
• How bad do you think the potential side effects are compared to the possible benefits?

The question of side effects can also be key when choosing which drug to take: Some people might be more keen to avoid digestion problems. Others might prefer to avoid dizziness, decreased sex drive or erection problems.

It only makes sense to use antidepressants if the diagnosis is correct. Specialists believe that some people are prescribed antidepressants unnecessarily. The fact that a lot more people take antidepressants nowadays suggests that this is true. They are sometimes already prescribed for milder symptoms, even though it’s not clear whether they help in mild depression.

But it’s still important to make sure that severe depression is diagnosed and treated properly. Antidepressants can be helpful here, and for some people may be the only way that they can get back into a daily routine or start going to psychotherapy.

How can we help?

If you have a diagnosis of depression and taking an antidepressant but are unsure if this is working for you or if you would like to explore other options but aren’t sure what is available, we can help guide you through this. It is important to have regular appointments with your healthcare professional when taking antidepressants. We provide adequate time to get to know and support you, providing long term follow up. With regular follow up you can talk about whether the symptoms have improved and whether there are any side effects, adjusting the dose if necessary. We will build a trusting relationship and work in an open, engaging and non-judgemental manner, explore treatment choices in an atmosphere of hope and optimism. Ensure discussions take place in settings where confidentiality, privacy and dignity are respected.

What will the review involve?

We will discuss what, if anything, you think might be contributing to the development of depression, your ideas or preferences about treatment, and what treatment options you have previously found helpful or might prefer. Your experience of any prior episodes of depression, or treatments for depression and what you hope to gain from treatment.

We will help build a trusting relationship and provide continuity of care and agree a management plan.

This will include:

• the reasons for offering medication
• the choices of medication (if a number of different antidepressants are suitable)
• the dose, and how the dose may need to be adjusted
• the benefits, covering what improvements the person would like to see in their life and how the medication may help
• the harms, covering both the possible side effects and withdrawal effects, including any side effects they would particularly like to avoid (for example, weight gain, sedation, effects on sexual function)
• any concerns they have about taking or stopping the medication

Lifestyle pharmacist can prescribe the antidepressant privately or can make a recommendation to your GP with a clinic letter with your consent.