As anyone who has experienced it knows, depression is far more than simply feeling sad. When we're depressed, nothing seems right. We don't sleep right, we can't eat, we have difficulty working, and we have a hard time enjoying our families and friends. Sometimes we feel hopeless and unworthy. More than 17 million people in the United States experience some type of depression each year. Women are disproportionately affected, experiencing it at roughly twice the rate of men.
According to the American Psychiatric Association, 80-90% of all cases can be treated effectively. Psychotherapy with a mental health clinician can help a woman understand and overcome the sources of depression, while drug therapy can help treat underlying symptoms, both physical and psychological. It may take several months to find the right medication and dosage, but doctors today can choose from among an ever-increasing assortment of drugs to maximize benefits and minimize side effects.
WIDE VARIETY OF THERAPIES
The vast majority of antidepressants act in the same general way. They increase circulating levels of neurotransmitters -- chemicals that carry signals between the nerve cells (neurons) in the brain. Antidepressants specifically target the neurotransmitters serotonin, norepinephrine, and dopamine. Because depression is not the same in every woman and we all metabolize drugs differently, antidepressants do not have universal effects. A doctor will determine which drug to prescribe based on the type of depression. If insomnia is a problem, for example, he or she may prescribe Remeron (mirtazapine) because of its sedating effects. Depression accompanied by lethargy may best be treated with Prozac (fluoxetine) or Wellbutrin (bupropion) because of their stimulatory properties.
Most antidepressants have side effects. A doctor should initially prescribe a medication at a low dose, then gradually increase the dose over several weeks in order to find the lowest effective dose to treat the disorder and to allow each person to adjust to the medication. If you experience any significantly unpleasant side effects, you should try another medication. The newest antidepressants, including Celexa (citalopram) and Vestra (reboxetine) -- which has yet to be FDA approved -- may have less pronounced side effects in some people than older, more established antidepressants. These drugs more specifically target the neurotransmitters involved in depression.
Sexual problems. Diminished libido and failure to reach orgasm are common side effects with many antidepressants, including the selective serotonin reuptake inhibitors, or SSRIs. Medications like Wellbutrin, Serzone (nefazodone), Remeron, and Celexa, the newest SSRI, have a reduced rate of sexual side effects.
Cardiovascular effects. Drugs from the tricyclic family (TCAs) --including Tofranil (imipramine) and Elavil (amitriptyline) -- can produce cardiovascular side effects, such as changes in heart rhythm, blood pressure, and heart rate. If you have heart disease, avoid TCAs. But don't be put off by them altogether; they have a 40-year history of safe use under a physician's monitoring.
Gastrointestinal upset. In some people, antidepressants cause gastrointestinal upset -- nausea, diarrhea, constipation, or vomiting. Stomach problems tend to be most pronounced in the first few weeks of use and often disappear over time. Constipation is a common problem with tricyclics, Wellbutrin, and Serzone. SSRIs and similar drugs called SNRIs (serotonin and norepinephrine reuptake inhibitors) like Effexor (venlafaxine) and long-acting Effexor XR often lead to diarrhea.
Neurological difficulties. TCAs can cause unsettling problems like confusion, hallucinations, numbness, tingling, tremors, and seizures. Reducing the dose will lessen these side effects but may also reduce effectiveness. Increasing the dose slowly can reduce seizure risk.
Effects on the autonomic system. The autonomic nervous system controls automatic functions such as relaxation and constriction of blood vessels, saliva production, and contractions of the colon. TCAs and MAOIs, in particular, have a strong effect on this system. Dry mouth is a common side effect with both drug types. MAOIs are infrequently used as a first-line treatment for depression because they can cause a sudden and dangerous change in blood pressure when taken with certain foods. Also, they generally should never be taken with other classes of antidepressants because of potentially dangerous, even fatal, drug interactions.
Weight changes. Some drugs, especially the MAOIs and tricyclics, lead to significant weight gain. Conversely, taking Wellbutrin may result in weight loss because of the drug's stimulatory effects.
Sedation/stimulation. For depressed patients experiencing anxiety, sleep disturbance, or agitation, a sedating antidepressant can be tremendously helpful. Elavil, Sinequan (doxepin), Desyrel (trazodone), Serzone, and Remeron are particularly effective. But if your depression makes it difficult for you to remain alert or functional, stimulatory drugs such as the SSRIs, Wellbutrin, and MAOIs are good options.
Some herbs and nutritional supplements have antidepressant effects. Because none has received FDA scrutiny thus far, reliable information about interactions, particularly with other antidepressants, is unknown. You should not use herbs and nutritional supplements that act like antidepressants without first consulting a mental health professional.
St. John's wort. Several studies suggest that St. John's wort, the most prescribed antidepressant in Germany, provides SSRI-like benefits without gastrointestinal upset and sexual side effects. The National Institute of Mental Health is sponsoring a nationwide study of St. John's wort to assess its efficacy in the treatment of major depression. Some researchers believe St. John's wort interacts with MAOIs and SSRIs and discourage its use when either type of antidepressant has been prescribed.
SAM-e. Like St. John's wort, SAM-e (S-adenosyl-L-methionine) is widely used in Europe as a natural, mild antidepressant. First identified around 1973, SAM-e has been the subject of many small studies examining its antidepressant benefits. Some of these investigations suggest it may be as effective as the tricyclics and that it acts more quickly. Stomach upset is the most common side effect reported.
Omega 3 fatty acids. A new study shows that these fatty acids, found in fish oils, can stabilize mood in those with bipolar disorder (manic depression). They may act in a manner similar to lithium, a standard treatment for this condition.
WHICH MEDICINE IS RIGHT FOR YOU?
Antidepressants affect each woman differently. None produces results immediately, and it may take up to six weeks before symptoms improve. But many of the newer medications have been designed to address the problem of treatment lag. Researchers at Harvard recently reported on double-blind, controlled studies that showed Remeron relieved depression significantly faster than Prozac and Paxil. So if you find the drug you're taking doesn't relieve your symptoms, talk to your doctor about possibly switching to another medicine.
There's no danger of becoming dependent on an antidepressant because they aren't addictive. But if medicine is stopped too abruptly, gastrointestinal problems, sleep disturbances, flu-like symptoms, dizziness, or anxiety may trouble you. Consequently, when you and your doctor decide it's time to stop therapy, you'll be weaned from the medicine slowly. In general, expect to have your medication reduced over a four-week period if you've been on it for more than eight weeks. Once the medicine is stopped, any side effects you experienced during therapy will disappear.
Selective Serotonin Reuptake SSRIs are generally the
Inhibitors (SSRIs) first-line choice because they
Citalopram (Celexa) have fewer side effects than
Fluoxetime (Prozac) other antidepressants, do not
Fluvoxamine (Luvox) require blood monitoring, and
Paroxetine (Paxil) are safe in overdose, Zoloft is
Sertraline (Zoloft) more effective in patients with
Selective Serotonin and Works something like a
Norepinephrine Reuptake combination of an SSRI and a
Inhibitors (SNRIs) tricyclic might. Useful for
Venlafaxine (Effexor and patients who don't respond to
Effexor XR) other antidepressants
Tricyclics (TCAs) Due to their sedating effects,
Amitriptyline (Elavil) TCAs are useful for patients with
Amoxapine (Asendin) insomnia. They may pose a risk
Clomipramine (Anafranil) for individuals with
Desipramine (Norpramin, cardiovascular disease, such as
Doxepin (Adapin, Sinequan)
Bupropion Doesn't interact significantly
Wellbutrin and Wellbutin SR with other drugs. At high doses
can cause seizures in some
people, most commonly those who
have seizure disorders, anorexia,
or bulimia. Used experimentally
to counteract sexual side effects
of SSRIs. No weight gain.
Trazodone Often used with another
Desyrel antidepressant to alleviate
insomnia induced by the initial
Mirtazapine (Remeron) Useful for depression with
anxiety accompanied by sleep
Nerfazodone (Serzone) Shouldn't be taken with the
terfenadine (Seldane) and
Monoamine Oxidase Inibitors Can use severe and sudden blood
(MAOIs) pressure crisis if ingested with
Isocarboxazid (Marplan) certain drugs (e.g.,
Nardil over-the-counter cold remedies,
Parnate diet pills, and amphetamines)
or foods containing tyramine
(e.g., red wines, aged cheeses).
Shouldn't be taken with other
Maprotiline To treat agitation and anxiety
Ludiomil associated with depression. Not
advised for people with seizure
disorders or cardiovascular