Medication Treatment

There are a large number of antidepressant medications available for the treatment of depression. Each patient responds differently to a specific medication. Where one patient may experience minimal or no side effects another patient may be more sensitive. When trying a new medication it is important to realize that many medications take four to six weeks to become effective and that most side effects go away over time. It may take a little time and effort you and your health care provider to find the medication or medications that are most effective for you.

Medications are frequently grouped according to how they work in the body or their chemical structure. Some groups of antidepressants that are popular today are:

• SSRIs - Selective Serotonin Reuptake Inhibitors
• SNRI - Serotonin-Norepinephrine Reuptake Inhibitors
• Tri-cyclic antidepressants
• MAOIs - (Irreversible) Monoamine Oxidase Inhibitors
• RIMAs - Reversible Monoamine Oxidase Inhibitors
• NDRIs - Norepinephrine-Dopamine Reuptake Inhibitors

SSRIs

Example: Celexa (citalopram)
Lexapro (escitalopram)
Paxil (paroxetin)
Prozac (fluoxetine)
Zoloft (sertraline)

SSRIs are one of the more commonly used groups of antidepressants. They are effective in treating a broad range of symptoms and are generally well tolerated. They have fewer side effects than some of the older medications. Patients tolerate these medications better when they start them at low doses and build up slowly. It is also important to withdraw these medications slowly when you are about to stop taking them to avoid withdrawal effects.

SNRIs

Example: Effexor XR (venlafaxine)

Effexor XR is a commonly used antidepressant. Like the SSRIs patients tolerate it better if they start on a low dose and build up slowly. People taking Effexor XR should have their blood pressure monitored regularly because this medication can cause an increase in blood pressure. The medication should be taken with food to reduce the chance of stomach upset. When Effexor XR is discontinued the dose should be reduces slowly.

Tetracyclic Antidepressants

Example: Maprotiline
Remeron (mirtazapine)

Remeron is a relatively new antidepressant on the market. It is sometimes used in patients who experience difficulty sleeping along with depression because it causes sedation. It causes less nausea or anxiety than the other newer agents. Because of the sedation it is important to be careful to wait until drowsiness has disappeared before operating a motor vehicle, dangerous machinery or participating in an activity requiring good focus. Sedation problems decrease after you have been on the medication for awhile and with increased doses, contrary to what one might expect. It is important to monitor for weight gain and increased cholesterol levels.

Tri-cyclic antidepressants

Example: Anafranil (clomipramine)
Aventyl (nortriptyline)
Elavil (amitriptyline)
Norpramin (desipramine)
Sinequan (doxepin)
Surmontil (trimipramine)
Tofranil (imipramine)

This is an older group of antidepressants still in use today. They are very effective and generally cheaper than the newer medications. However, they are less popular because they have more side effects such as dry mouth, drowsiness, dizziness and constipation. These medications should be started at low doses and built up slowly and when being stopped they should be tapered gradually.

Irreversible MAOIs

Example:Nardil (phenelzine)
Parnate (tranylcypromine)

MAOIs are one of the oldest classes of antidepressants. Like most antidepressants they are tolerated best when a patient goes on the medication at a low dose and builds up slowly. These medications are very effective but chosen when other newer medications have not worked because of their side effects and drug-food interactions. When combined with food containing high amounts of tryamine a patient can experience what is known as "hypertensive crisis". A hypertensive crisis is a rapid rise in blood pressure which can precipitate a stroke.

Foods high in tryamine include:

• Aged cheese
• Smoked meat
• Sour cream
• Pickled herring
• Soya sauce
• Canned figs
• Meat prepared with tenderizers
• Chocolate
• Red wines and beer
• Decongestants (Pseudephedrine, Phenylephrine)

Symptoms of hypertensive crisis include:

• A severe headache at the back of the head, possibly radiating forward
• Stiff neck
• Nausea, vomiting
• Sweating or cold and clammy skin
• Rapid heart rate
• Agitation
• Pale skin and then flushing
• Photophobia (extreme sensitivity to light)

It is important to withdraw MAOI medications slowly to prevent withdrawal effects.

Reversible Monoamine Oxidase Inhibitors (RIMA)

Example: Manerix (moclobomide)

Unlike the irreversible monoamine oxidase inhibitors, reversible monoamine oxidase inhibitors do not require the strict dietary restrictions. It is recommended that you avoid large quantities of foods containing tryamine and that you take the medication immediately after meals to minimize any tryamine related response to food.

Norepinephrine-Dopamine Reuptake Inhibitor (NDRI)

Example: Wellbutrin (bupropion)

A side effect of many antidepressants is sexual dysfunction. Wellbutrin does not cause sexual dysfunction and may improve sexual function. It may lower seizure threshold and therefore should not be used in people with seizure disorders or who are at risk for seizures such as people with bulimia, anorexia, or people undergoing withdrawal from alcohol or benzodiazepines. If you take more than 150 mg daily of this medication you should space the doses eight hours apart to prevent seizures. Wellbutrin can interfere with sleep so the last dose of the day should be taken no later than 4 PM to minimize sleep problems. The drug should be taken with food to avoid nausea. Tablets are formulated for slow release of the medication and therefore patients should not break, crush or chew the tablets.