Although prescription antidepressants have the most evidence for their use, there are over-the-counter medications and supplements that are recommended to treat the symptoms of depression. These include 5-HTP and SAMe, among others. These may not be clinically proven to work and may not be FDA approved or regulated. Talk to your doctor before trying any of these types of medicines or supplements.
Tricyclic antidepressants affect three brain chemicals. They are serotonin, norepinephrine, and dopamine. This is one of the oldest types of antidepressants. The drugs are effective but are used less often because of increased side effects. They take a long time to start working compared to SSRIs and SNRIs. These drugs are not used for older patients, people who have glaucoma, or men who have enlarged prostates.
You may find that taking antidepressants helps you feel happier and less worried, and that you can get back to your daily routine, enjoying work, hobbies, and socialising. Antidepressants can also help ease suicidal thoughts, and the impulse to self-harm.
Drowsiness and not feeling as alert can also be very common side effects when you first start taking antidepressants. Try not to put too much pressure on yourself, when you first start taking these medications, it can take your body a little bit of time to get used them.
In rare cases, antidepressants can cause an increase in suicidal thoughts and the impulse to self-harm. If you ever find yourself thinking of self-harming or having suicidal thoughts, contact your doctor or go to the hospital immediately.
You should only ever take your antidepressants as directed by the GP or specialist who prescribed them. There will also be lots of guidance in the patient information leaflet inside the packaging of your tablets.
Antidepressant drugs (often called \"antidepressants\") are widely used in Canada to treat depression and other mental health issues. It is important to take them as directed. Side effects are usually manageable, but stopping treatment suddenly can cause problems.
Even once you start to feel better, keep taking the antidepressant as directed by your health care provider. Most people take antidepressants for at least 6 to 12 months, and some for longer. Make sure you talk to your health care provider before you stop using yours.
All drugs, including antidepressants, have some risk of side effects, even if you use them as directed. For most people, these side effects are usually temporary and manageable. But some may be serious.
Clinical expertise is needed for more rapid or cross-taper switching as drug toxicity, including serotonin syndrome, may result from inappropriate co-administration of antidepressants. Some antidepressants must not be combined.
Antidepressant drugs are indicated for the treatment of depression, anxiety disorders (including panic and social phobia), obsessive compulsive disorder and post-traumatic stress disorder. There are over 20 antidepressants currently available in Australia. These can be divided into 13 clinically relevant groups, which differ substantially in their pharmacodynamic and pharmacokinetic characteristics.
Up to two-thirds of patients with major depression fail to respond to their first antidepressant drug. After assuring correct diagnosis, optimal dose, duration and adherence to treatment, a change of antidepressant drug is indicated.1A patient is unlikely to respond if there has been no improvement after three to four weeks on an adequate dose of antidepressant.2About a quarter of patients switched to a second antidepressant can be expected to achieve remission.3There is no evidence that switching between classes of antidepressants is more effective than switching within a class.4Unacceptable adverse effects from antidepressants, such as sexual dysfunction and weight gain, may also necessitate a change of therapy.5Switching from one antidepressant to another is a common clinical challenge.
Withdrawal of an antidepressant is also indicated after an episode of depression has been adequately treated - usually six to nine months after recovery from a single episode. Serious physical illness, pregnancy and surgery may also be reasons for stopping antidepressant therapy. Up to a third of patients stop antidepressants soon after starting and many more only partially adhere to treatment.6
If used for longer than six weeks, all antidepressants have the potential to cause withdrawal syndromes if they are stopped or rapidly reduced (with the possible exception of agomelatine). As a result many patients believe that antidepressants are addictive. This is not the case as abusive and compulsive use, tolerance and drug seeking do not occur with antidepressant drugs. Withdrawal syndromes occur with many drugs (such as corticosteroids) when used long term.
Venlafaxine is associated with the most severe withdrawal effects. Paroxetine is also troublesome while fluoxetine rarely causes withdrawal symptoms (especially if the dose is under 40 mg) due to the long half-life of the parent drug and its active metabolite (about 7 days). Withdrawal of tricyclic antidepressants can cause nausea, headache, abdominal pain, diarrhoea, lethargy, anxiety, insomnia and vivid dreams. It is unlikely that withdrawal symptoms will occur after cessation of low-dose tricyclics used in pain treatment. Withdrawing irreversible monoamine oxidase inhibitors such as tranylcypromine is particularly troublesome. It often causes agitation, irritability, mood disorders, dreams, cognitive impairment and occasionally psychosis and delirium.
Stopping antidepressants can also result in relapse or exacerbation of the psychiatric illness. Relapse of depressive symptoms (including suicidal ideation and self-harm) and recurrence of panic attacks and severe anxiety can all occur with dose reduction and cessation. Such exacerbations can cause life-threatening behaviours in high-risk patients, and antidepressant withdrawal must be a carefully considered decision made by the well-informed patient, often their family, and the prescriber. Avoid stopping an antidepressant abruptly - withdrawal over weeks to months (if possible) reduces the risk of relapse.2
A number of strategies are available for switching between antidepressants (Table 2).6,8 Close clinicalobservation and caution is required with all approaches, as some patients mayrespond idiosyncratically and serious complications can occur. Individualpatient factors and illness factors may require considerable modification of aswitching strategy.
The most conservative strategy, with the lowest risk of drug interactions, is to gradually taper the dose of the first antidepressant to minimise withdrawal symptoms then start a washout period equivalent to five half-lives of the drug (Table 1). This does not apply to irreversible monoamine oxidase inhibitors where a specified long period of washout is mandatory (see Table 3). Five half-lives equates to about five days for most SSRIs except fluoxetine, which can still be significantly active five or more weeks after cessation. The second antidepressant is then introduced according to the starting dose recommendations.
As the conservative switch can take quite a long time and usually includes at least several days where the patient is not on an antidepressant, a compromise strategy is the moderate switch. Here the washout period can generally be shortened to about two days. The risk of drug interactions is increased with this approach, but is still quite low. The conservative and moderate switch techniques are both suitable for general practice.
Table 3 lists generalised guidelines for switching patients from one antidepressant to another.2,8-10 The recommendations are applicable to any switching strategy. Circumstances where only a conservative strategy can be used are identified. Table 3 also states when antidepressants should not be co-administered or tapered at the same time.
As many antidepressants have serotonergic activity, serotonin syndrome can occur during antidepressant switching. While the syndrome may cause mild symptoms such as nervousness, agitation, tremor, diaphoresis, shivering, mydriasis, hyperreflexia and diarrhoea, in more severe cases tachycardia, hyperthermia, hypertension, myoclonus, muscular rigidity and delirium can occur. Convulsions, organ system failure and death may follow. Prevention through minimising interactions between potent serotonergic drugs is critical.11
The only significant interaction for agomelatine is with fluvoxamine (Table 3). Vortioxetine (an SSRI with possible other serotonergic effects) can interact with a variety of antidepressants. Caution is required for switching and the prescriber should consult relevant drug information before proceeding. The same caution applies to duloxetine (Table 3).
Fluoxetine is a particular challenge for switching because of its long half-life. Serotonin syndrome can occur if clomipramine, fluvoxamine or monoamine oxidase inhibitors are introduced before an adequate washout of fluoxetine, which can take five or more weeks. Tricyclic antidepressants can be introduced at a low dose after fluoxetine withdrawal. However, the low dose needs to be continued for several weeks to avoid cardiotoxic plasma concentrations of tricyclic