Depression currently affects the lives of about 16 million Americans, as estimated by the Centers for Disease Control and Prevention. While the range of therapeutic options is more varied and sophisticated than ever, antidepression drugs remain the go-to treatment around the country. In a recent study by the National Center for Health Statistics, roughly 13 percent of individuals over the age of 12 reported taking an antidepressant within the last month. This data set represents a nearly 65 percent increase in the overall use of antidepressants since the late 1990s and early 2000s. That’s quite the upward trend, especially when considered alongside the latest data on antidepressant efficacy.
While depression medication may work for some, many others do not receive adequate relief from their prescribed medication for depression. In fact, less thanone-third of patients respond to their first antidepressant, and only about25 percent of patients switching to a second antidepressant can expect to experience remission. Because many individuals who are prescribed drugs for depression do not experience relief with their first or even second trial of antidepression drugs, a pathway to recovery based solely on drug therapy may involve a frustrating amount of dosage guesswork and chemical trial-and-error.
Some have wondered, “Why, if the biological causes of depression are so varied, is such a singular approach taken to treat it?”
For those battling depression, this is a worthy question. Drug therapy is just one of the many treatment options to consider. If antidepressant medications have failed to treat your condition, there are other promising alternatives that can offer fewer side effects and quicker relief.
WHAT ARE SSRIS?
Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed depression medication currently on the market. SSRIs are designed to provide depression relief by positively impacting a patient’s brain chemistry. This kind of treatment focuses on the distribution and the reuptake of serotonin (one of many known neurotransmitters). Our brains use various neurotransmitters to pass chemical messages from one cell to another. Once a message has been delivered, these neurotransmitters are absorbed by the brain. SSRIs work by binding to serotonin transporters and then blocking the reuptake (absorption) of serotonin by the brain. This allows more serotonin to exist between neurons in the brain which, in theory, allows more serotonin to be transmitted to downstream neurons thus improving depressive symptoms.
Some of the most frequently prescribed and well-known SSRIs include Lexapro, Zoloft, Celexa, and Prozac. Compared with other types of antidepressants, SSRIs have fewer side effects and a lower risk of negative food and drug interactions. Common SSRI side effects include drowsiness, insomnia, restlessness, dizziness, nausea, headache, and blurred vision, among others. The most common long-term side effect of SSRIs are sexual side effects that can range from decreased libido to increased time to climax. The risk of nausea may be reduced for many patients by taking SSRIs with food.
It’s possible, though rare, for the increased serotonin levels produced by SSRIs to cause a condition known as serotonin syndrome.Serotonin syndrome usually occurs within a few hours of beginning an SSRI regimen or increasing an existing SSRI dosage. It can also result from an interaction between an SSRI and another medication. For example, over-the-counter products containingdextromethorphan (a drug commonly found in cough suppressants) may lead to serious toxicity when taken with certain SSRIs. Symptoms of serotonin syndrome include confusion, agitation, tremors, elevated heart rates, muscles spasms, changes in blood pressure, and others.
It’s important to note that some individuals are more likely to have a positive response to certain types of antidepressants than others. For example, according to multiplestudies, women tend to experience better results from SSRIs than men. On the other hand, due to differences in digestive system acidity between males and females, women may absorb SSRIs faster, leading to a potential toxicity increase.
Before stopping an SSRI regimen or switching to another depression medicine, you will need to discuss discontinuation steps with your doctor to prevent discontinuation syndrome. The abrupt cessation of an SSRI regimen may cause a depression relapse, alongside other negative effects including flu-like symptoms, insomnia, and nausea. To protect against discontinuation syndrome, you will need to taper off your antidepressant dosage steadily, under the direction of a medical professional.
If the first SSRI recommended by your doctor has not provided adequate relief, you may be prescribed a different type of antidepressant, to target different or additional neurotransmitters. Currently, thetotal number of neurotransmitters involved in human brain chemistry is not known, and neurologistsestimate that there are hundreds of neurotransmitters yet to be identified.
While SSRIs are predominantly considered a medication for depression, they may also be used to treat other conditions, which often present comorbidly in cases of depression. These conditions include, but are not limited to, generalized anxiety disorder, obsessive compulsive disorder, severe phobias, PTSD, and some eating disorders.
WHAT ARE SNRIS?
Similar to the overall function of SSRIs, serotonin and norepinephrine reuptake inhibitors (SNRIs) are designed to positively affect overall brain chemistry by increasing the available amount of specific neurotransmitters between cells. While SSRIs focus solely on inhibiting (blocking) the absorption (reuptake) of serotonin, SNRIs block the reabsorption of both serotonin and norepinephrine. Commonly prescribed SNRI depression medicines include Cymbalta, Effexor, Pristiq, Savella.
There are a few safety factors to consider and discuss with your doctor before starting SNRI drug therapy. For example, certain SNRIs may cause blood pressure fluctuations or increase your risk of liver damage. Your doctor may require a physical before prescribing a specific SNRI (or any other depression medicines for that matter) and will likely inquire about your personal and family medical history to minimize the risk of potential side effects.
SNRIs and SSRIs have similar side effects including nausea, sweating, dry mouth, insomnia, difficult urination, headache, reduced sexual arousal, and others. If you experience nausea or upset stomach soon after taking your medication for depression, your doctor may recommend scheduling your doses to coincide with meals.
The latest SSRIs and SNRIs aremore tolerable than the first wave of antidepressants made available in the mid-twentieth century (namely tricyclics). This superior safety and tolerability has allowed primary care physicians to treat a larger number of individuals suffering from depression. Nonetheless, effective depression management varies on a patient-by-patient basis, and for many individuals, cyclic antidepressants may offer superior relief when other medications have failed.
WHAT ARE TRICYCLIC ANTIDEPRESSANTS?
Tricyclic antidepressants (TCAs) are some of the earliest types of depression medications, first synthesized in the 1950s. Over the last 15 years, the use of TCAs as a medication for depression has decreased in favor of milder drug therapy options.
TCAs are designed toinhibit norepinephrine and serotonin presynaptic reuptake in the central nervous system. While TCAs may be less popular in modern psychopharmacology, they are still used to treat specific types of major depressive disorder, especially in cases where there has been no response toless toxic preliminary treatments.
TCAs offer many benefits when compared with more popular treatments used today. While some antidepressants may take over a month to begin to provide symptom relief, TCAs may only requiretwo to four weeks before patients can observe results.
Certain TCAs have shown promise in treating a host of conditions other than depression. Bothamitriptyline andnortriptyline, for example, are routinely used to treat nerve pain and nerve damage in adults. However, such neuropathic treatmentstypically involve lower doses than those used for antidepressant purposes.
Today, Amitril and Pamelor are two of the more common cyclic antidepressants currently prescribed. Amitril in particular is known for its high effectiveness. However, this antidepressant also comes with a rather lengthy list of intolerable side effects including confusion, unsteadiness, nightmares, burning in the hands or feet, and difficulty urinating.
Age also plays a pivotal role in determining treatment options. For example, according to a report by the Harvard Medical School, medical professionals may be more likely to prescribe SSRIs to older individuals suffering from major depressive disorder, rather than tricyclics. The reason for this is that tricyclics may cause arrhythmia, dizziness, and disorientation, resulting in falls and injuries. This medical opinion appears to be commonly held;according to Dr. Lauren J. Gleason, a physician at the Harvard-affiliated Brigham and Women’s Hospital, tricyclic antidepressants may be “inappropriate” for older patients, due to the numerous negative cognitive side effects (confusion, clouded thinking, and memory lapses).
These potential complications from tricyclic antidepressants are often the result of their anticholinergic properties.Anticholinergic drugs are used to block acetylcholine, a neurotransmitter involved inlearning and memory.
It’s worth noting again that some individuals are more likely to have a positive response to certain types of antidepressants than others. Just as women tend to respond more positively to SSRI antidepressant treatment than men, men statisticallyrespond better to the tricyclic class of antidepressants. As stated in a report by theScientific American, “Women have less binding capacity in their blood, meaning their blood proteins mop up fewer foreign substances. If taken with other drugs, certain tricyclic antidepressants (such as amitriptyline) could overflow into the bloodstream, potentially causing more side effects.”
WHAT ARE ATYPICAL ANTIDEPRESSANTS?
Atypical antidepressants act “atypically” (when compared to older SSRIs), because these atypical medications are designed to focus on more than one neurotransmitter. The latest atypical antidepressants (many of which were first released after the rollout ofSSRIs in the early 1990s and late 1980s) focus on increasing the amount of dopamine and norepinephrine in the brain.
It’s common for certain atypical antidepression drugs to be used to treat a host of other conditions, as well as major depressive disorder. These atypical medications have been used to treat insomnia, seasonal affective disorder, bipolar disorder, schizophrenia, and others. Bupropion in particular has also been used to aid individuals who are attempting to quit smoking. Wellbutrin, trazodone, and Remeron are just a few of the more popular atypical antidepressants on the market today.
Wellbutrin has been prescribed specifically as a medication for depression for more than20 years and is currently thefourth most commonly prescribed antidepressant in the United States. It is usually a third- or fourth-line depression treatment agent, perTherapeutic Advances in Psychopharmacology. Compared with SSRIs,studies have shown Wellbutrin to be more effective than SSRIs alone, and it is often used toenhance the performance of various SSRIs.
Trazodone, another common atypical antidepressant, is classified specifically as a serotonin antagonist and reuptake inhibitor (SARI). This class of medications has been used to treat major depressive disorder since the 1970s.
Mirtazapine, marketed as Remeron, was first synthesized in the Netherlands in the late 1980s and wasn’t introduced in the United States until 1996. Many antidepressants take up to six weeks to show results, and mirtazapine is known by contrast for its rapid symptom improvement. In fact, when specifically compared with patients taking SSRIs, those prescribed mirtazapine were74 percent more likely to experience remission within the first two weeks of treatment. Furthermore, in a separate drug trial, mirtazapine patients reported improvement “as early as the fourth day of treatment.” Due to this rapid response, mirtazapine is commonly prescribed for patients suffering fromcomorbid medical issues. It’s routinely used alongside other antidepressants, either tominimize side effects of the preliminary antidepression drug, or to improve the overall efficacy of the treatment.
Again, many atypical antidepressants are used in conjunction with antidepressants that have already been prescribed. For many, adding additional medications to an existing treatment strategy can feel daunting. Fortunately, if antidepressants have failed to offer symptom relief, there are options beyond traditional drug therapies.
TMS IS A TOLERABLE AND EFFECTIVE TREATMENT FOR DEPRESSION
As noted previously,two-thirds of individuals with depression do not achieve remission with their first antidepressant trial, and another one-third of patients may never remit throughsubsequent antidepressant trials.
There is no cure for depression, and that is likely due in part to the fact that depression is not fully understood from a biochemical perspective. There are numerous biological causes of depression, yet SSRIs and other antidepressants have become the literal first line of defense. Alan Gelenberg, a depression and psychiatric researcher at the Pennsylvania State University, recently raised questions about the predominance of SSRI treatment. “There’s really no evidence that depression is a serotonin-deficiency syndrome,”explained Gelenberg. “It’s like saying that a headache is an aspirin-deficiency syndrome.”
Antidepressant medication may offer moderate relief for some, but many patients struggle with negative pharmaceutical side effects. Depression treatment shouldn’t mean simply trading one symptom for another. You don’t have to tolerate the side effects of your depression medication just to experience minimal relief.
While antidepressants may take up to six weeks to offer any symptom relief, there are faster FDA-approved alternatives. With transcranial magnetic stimulation (TMS), many patients are able to identify positive results by the fourth week of treatment. TMS does not block the reuptake of neurotransmitters, but instead uses a magnetic field to stimulate brain cells in the prefrontal cortex. The most common side effect from TMS is mild discomfort or irritation along the scalp, and this can easily be treated with over-the-counter medications.
If you or a loved one are tired of trying antidepressant after antidepressant to no avail, it may be time to consider TMS, an easily tolerated, noninvasive depression therapy with a proven track record of effective depression relief and remission.
FAQ’S
What are SSRIs?
SSRI stands for selective serotonin reuptake inhibitors. These are the most common antidepressants. SSRIs block the absorption of serotonin to improve depressive symptoms.
What are SNRIs?
SNRI stands for serotonin and norepinephrine reuptake inhibitors.SNRIs block the reabsorption of both serotonin and norepinephrine.
What are TCAs?
TCA stands for tricyclic antidepressants. TCAs were first used in the 1950s. They are less prevalent today but still used particularly when symptoms have proved non-responsive to modern psychopharmacology.
What is TMS?
TMS stands for transcranial magnetic stimulation. It’s a treatment that uses magnets to stimulate the prefrontal cortex to promote brain cell activity to decrease depressive symptoms. It’s a drug free therapy with contraindications so limited that patients require no post-treatment monitoring and are able to drive home straight away.
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