What are antidepressants

Antidepressants are medicines that treat clinical depression. Your doctor can prescribe antidepressants for you. Antidepressants work to balance some of the natural chemicals in your brain. It may take several weeks for antidepressants to help. There are several types of antidepressants. You and your doctor may have to try a few before finding what works best for you.

Doctors often start by prescribing an selective serotonin reuptake inhibitor (SSRI). These medications generally cause fewer bothersome side effects and are less likely to cause problems at higher therapeutic doses than other types of antidepressants are. Selective serotonin reuptake inhibitors (SSRIs) include fluoxetine (Prozac), paroxetine (Paxil, Pexeva), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro).

Other types of antidepressants are serotonin and norepinephrine reuptake inhibitors (SNRIs). Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to selective serotonin reuptake inhibitors (SSRIs) and include venlafaxine and duloxetine.

Another antidepressant that is commonly used is bupropion. Bupropion is a third type of antidepressant which works differently than either selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs). Bupropion is also used to treat seasonal affective disorder and to help people stop smoking.

Selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and bupropion are popular because they do not cause as many side effects as older classes of antidepressants, and seem to help a broader group of depressive and anxiety disorders. Older antidepressant medications include tricyclics, tetracyclics, and monoamine oxidase inhibitors (MAOIs). For some people, tricyclics, tetracyclics, or monoamine oxidase inhibitors (MAOIs) may be the best medications.

Antidepressants can also be used to treat a number of other conditions, including:

• Obsessive compulsive disorder (OCD)
• Generalized anxiety disorder
• Post-traumatic stress disorder (PTSD)

Although antidepressants are not U.S. Food and Drug Administration (FDA) approved specifically to treat attention deficit hyperactivity disorder (ADHD), antidepressants are sometimes used to treat ADHD in adults.

Antidepressants are also sometimes used to treat people with long-term (chronic) pain.

Antidepressants may cause mild side effects that usually do not last long. These may include headache, nausea, sleep problems, restlessness, and sexual problems. Tell your doctor if you have any side effects. You should also let your doctor know if you take any other medicines, vitamins, or herbal supplements.

It is important to keep taking your antidepressants, even if you feel better. Do not stop taking your antidepressants without talking to your doctor. You often need to stop antidepressants gradually.

Other treatments for depression include talking therapies such as cognitive behavioral therapy (CBT). Increasingly, people with moderate to severe depression are treated using a combination of antidepressants and cognitive behavioral therapy (CBT). Antidepressants work quickly in reducing symptoms, whereas cognitive behavioral therapy (CBT) takes time to deal with causes of depression and ways of overcoming it.

Regular exercise has also been shown to be useful for those with mild depression.

What are the possible side effects of antidepressants?

Some antidepressants may cause more side effects than others. You may need to try several different antidepressant medications before finding the one that improves your symptoms and that causes side effects that you can manage.

The most common side effects listed by the FDA include:

• Nausea and vomiting
• Weight gain
• Diarrhea
• Sleepiness
• Sexual problems

Call your doctor right away if you have any of the following symptoms, especially if they are new, worsening, or worry you (U.S. Food and Drug Administration, 2011):

• Thoughts about suicide or dying
• Attempts to commit suicide
• New or worsening depression
• New or worsening anxiety
• Feeling very agitated or restless
• Panic attacks
• Trouble sleeping (insomnia)
• New or worsening irritability
• Acting aggressively, being angry, or violent
• Acting on dangerous impulses
• An extreme increase in activity and talking (mania)
• Other unusual changes in behavior or mood

Combining the newer selective serotonin reuptake inhibitor (SSRI) or serotonin-noradrenaline reuptake inhibitor (SNRI) antidepressants with one of the commonly-used “triptan” medications used to treat migraine headaches could cause a life-threatening illness called “serotonin syndrome.” A person with serotonin syndrome may be agitated, have hallucinations (see or hear things that are not real), have a high temperature, or have unusual blood pressure changes. Serotonin syndrome is usually associated with the older antidepressants called monoamine oxidase inhibitors (MAOIs), but it can happen with the newer antidepressants as well, if they are mixed with the wrong medications.

How long do they take to work?

Many people will start to feel better within two to four weeks after starting an antidepressant, but it can take up to eight weeks or longer for full effectiveness. In some people, they are not effective, no matter how long they are taken for. In general, you should see your healthcare provider at regular intervals to review your progress and discuss any issues related to treatment.

• Anybody who takes antidepressants should see their doctor regularly, especially in the first few weeks.

If you are not improving, your healthcare professional may discuss increasing your dose, switching to another antidepressant or referring you to another specialist.

If you are feeling better with antidepressant treatment you will usually need to keep taking it for 6 to 12 months to reduce the risk of your depression coming back. Having psychological therapy at the same time can further reduce the risk of your depression coming back. Some people may need to keep taking an antidepressant for a long time to prevent their symptoms coming back.

How long should I be on antidepressants?

Most people are advised to keep taking their antidepressant for at least six to twelve months after they start to feel better, to reduce the risk of symptoms returning. It’s important to discuss with your doctor about the best time to stop an antidepressant.

In some people, ongoing antidepressant treatment is recommended to maintain long-term control over their illness.

How do I stop taking antidepressants?

Slowly, and under a doctor’s supervision.

Stopping most antidepressants suddenly can result in unpleasant symptoms such as dizziness, nausea or feeling edgy.

It’s important to work closely with a doctor to lower the dose, stop or switch antidepressant medicines.

Are antidepressants addictive?

Antidepressants are not addictive, however it’s important to talk to a doctor before stopping them to avoid unpleasant side effects.

Types of antidepressants

There are several different types of antidepressants.

Selective serotonin reuptake inhibitors

Selective serotonin reuptake inhibitors (SSRIs) are the most widely prescribed type of antidepressants. They’re usually preferred over other antidepressants, as they cause fewer side effects. An overdose is also less likely to be serious.

Fluoxetine is probably the best known selective serotonin reuptake inhibitor (SSRI) (sold under the brand name Prozac). Other selective serotonin reuptake inhibitors (SSRIs) include citalopram (Celexa, Cipramil), escitalopram (Lexapro), paroxetine (Paxil, Pexeva, Seroxat) and sertraline (Zoloft, Lustral).

Serotonin-noradrenaline reuptake inhibitors

Serotonin-noradrenaline reuptake inhibitors (serotonin and norepinephrine reuptake inhibitors) are similar to selective serotonin reuptake inhibitors (SSRIs). They were designed to be a more effective antidepressant than selective serotonin reuptake inhibitors (SSRIs). However, the evidence that serotonin-noradrenaline reuptake inhibitors (SNRIs) are more effective in treating depression is uncertain. It seems that some people respond better to selective serotonin reuptake inhibitors (SSRIs), while others respond better to serotonin-noradrenaline reuptake inhibitors (SNRIs).

Examples of serotonin-noradrenaline reuptake inhibitors (SNRIs) include duloxetine (Cymbalta and Yentreve), venlafaxine (Efexor), desvenlafaxine (Pristiq, Khedezla) and levomilnacipran (Fetzima).

Atypical antidepressants

Atypical antidepressants includes tetracyclic analogues of mianserin (sometimes called noradrenergic and specific serotonergic antidepressant [NaSSA]): mirtazapine, may be effective for some people who are unable to take selective serotonin reuptake inhibitors (SSRIs). The side effects of noradrenaline and specific serotonergic antidepressants are similar to those of selective serotonin reuptake inhibitors (SSRIs), but they’re thought to cause fewer sexual problems. However, they may also cause more drowsiness at first.

The Food and Drug Administration (FDA) approved these atypical antidepressants to treat depression:

• Bupropion (Wellbutrin, Forfivo XL, Aplenzin), which under the name Zyban is used to aid in smoking cessation
• Mirtazapine (Remeron)
• Nefazodone
• Trazodone, which is also used to treat insomnia
• Vortioxetine (Trintellix)

The main noradrenaline and specific serotonergic antidepressant prescribed is mirtazapine (Remeron, Zispin), trazodone, vortioxetine (Trintellix), vilazodone (Viibryd) and bupropion (Wellbutrin, Aplenzin, Forfivo XL). Bupropion is one of the few antidepressants not frequently associated with sexual side effects.

Tricyclic antidepressants

Tricyclic antidepressants are an older type of antidepressant. They’re no longer usually recommended as the first treatment for depression because they can be more dangerous if an overdose is taken. They also cause more unpleasant side effects than selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs).

Exceptions are sometimes made for people with severe depression that fail to respond to other treatments. Tricyclic antidepressants may also be recommended for other mental health conditions, such as OCD (obsessive compulsive disorder) and bipolar disorder.

Examples of tricyclic antidepressants include amitriptyline (Tryptizol), clomipramine (Anafranil), doxepin, imipramine (Tofranil), desipramine (Norpramin), lofepramine (Gamanil) and nortriptyline (Pamelor, Allegron).

Some types of tricyclic antidepressants, such as amitriptyline, can also be used to treat chronic nerve pain.

Tetracyclic antidepressants

Mianserin and Maprotiline.

Monoamine oxidase inhibitors

Monoamine oxidase inhibitors (MAOIs) are an older type of antidepressant that are rarely used nowadays.

They can cause potentially serious side effects so should only be prescribed by a specialist doctor and often when other medications haven’t worked. Using an monoamine oxidase inhibitor requires a strict diet because of dangerous (or even deadly) interactions with foods — such as certain cheeses, pickles and wines — and some medications, including birth control pills, decongestants and certain herbal supplements. Selegiline (Emsam), an monoamine oxidase inhibitor that you stick on your skin as a patch, may cause fewer side effects than other monoamine oxidase inhibitors. These medications can’t be combined with selective serotonin reuptake inhibitors (SSRIs).

Examples of monoamine oxidase inhibitors include tranylcypromine (Parnate), phenelzine (Nardil) and isocarboxazid (Marplan).

Melatonergic antidepressants

Agomelatine a melatonin receptor agonist.

Reversible inhibitors of monoamine oxidase A

Moclobemide is used to treat depression and social phobia.

How do antidepressants work

Experts don’t not know exactly how antidepressants work. It’s thought antidepressants work by increasing levels of chemicals in your brain called neurotransmitters. Certain neurotransmitters, such as serotonin, noradrenaline (norepinephrine) and dopamine, are linked to mood and emotion. Serotonin is one of the neurotransmitters (brain chemicals) that transmit signals between cells in your brain. Serotonin, along with other neurotransmitters such as noradrenaline and dopamine, are thought to have an important effect on your mood. Different neurotransmitters control different functions — often more than one. The role of neurotransmitters in causing depression is not fully understood.

Most antidepressants relieve depression by affecting these neurotransmitters. Antidepressants increase the amount of certain neurotransmitters, and this is how they are thought to reduce the symptoms of depression. Each type (class) of antidepressant affects these neurotransmitters in slightly different ways.

Neurotransmitters may also affect pain signals sent by nerves, which may explain why some antidepressants can help relieve long-term pain.

While antidepressants can treat the symptoms of depression, they don’t always address its causes. This is why they’re usually used in combination with therapy to treat more severe depression or other mental health conditions.

Is there such a thing as antidepressant withdrawal?

Antidepressant withdrawal is possible if you abruptly stop taking an antidepressant, particularly if you’ve been taking it longer than six weeks. Symptoms of antidepressant withdrawal are sometimes called antidepressant discontinuation syndrome and typically last for a few weeks. Certain antidepressants are more likely to cause withdrawal symptoms than others.

Quitting an antidepressant suddenly may cause symptoms within a day or two, such as:

• Anxiety
• Insomnia or vivid dreams
• Headaches
• Dizziness
• Tiredness
• Irritability
• Flu-like symptoms, including achy muscles and chills
• Nausea
• Electric shock sensations
• Return of depression symptoms

Having antidepressant withdrawal symptoms doesn’t mean you’re addicted to an antidepressant. Addiction represents harmful, long-term chemical changes in the brain. It’s characterized by intense cravings, the inability to control your use of a substance and negative consequences from that substance use. Antidepressants don’t cause these issues.

To minimize the risk of antidepressant withdrawal, talk with your doctor before you stop taking an antidepressant. Your doctor may recommend that you gradually reduce the dose of your antidepressant for several weeks or more to allow your body to adapt to the absence of the medication.

In some cases, your doctor may prescribe another antidepressant or another type of medication on a short-term basis to help ease symptoms as your body adjusts. If you’re switching from one type of antidepressant to another, your doctor may have you start taking the new one before you completely stop taking the original medication.

It’s sometimes difficult to tell the difference between withdrawal symptoms and returning depression symptoms after you stop taking an antidepressant. Keep your doctor informed of your signs and symptoms. If your depression symptoms return, your doctor may recommend that you start taking an antidepressant again or that you get other treatment.

How effective are antidepressants?

Research suggests that antidepressants can be helpful for people with moderate or severe depression. Antidepressants are more effective for reducing symptoms in people with moderate or severe depression, rather than mild depression. Psychological therapies, such as cognitive behavioral therapy (CBT), are more effective than antidepressants for mild depression, and about equally effective for moderate depression, although the effects of cognitive behavioral therapy (CBT) may last longer.

Studies ¹, ² have shown that antidepressants better than placebo (“dummy medicine”) for people with these conditions.

They’re not usually recommended for mild depression, unless other treatments like therapy haven’t helped.

The Royal College of Psychiatrists estimates that 50 to 65% of people treated with an antidepressant for depression will see an improvement, compared to 25 to 30% of those taking a placebo.

In clinical trials studying the effects of antidepressants, some people who took a placebo (an inactive, or sugar, pill) also felt better – about 30% of the placebo group found their symptoms were halved.

Placebos can have an effect because of the expectation of getting better, and because of other factors such as talking to the staff running the clinical trial. It may also be that some people improve over time anyway, regardless of treatment. This could be the case particularly with trials that recruited people with mild depression.

According to a research review by the Agency for Healthcare Research and Quality ³, all antidepressant medications work about as well as each other to improve symptoms of depression and to keep depression symptoms from coming back. For reasons not yet well understood, some people respond better to some antidepressant medications than to others.

Therefore, it is important to know that some people may not feel better with the first medicine they try and may need to try several medicines to find the one that works for them. Others may find that a medicine helped for a while, but their symptoms came back. It is important to carefully follow your doctor’s directions for taking your medicine at an adequate dose and over an extended period of time (often 4 to 6 weeks) for it to work.

Once a person begins taking antidepressants, it is important to not stop taking them without the help of a doctor. Sometimes people taking antidepressants feel better and stop taking the medication too soon, and the depression may return. When it is time to stop the medication, the doctor will help the person slowly and safely decrease the dose. It’s important to give the body time to adjust to the change. People don’t get addicted (or “hooked”) on these medications, but stopping them abruptly may also cause withdrawal symptoms.

Can antidepressants stop working?

When depression symptoms improve after starting an antidepressant, many people need to continue taking medication long term to prevent symptoms from returning.

However, in some people, a particular antidepressant may simply stop working over time. Doctors don’t fully understand what causes the so-called “poop-out” effect or antidepressant tolerance — known as tachyphylaxis — or why it occurs in some people and not in others.

There also can be other reasons an antidepressant is no longer working for you, such as:

• Worsening depression. It’s common for depression symptoms to return or worsen at some point, despite treatment. Called breakthrough depression, symptoms may be triggered by stress or appear with no apparent cause. The current dose of medication you’re taking may not be enough to prevent your symptoms when depression gets worse.
• Another medical condition. Underlying health problems, such as hypothyroidism, can cause or worsen depression.
• A new medication. Some medications for unrelated conditions can interfere with the way your body breaks down and uses antidepressants, decreasing their effectiveness.
• Undiagnosed bipolar disorder. Bipolar disorder, formerly called manic-depressive disorder, causes periodic mood swings. While an antidepressant is sometimes used to treat bipolar disorder, a mood-stabilizing or antipsychotic medication is generally needed along with an antidepressant to keep emotional highs and lows in check.
• Age. In some people, depression gets worse with age. As you get older, you may have changes in your brain and thinking (neurological changes) that affect your mood. In addition, the manner in which your body processes medications may be less efficient. You’re also likely to be taking more medications. All of these factors can play a role in depression.

In most cases, depression symptoms get better with adjustments to medication. Your doctor may recommend that you change the dose of your current antidepressant, change to another antidepressant or add another antidepressant or other type of medication to your current treatment. Psychological counseling (psychotherapy) also may help.

Because there are so many reasons depression treatment can stop working, you may need to see a medical doctor who specializes in diagnosing and treating mental illness (psychiatrist) to figure out the best course of action.

Antidepressant doses and duration of treatment

Antidepressants are usually taken in tablet form. When they’re prescribed, you’ll start on the lowest possible dose thought necessary to improve your symptoms.

Antidepressants usually need to be taken for 1 or 2 weeks (without missing a dose) before the benefit starts to be felt. It’s important not to stop taking them if you get some mild side effects early on, as these effects usually wear off quickly.

If you take an antidepressant for 4 weeks without feeling any benefit, speak to your doctor or mental health specialist. They may recommend increasing your dose or trying a different medicine.

A course of treatment usually lasts at least 6 months. Some people with recurrent depression may be advised to take them indefinitely.

Antidepressants dosage

When prescribing antidepressants, your doctor usually selects the lowest possible dose thought necessary to improve your symptoms. This approach is intended to reduce the risk of side effects. If this dose doesn’t work, it can be gradually increased.

Antidepressants are usually taken in tablet form. Depending on the type of antidepressant prescribed and the severity of your depression, you’ll usually have to take 1 to 3 tablets a day.

It usually takes around 7 days before you begin to notice the effects of antidepressants. Contact your doctor if you haven’t noticed any improvement after 4 weeks, as they may recommend increasing your dose or trying a different antidepressant.

It’s usually recommended that a course of antidepressants lasts at least 6 months, to prevent your condition recurring when you stop. Some people with recurrent illness are advised to carry on taking medicine indefinitely.

The recommended course of treatment largely depends on weighing up the benefits of the medicine against the side effects. If your illness is severe and the medicine is effective, treatment will often be continued. If your illness is mild and the medicine doesn’t help and causes side effects, continued treatment won’t be recommended.

Missed or extra doses

It’s important not to miss any of your doses, as this could make your treatment less effective.

If you do miss 1 of your doses, take it as soon as you remember, unless it’s almost time to take your next dose. In this case, you should just skip the missed dose. Don’t take a double dose to “make up” for the 1 you missed. Taking a double dose is unlikely to be harmful, but you should only do so if advised by a medical professional.

Antidepressants uses

The main use for antidepressants is treating clinical depression in adults. Antidepressants are also used for other mental health conditions and treatment of long-term pain.

In most cases, adults with moderate to severe depression are given antidepressants as a first form of treatment. Antidepressants are often prescribed along with a talking therapy (psychotherapy) such as cognitive behavioral therapy (CBT). Cognitive behavioral therapy (CBT) is a type of therapy that uses a problem-solving approach to help improve thought, mood and behavior.

Antidepressants aren’t always recommended for treating mild depression because research has found limited effectiveness. However, antidepressants are sometimes prescribed for a few months for mild depression to see if you experience any improvement in your symptoms. If you don’t see any benefits in this time, the antidepressant will be slowly withdrawn.

Initially, a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI) is usually prescribed. If your symptoms haven’t improved after about 4 weeks, an alternative antidepressant may be recommended or your dose may be increased.

Many antidepressants can be prescribed by your doctor, but some types can only be used under the supervision of a mental health professional. If the depression doesn’t respond to antidepressants alone, other treatments, such as cognitive behavioral therapy (CBT), may also be used to help achieve better results. Doctors (psychiatrists) may also give higher doses of the antidepressant.

Children and young people

Children and young people with moderate to severe depression should first be offered a course of psychotherapy that lasts for at least 3 months.

In some cases, an selective serotonin reuptake inhibitor (SSRI) called fluoxetine may be offered in combination with psychotherapy to treat moderate to severe depression in young people aged 12 to 18.

Other mental health conditions

Antidepressants can also be used to help treat other mental health conditions, including:

• Anxiety disorder
• Obsessive compulsive disorder (OCD)
• Panic disorder
• Serious phobias, such as agoraphobia and social phobia
• Bulimia
• Post traumatic stress disorder (PTSD)

As with depression, selective serotonin reuptake inhibitors (SSRIs) are usually the first choice of treatment for these conditions. If selective serotonin reuptake inhibitors (SSRIs) prove ineffective, another type of antidepressant can be used.

Long-term pain

Even though a type of antidepressant called tricyclic antidepressants weren’t originally designed to be painkillers, there’s evidence to suggest they’re effective in treating chronic (long-term) nerve pain in some people.

Chronic nerve pain, also known as neuropathic pain, is caused by nerve damage or other problems with the nerves, and is often unresponsive to regular painkillers, such as paracetamol.

Amitriptyline is a tricyclic antidepressant that’s usually used to treat neuropathic pain. Conditions that may benefit from treatment with amitriptyline include:

• Complex regional pain syndrome
• Peripheral neuropathy
• Multiple sclerosis (MS)
• Conditions where a nerve becomes trapped, such as sciatica

Antidepressants have also been used to treat cases of chronic pain that don’t involve nerves (non-neuropathic pain). However, they’re thought to be less effective for this purpose. As well as tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) can also be used to treat chronic non-neuropathic pain.

Conditions that cause non-neuropathic pain which may benefit from treatment with antidepressants include fibromyalgia, chronic back pain and chronic neck pain.

Bedwetting in children

Tricyclic antidepressants are sometimes used to treat bed wetting in children, as they can help relax the muscles of the bladder. This increases bladder capacity and reduces the urge to urinate.

How to select one antidepressant that’s right for you?

Finding the right antidepressant

There are a number of antidepressants available that work in slightly different ways and have different side effects. When prescribing an antidepressant that’s likely to work well for you, your doctor may consider:

• Your particular symptoms. Symptoms of depression can vary, and one antidepressant may relieve certain symptoms better than another. For example, if you have trouble sleeping, an antidepressant that’s slightly sedating may be a good option.
• Possible side effects. Side effects of antidepressants vary from one medication to another and from person to person. Bothersome side effects, such as dry mouth, weight gain or sexual side effects, can make it difficult to stick with treatment. Discuss possible major side effects with your doctor or pharmacist.
• Whether it worked for a close relative. How a medication worked for a first-degree relative, such as a parent or sibling, can indicate how well it might work for you. Also, if an antidepressant has been effective for your depression in the past, it may work well again.
  Interaction with other medications. Some antidepressants can cause dangerous reactions when taken with other medications.
• Pregnancy or breastfeeding. A decision to use antidepressants during pregnancy and breast-feeding is based on the balance between risks and benefits. Overall, the risk of birth defects and other problems for babies of mothers who take antidepressants during pregnancy is low. Still, certain antidepressants, such as paroxetine (Paxil, Pexeva), may be discouraged during pregnancy. Work with your doctor to find the best way to manage your depression when you’re expecting or planning on becoming pregnant.
• Other health conditions. Some antidepressants may cause problems if you have certain mental or physical health conditions. On the other hand, certain antidepressants may help treat other physical or mental health conditions along with depression. For example, bupropion (Wellbutrin, Aplenzin, Forfivo XL) may help relieve symptoms of both attention-deficit/hyperactivity disorder (ADHD) and depression. Other examples include using duloxetine (Cymbalta) to help with pain symptoms or fibromyalgia, or using amitriptyline to prevent migraines.
• Cost and health insurance coverage. Some antidepressants can be expensive, so it’s important to ask if there’s a generic version available and discuss its effectiveness. Also find out whether your health insurance covers antidepressants and if there are any limitations on which ones are covered.

Stopping antidepressants

You shouldn’t suddenly stop taking antidepressants, even if you feel better. Stopping suddenly can lead to withdrawal symptoms, such as:

• stomach upsets
• flu-like symptoms
• anxiety
• dizziness
• sensations in the body that feel like electric shocks
• seizures (fits)

Coming off antidepressants too soon can cause your condition to return. Stopping before you have been taking them for 4 weeks may mean the medicine hasn’t had a chance to take effect.

If your doctor or mental health specialist decides to stop your course of antidepressants, they’ll reduce the dose gradually over a few weeks.

Side effects of antidepressants

The side effects of antidepressants can cause problems at first, but then generally improve with time. It’s important to continue your treatment, even if you’re affected by side effects, as it will take several weeks before you begin to benefit from the treatment. With time, you should find that the benefits of antidepressant outweigh any problems from side effects.

During the first few months of treatment, you’ll usually see your doctor or a specialist at least once every 2 to 4 weeks to see how well the antidepressant is working.

For more information about your specific medicine and its side effects, see the patient information leaflet that comes with it.

Selective serotonin reuptake inhibitors and serotonin-noradrenaline reuptake inhibitors

Common side effects of selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) can include:

• feeling agitated, shaky or anxious
• feeling and being sick
• indigestion and stomach aches
• diarrhea or constipation
• loss of appetite
• dizziness
• not sleeping well (insomnia), or feeling very sleepy
• headaches
• low sex drive
• difficulties achieving orgasm during sex or masturbation
• in men, difficulties obtaining or maintaining an erection (erectile dysfunction)

These side effects should improve within a few weeks, although some can occasionally persist.

Atypical antidepressants

Side effects may occur with antidepressants, including atypical antidepressants, though some people may not experience any. Some side effects may go away after a time, while others may lead you and your doctor to try a different medication.

Because of the different ways atypical antidepressants work, each has unique characteristics and varying possible side effects. For example:

• Most of the atypical antidepressants list dry mouth, dizziness or lightheadedness as possible side effects.
• Some antidepressants may help you sleep and are best taken at night, while others may cause insomnia.
• Some antidepressants may cause constipation, while others may increase the risk of diarrhea.
• Some antidepressants may increase your appetite, resulting in weight gain, while others may cause nausea.
• Some antidepressants are less likely than others to cause sexual side effects.

Which antidepressant is best for you depends on a number of issues, such as your symptoms and any other health conditions you may have. Ask your doctor and pharmacist about the most common possible side effects for your specific antidepressant and read the patient medication guide that comes with the prescription.

Safety issues

Atypical antidepressants are safe for most people. However, in some circumstances they can cause problems. For example:

• Bupropion should not be used by people who have a seizure disorder or an eating disorder such as bulimia or anorexia.
• Mirtazapine has been associated with an increase in cholesterol.
• Nefazodone has been linked to liver failure in some people ― don’t take it if you already have liver problems.
• Trazodone has been associated with rare cases of priapism — a persistent, usually painful erection not associated with sexual arousal. In rare cases, trazodone has been linked to heart rhythm problems (cardiac arrhythmias), so if you have heart disease, ask your doctor whether this medication is safe for you.
• Vortioxetine may increase the risk of bleeding, especially in people taking other medications that can increase the risk of bleeding.

For antidepressants that cause sleepiness, be careful about doing activities that require you to be alert, such as driving a car, until you know how the medication will affect you.

Other issues to discuss with your doctor before you take an atypical antidepressant include:

• Antidepressants and pregnancy. Talk to your doctor about the risks and benefits of using specific antidepressants. Some antidepressants may harm your baby if you take them during pregnancy or while you’re breast-feeding. If you’re taking an antidepressant and you’re considering getting pregnant, talk to your doctor or mental health professional about the possible risks. Don’t stop taking your medication without contacting your doctor first, as stopping might pose risks for you.
• Drug interactions. When taking an antidepressant, be sure to tell your doctor about any other prescription or over-the-counter medications, herbs or other supplements you’re taking. Some antidepressants can cause dangerous reactions when combined with certain medications or herbal supplements.
• Serotonin syndrome. Rarely, an antidepressant can cause high levels of serotonin to accumulate in your body. Serotonin syndrome most often occurs when two medications that raise the level of serotonin are combined. These include other antidepressants, certain pain or headache medications, and the herbal supplement St. John’s wort. Symptoms of serotonin syndrome include anxiety, agitation, sweating, confusion, tremors, restlessness, lack of coordination and a rapid heart rate. Seek immediate medical attention if you have any of these symptoms.

Tricyclic antidepressants

Common side effects of tricyclic antidepressants can include:

• dry mouth
• slight blurring of vision
• constipation
• problems passing urine
• drowsiness
• dizziness
• increased appetite leading to weight gain
• weight loss
• excessive sweating (especially at night)
• tremor
• sexual problems, such as difficulty achieving an erection, delayed orgasm or low sex drive
• heart rhythm problems, such as noticeable palpitations or a fast heartbeat (tachycardia)

The side effects should ease after a couple of weeks as your body begins to get used to the medicine.

Generally speaking:

• Amitriptyline, doxepin, imipramine and trimipramine are more likely to make you sleepy than other tricyclic antidepressants are. Taking these medications at bedtime may help.
• Amitriptyline, doxepin and imipramine are more likely to cause weight gain than other tricyclic antidepressants are.
• Nortriptyline and desipramine appear to have better tolerated side effects than other tricyclic antidepressants do.

Which antidepressant is best for you depends on a number of issues, such as your symptoms and any other health conditions you may have. Ask your doctor and pharmacist about the most common possible side effects for your specific antidepressant and read the patient medication guide that comes with the prescription.

Safety issues

Some tricyclic antidepressants are more likely to cause side effects that affect safety, such as:

• Disorientation or confusion, particularly in older people when the dosage is too high
• Increased or irregular heart rate
• More-frequent seizures in people who have seizures

Other issues to discuss with your doctor before you take a cyclic antidepressant:

• Antidepressants and pregnancy. Talk to your doctor about the risks and benefits of using specific antidepressants. Some antidepressants may harm your baby if you take them during pregnancy or while you’re breast-feeding. If you’re taking an antidepressant and you’re considering getting pregnant, talk to your doctor or mental health professional about the possible risks. Don’t stop taking your medication without contacting your doctor first, as stopping might pose risks for you.
• Drug interactions. When taking an antidepressant, tell your doctor about any other prescription or over-the-counter medications, herbs or other supplements you’re taking. Some antidepressants can cause dangerous reactions when combined with certain medications or herbal supplements.
• Serotonin syndrome. Rarely, an antidepressant can cause high levels of serotonin to accumulate in your body. Serotonin syndrome most often occurs when two medications that raise the level of serotonin are combined. These include other antidepressants, certain pain or headache medications, and the herbal supplement St. John’s wort. Signs and symptoms of serotonin syndrome include anxiety, agitation, sweating, confusion, tremors, restlessness, lack of coordination and a rapid heart rate. Seek immediate medical attention if you have any of these signs and symptoms.
• Safety and blood tests. Your doctor may recommend blood levels to determine the most effective dose. Some side effects and benefits of cyclic antidepressants depend on the dose. Overdose of cyclic antidepressants can be dangerous.
• Chronic health conditions. Cyclic antidepressants can cause problems in people with certain health conditions. For example, if you have glaucoma, an enlarged prostate, heart problems, diabetes, liver disease or a history of seizures, talk to your doctor about whether a cyclic antidepressant is a safe choice for you.

Serotonin syndrome

Serotonin syndrome is an uncommon, but potentially serious, set of side effects linked to selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs).

Serotonin syndrome occurs when the levels of a chemical called serotonin in your brain become too high. It’s usually triggered when you take an selective serotonin reuptake inhibitor (SSRI) or serotonin-noradrenaline reuptake inhibitor (SNRI) in combination with another medicine (or substance) that also raises serotonin levels, such as another antidepressant or St John’s Wort.

Symptoms of serotonin syndrome can include:

• confusion
• agitation
• muscle twitching
• sweating
• shivering
• diarrhea

If you experience these symptoms, you should stop taking the medicine and seek immediate advice from your doctor or specialist.

Symptoms of severe serotonin syndrome include:

• seizures (fits)
• irregular heartbeat (arrhythmia)
• unconsciousness

If you experience symptoms of severe serotonin syndrome, seek emergency medical help immediately by dialing your local emergency services number to ask for an ambulance.

Hyponatremia

Elderly people who take antidepressants, particularly those who take selective serotonin reuptake inhibitors (SSRIs), may experience a severe fall in sodium (salt) levels, known as hyponatremia. This may lead to a build-up of fluid inside the cells of the body, which can be potentially dangerous.

This can happen because selective serotonin reuptake inhibitors (SSRIs) can block the effects of a hormone that regulates levels of sodium and fluid in the body. Elderly people are vulnerable because fluid levels become more difficult for the body to regulate as people age.

Mild hyponatremia can cause symptoms similar to depression or side effects of antidepressants, such as:

• feeling sick
• headache
• muscle pain
• reduced appetite
• confusion

More severe hyponatremia can cause:

• feeling listless and tired
• disorientation
• agitation
• psychosis
• seizures (fits)

The most serious cases of hyponatremia can cause you to stop breathing or enter a coma.

If you suspect mild hyponatremia, you should call your doctor for advice and stop taking selective serotonin reuptake inhibitors (SSRIs) for the time being.

If you suspect severe hyponatremia, call your local emergency services number and ask for an ambulance.

Hyponatremia can be treated by feeding a sodium solution into the body through an intravenous drip.

Diabetes

Long-term use of selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants has been linked to an increased risk of developing type 2 diabetes, although it’s not clear if the use of these antidepressants directly causes diabetes to develop.

It may be that the weight gain some people using antidepressants experience increases the risk of them developing type 2 diabetes.

Suicidal thoughts and risk of suicide

Most antidepressants are generally safe, but the Food and Drug Administration (FDA) requires that all antidepressants carry black box warnings, the strictest warnings for prescriptions. In some cases, children, teenagers and young adults under 25 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed.

Anyone taking an antidepressant should be watched closely for worsening depression or unusual behavior. If you or someone you know has suicidal thoughts when taking an antidepressant, immediately contact your doctor or get emergency help.

Keep in mind that antidepressants are more likely to reduce suicide risk in the long run by improving mood.

However, in rare cases, some people experience suicidal thoughts and a desire to self-harm when they first take antidepressants. Young people under 25 seem particularly at risk.

Contact your doctor, or go to hospital immediately, if you have thoughts of killing or harming yourself at any time while taking antidepressants.

It may be useful to tell a relative or close friend if you’ve started taking antidepressants and ask them to read the leaflet that comes with your medicines. You should then ask them to tell you if they think your symptoms are getting worse, or if they’re worried about changes in your behavior.

Antidepressant precautions

There are several important things to consider when taking antidepressants. You should discuss these with your doctor or mental health professional.

Interactions with other medicines

Antidepressants can react unpredictably with other medicines, including some over-the-counter medicines such as ibuprofen. Always read the patient information leaflet that comes with your medicine to see if there are any medicines you should avoid.

If in doubt, your pharmacist or doctor should be able to advise you.

Pregnancy

As a precaution, antidepressants aren’t usually recommended for most pregnant women, especially during the early stages of a pregnancy.

This is because they might be dangerous for your baby. But exceptions can be made if the risks posed by depression (or other mental health conditions) outweigh any potential risks of treatment.

If you’re pregnant and depressed, you should discuss the pros and cons of antidepressants with the doctor in charge of your care.

Breastfeeding

As a precaution, the use of antidepressants if you’re breastfeeding isn’t usually recommended. However, there are circumstances when both the benefits of treatment for depression (or other mental health conditions) and the benefits of breastfeeding your baby outweigh the potential risks. Speak to your doctor for advice.

Children and young people

The use of antidepressants isn’t usually recommended in children and young people under the age of 18. This is because there’s evidence that, in rare cases, they can trigger thoughts about suicide and acts of self-harm in this age group.

Concerns have also been raised that their use could affect the development of the brain in children and young people.

An exception can usually only be made if the following points are met:

• the person being treated has failed to respond to talking therapies such as cognitive behavioral therapy, and
• the person being treated will continue to receive talking therapies in combination with antidepressants, and
• the treatment is supervised by a psychiatrist (a doctor who specializes in treating mental health conditions)

Alcohol

You should be wary of drinking alcohol if you’re taking antidepressants, as alcohol is itself a depressant and drinking alcohol can make your symptoms worse.

If you drink alcohol while taking types of antidepressants called tricyclic antidepressants (TCAs) or monoamine oxidase inhibitors (MAOIs), you may become drowsy and dizzy.

You’re less likely to experience unpleasant or unpredictable effects if you drink alcohol while taking an selective serotonin reuptake inhibitor (SSRI) or a serotonin-noradrenaline reuptake inhibitor (SNRI) antidepressant, but avoiding alcohol is often still recommended.

Illegal drugs

The use of illegal drugs isn’t recommended if you’re taking antidepressants, particularly if you’ve been prescribed a tricyclic antidepressant. This is because they can cause unpredictable and unpleasant effects.

In particular, you should avoid taking:

• cannabis – smoking cannabis while taking a tricyclic antidepressant can make you feel very ill
• amphetamines (speed)
• cocaine
• heroin
• ketamine

As with alcohol, illegal drugs can make symptoms of depression or other mental health conditions worse.

Other antidepressants

You should never take 2 different types of antidepressants, such as an selective serotonin reuptake inhibitor (SSRI) and a tricyclic antidepressant, unless advised by a doctor. This is because taking certain combinations of antidepressants can make you feel very ill and can be life-threatening.

If a decision is taken to switch you from 1 type to another, the dosage of the first antidepressant will usually be gradually reduced before the second is started.

St John’s Wort

St John’s Wort is a popular herbal remedy promoted for the treatment of depression. While there’s evidence of its effectiveness, many experts advise against its use, because the amount of active ingredient varies among individual brands and batches, making the effects unpredictable.

Taking St John’s Wort with other medicines, such as anticonvulsants, anticoagulants, antidepressants and the contraceptive pill, can also cause serious health problems.

You shouldn’t take St John’s Wort if you’re pregnant or breastfeeding, as it’s unclear whether it’s safe.

Driving and operating machinery

Some antidepressants can cause dizziness, drowsiness and blurred vision, particularly when you first start taking them.

If you do experience these problems, you should avoid driving or using tools and machinery.

Cautions for selective serotonin reuptake inhibitors

Selective serotonin reuptake inhibitors (SSRIs) may not be suitable if you have:

• bipolar disorder and you’re in a manic phase (a period where you’re extremely excitable), although they can be useful for depressive phases
• a bleeding disorder, or if you’re taking medicines that make it more likely you may bleed (such as warfarin)
• type 1 diabetes and type 2 diabetes
• epilepsy – selective serotonin reuptake inhibitors (SSRIs) should only be taken if your epilepsy is well controlled, and the medicine should be stopped if your epilepsy gets worse
• kidney disease

Cautions for serotonin-noradrenaline reuptake inhibitors

Serotonin-noradrenaline reuptake inhibitor (SNRI) may not be suitable if you have a history of heart disease or you have poorly controlled high blood pressure.

Cautions for tricyclic antidepressants

Tricyclic antidepressants may not be suitable if you have:

• a history of heart disease
• recently had a heart attack
• liver disease
• an inherited blood disorder called porphyria
• bipolar disorder
• schizophrenia
• a growth on your adrenal glands that is causing high blood pressure (pheochromocytoma)
• an enlarged prostate gland
• narrow angle glaucoma – increased pressure in the eye
• epilepsy

What are alternatives to antidepressants?

Several treatments can be used instead of antidepressants for treating depression and other mental health conditions.

Talking therapies

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a type of talking therapy that’s increasingly being used in the treatment of depression. Most experts recommend that people with moderate to severe depression are treated with a combination of cognitive behavioral therapy and antidepressants.

However, if you’re unable or unwilling to take antidepressants, you have the option of receiving cognitive behavioral therapy on its own.

Cognitive behavioral therapy (CBT) helps you understand your thoughts and behaviour, and how they affect you. It helps you recognise that events in your past may have shaped you, but it concentrates mostly on how you can change the way you think, feel and behave in the present. It also teaches you how to overcome negative thoughts.

You normally have a short course of sessions, usually 6 to 8 sessions, over 10 to 12 weeks, on a one-to-one basis, with a therapist trained in cognitive behavioral therapy. In some cases, you may be offered group cognitive behavioral therapy.

Online cognitive behavioral therapy

Computerised cognitive behavioral therapy is a form of cognitive behavioral therapy that works through a computer screen, rather than face-to-face with a therapist. These therapies can be prescribed by your doctor or a mental health specialist and are carried out with their advice and support.

Ask your doctor for more information or read more about self-help therapies.

If you are not sure you want to commit to a long course of sessions with a clinical psychologist, there are various resources on the Internet which will provide an introduction to cognitive behavioral therapy or even a course of computer-aided cognitive behavioral therapy sessions:

• Developed by the Australian National University, MoodGYM (https://moodgym.com.au/) is a fun, free interactive web program that teaches the principles of CBT using flashed diagrams and online exercises. MoodGYM (https://moodgym.com.au/) demonstrates the relationship between thoughts and emotions, and works through dealing with stress and relationship break-ups, as well as teaching relaxation and meditation techniques. It consists of five modules (why you feel the way you do, changing the way you think, changing ‘warped’ thoughts, knowing what makes you upset, assertiveness and interpersonal skills training), an interactive game, anxiety and depression assessments, downloadable relaxation audio, a workbook and feedback assessment. Scientific trials have shown that using two or more modules is linked to significant reductions in depression and anxiety symptoms. These benefits last after 12 months. MoodGYM has won several IT and health awards, and has over 1,000,000 users worldwide. MoodGYM (https://moodgym.com.au/)

• Living Life to the Full (https://llttf.com/) is a free online life skills course for people feeling distressed. It aims to provide easy access to cognitive behavioral therapy skills in a way that cuts through jargon. It helps you understand why you feel as you do, and to learn new ways of improving how you feel, by making changes in your thinking, activities, sleep and relationships. The course is based on the idea of helping you to help yourself. It is supported by a series of cognitive behavioral therapy self-help workbooks that can be used between the e-learning sessions. These encourage you to put what you are learning into practice, and to stop, think and reflect on what you are learning. Living Life to the Full (https://llttf.com/)

• FearFighter (http://www.fearfighter.com/) delivers cognitive behavioral therapy over the internet, useful for those who may be concerned about the stigma associated with seeing a therapist. Taking only three months to complete, with minimal telephone support, FearFighter helps you improve even if you have virtually no computer skills. You are encouraged to use FearFighter as often as you wish but for at least once a week. It helps you identify specific problems, work on realistic treatment goals, and monitor achievement of those goals by repeated self-exposure. You get scheduled brief helpline support to a total of one hour over 10 weeks. FearFighter helps you to work out exactly what brings on your fear, so you can learn how to face it until it subsides. This is called exposure therapy. It consists of nine steps that need to be worked through one by one to obtain the greatest benefits. Like a therapist, FearFighter asks you to return every week to report on how you’ve been doing. You can ask it to print out questionnaires and graphs of your progress. It guides you through CBT as much as a therapist does.
  • Step 1: Welcome to FearFighter – Introduces the system, asks you to rate your problem on the Fear Questionnaire (FQ) and Work & Social Adjustment Scale (WSA), and asks about suicidal feelings and alcohol misuse.
  • Step 2: How to Beat Fear – Explains the principles of CBT, with case examples. You are asked to keep a daily record of your triggers.
  • Step 3: Problem Sorting – Helps you identify your triggers, shows you scenarios relevant to your problem, and helps you personalise your triggers and rate them on a 0-8 scale.
  • Step 4: How to Get a Helper – Explains the value of recruiting a CBT co-therapist and gives hints on how to find one.
  • Step 5: Setting Goals – Guides you through the process of setting good goals and tests them. You record and rate these on the system and can print personalised homework diaries.
  • Step 6: Managing anxiety – Offers a menu of coping strategies for use during CBT homework.
  • Step 7: Rehearsing Goals – Guides you on how to practise personal coping strategies during both imagined and live cognitive behavioral therapy homework.
  • Step 8: Carrying On – Reviews progress with the help of graphs, allows new goals to be devised, and offers feedback and advice.
  • Step 9: Troubleshooting – Offers a menu of tips on overcoming common sticking points in treatment.

You may have found that when you avoid things that make you panic or feel uncomfortable, the situation tends to get worse and worse. FearFighter can teach you how to face your fear until you adapt and no longer want to run away from it. It helps you learn to face the things that make you panic, such that, with time, you’ll find that, one by one, they’ll get easier.

Self-exposure therapy guided by computer is as effective as clinician-guided therapy and both are superior to relaxation to improve phobia/panic. FearFighter has been tested in four clinical trials and is as effective as the best cognitive behavioral therapy therapists.

Approved by the National Institute of Clinical Excellence (NICE), free access can only be prescribed by your doctor in England and Wales. FearFighter (http://www.fearfighter.com/)

Interpersonal therapy

Interpersonal therapy focuses on your relationships with other people and on problems you may be having in your relationships, such as difficulties with communication or coping with bereavement. A course of interpersonal therapy is usually structured in the same way as a course of cognitive behavioral therapy.

There’s some evidence that interpersonal therapy can be as effective as antidepressants or cognitive behavioral therapy, but more research is needed.

Counseling

Counseling is a form of therapy that helps you think about the problems you’re experiencing in your life to find new ways of dealing with them. Counselors support you in finding solutions to problems, but don’t tell you what to do.

Counseling usually consists of 6 to 12 sessions lasting an hour each. You talk in confidence to a counselor, who supports you and offers practical advice.

Counseling is ideal for people who are healthy but need help coping with a current crisis, such as anger, relationship issues, bereavement, redundancy, infertility or the onset of a serious illness.

Exercise

Research suggests that regular exercise may be a more effective treatment for mild depression than antidepressants. Exercise helps boost levels of chemicals called serotonin and dopamine in the brain, which can lift your mood. Exercising on a regular basis can boost self-esteem and confidence, which can help to relieve symptoms of depression.

Exercise for depression

Being depressed can leave you feeling low in energy, which might put you off being more active. Regular exercise can boost your mood if you have depression, and it’s especially useful for people with mild to moderate depression.

Any type of exercise is useful, as long as it suits you and you do enough of it. Exercise should be something you enjoy; otherwise, it will be hard to find the motivation to do it regularly.

How often do you need to exercise?

To stay healthy, adults should do 150 minutes of moderate-intensity activity every week.

If you haven’t exercised for a while, gradually introduce physical activity into your daily routine. Any exercise is better than none. Even a 15-minute walk can clear your mind and relax.

How to get started with exercise

Find an activity you can do regularly. You can take part in a team sport, attend classes at a leisure center, or just be more active in your daily routine by walking or cycling instead of traveling by car or public transport.

Self-help groups

Talking through your feelings can be helpful. You can either talk to a friend or relative, or you can ask your doctor to suggest a local self-help group. There are also chat rooms on the internet that offer support.

Lithium

If you’ve tried several different antidepressants and seen no improvement, your doctor may offer you a medicine called lithium, in addition to your current treatment. If the level of lithium in your blood becomes too high, it can become toxic. So, you’ll need blood tests every few months to check your lithium levels while you’re taking it.

You’ll also need to avoid eating a low-salt diet because this can also cause the lithium to become toxic. Ask your doctor for advice about your diet.

Side effects of lithium include:

• dry mouth
• a metallic taste in your mouth
• some mild shaking of your hands
• diarrhea

These side effects usually pass with time once your body gets used to the medicine.

Electric shock treatment

Sometimes a treatment called electroconvulsive therapy (ECT) may be recommended if you have severe depression and other treatments haven’t worked, as it can be highly effective.

During electroconvulsive therapy, you’ll first be given an anaesthetic and medicine to relax your muscles. Then you’ll receive an electric current to your brain through electrodes placed on your head.

You may be given a series of electroconvulsive therapy sessions. It’s usually given twice a week for 3 to 6 weeks.

It’s not exactly clear how electroconvulsive therapy works, but recent studies suggest it may help reduce connections in an area of the brain linked to depression.

For most people, electroconvulsive therapy is good for relieving severe depression, but the beneficial effect tends to wear off after several months. Some people get unpleasant side effects, including short-term headaches, memory problems, nausea and muscle aches. However, these risks need to be balanced against the risks of other treatments and the effects of not treating depression.

Natural antidepressants

Many people turn to complementary health approaches in addition to conventional antidepressant treatment. Although complementary approaches are commonly used and readily available in the marketplace, many of these treatments have not been rigorously studied for depression. For this reason, it’s important that you understand the benefits and risks of these complementary approaches to make informed decisions about your health.

Here are some things you should know about some complementary health approaches for depression:

1. Some studies suggest that omega-3 fatty acid supplements may provide a small improvement along with conventional treatment, such as antidepressants, in patients with major depressive disorder and in depressed patients without a diagnosis of major depressive disorder. However, a lot of questions remain about how, or if, omega-3 supplements work in the body to produce such an effect.
2. Although some studies of St. John’s wort (Hypericum perforatum) have shown benefits similar to standard antidepressants for depression in a limited number of patients, others have not. Research has shown that St. John’s wort interacts with many medications in ways that can interfere with their intended effects, making its safety risks outweigh the benefit of any use of St. John’s wort.
3. Current scientific evidence does not support the use of other dietary supplements, including S-Adenosyl-L-Methionine (SAMe) or inositol, for depression.
4. Some studies on mind and body practices, when used along with standard treatment for depression in adults, have had modestly promising results. For example, there is limited evidence that music therapy may provide an improvement in mood. In addition, studies indicate that relaxation training is better than no treatment in reducing symptoms of depression, but is not as beneficial as psychological therapies such as cognitive-behavioral therapy.

Yoga

Yoga is an ancient Indian exercise philosophy that provides a gentle form of exercise and stress management. It consists of postures or ‘asanas’ that are held for a short period of time and are often synchronized with your breathing. Yoga is very helpful for reducing stress and anxiety, which are often precursors to depression.

A number of studies have shown that yoga breathing exercises are beneficial for depression.

Massage therapy

Massage therapy is believed to be helpful for people with depression, although further studies are needed to conclusively demonstrate this.

Massage produces chemical changes in the brain that result in a feeling of relaxation, calm and wellbeing. It also reduces levels of stress hormones, such as adrenaline, cortisol and norepinephrine, which in some people can trigger depression.

Meditation and mindfulness

Mindfulness is a form of self-awareness training adapted from Buddhist mindfulness meditation. Mindfulness is about being in the present moment, without making judgment. It allows us to experience our body and feelings in each moment with acceptance, and helps free us of mental ‘clutter’.

Mindfulness helps us stop getting caught up in thinking about the past or worrying about the future. Mindfulness can change the way our brain and nervous system function. It can allow our parasympathetic nervous system to take over and place us in a state of rest, healing and restoration.

Mindfulness has been adapted for use in treatment of depression, especially preventing relapse and for assisting with mood regulation.

Antidepressants and alcohol

It’s best to avoid combining antidepressants and alcohol. It may worsen your symptoms, and it can be dangerous. If you mix antidepressants and alcohol:

• You may feel more depressed or anxious. Drinking can counteract the benefits of your antidepressant medication, making your symptoms more difficult to treat. Alcohol may seem to improve your mood in the short term, but its overall effect increases symptoms of depression and anxiety.
• Side effects may be worse if you also take another medication. Many medications can cause problems when taken with alcohol — including anti-anxiety medications, sleep medications and prescription pain medications. Side effects may worsen if you drink alcohol and take one of these drugs along with an antidepressant.
• You may be at risk of a dangerous reaction if you take monoamine oxidase inhibitors (MAOIs). When combined with certain types of alcoholic beverages and foods, antidepressants called monoamine oxidase inhibitors (MAOIs) can cause a dangerous spike in blood pressure. If you take an MAOI, be sure you know what’s safe to eat and drink, and which alcoholic beverages are likely to cause a reaction.
• Your thinking and alertness may be impaired. The combination of antidepressants and alcohol will affect your judgment, coordination, motor skills and reaction time more than alcohol alone. Some combinations may make you sleepy. This can impair your ability to drive or do other tasks that require focus and attention.
• You may become sedated or feel drowsy. A few antidepressants cause sedation and drowsiness, and so does alcohol. When taken together, the combined effect can be intensified.

Don’t stop taking an antidepressant or other medication just so that you can drink. Most antidepressants require taking a consistent, daily dose to maintain a constant level in your system and work as intended. Stopping and starting your medications can make your depression worse.

While it’s generally best not to drink at all if you’re depressed, ask your doctor. If you have depression:

• You may be at risk of alcohol abuse. People with depression are at increased risk of substance abuse and addiction. If you have trouble controlling your alcohol use, you may need treatment for alcohol dependence before your depression improves.
• You may have trouble sleeping. Some people who are depressed have trouble sleeping. Using alcohol to help you sleep may let you fall asleep quickly, but you tend to wake up more in the middle of the night.

If you’re concerned about your alcohol use, you may benefit from substance abuse counseling and treatment programs that can help you overcome your misuse of alcohol. Joining a support group or a 12-step program such as Alcoholics Anonymous may help.

If you’re at low risk of addiction to alcohol, it may be OK to have an occasional drink, depending on your particular situation, but talk with your doctor.

Also, tell your doctor about any other health conditions you might have and any other medications you take, including over-the-counter medications or supplements. Keeping your doctor informed is important because:

• Some liquid medications, such as cough syrups, can contain alcohol
• As you age, your body processes medication differently and levels of medication in your body may need to be adjusted
• Adding a new medication may change the level of another medication in your body and how it reacts to alcohol

Antidepressants and weight gain

Weight gain is a possible side effect of nearly all antidepressants. However, each person responds to antidepressants differently. Some people gain weight when taking a certain antidepressant, while others don’t.

Generally speaking, some antidepressants seem more likely to cause weight gain than others. These include:

• Certain tricyclic antidepressants, such as amitriptyline, imipramine (Tofranil) and doxepin
• Certain monoamine oxidase inhibitors (MAOIs), such as phenelzine (Nardil)
• Paroxetine (Paxil, Pexeva), a selective serotonin reuptake inhibitor (SSRI)
• Mirtazapine (Remeron), which is an atypical antidepressant — medication that doesn’t fit neatly into another antidepressant category

While some people gain weight after starting an antidepressant, the antidepressant isn’t always a direct cause. Many factors can contribute to weight gain during antidepressant therapy. For example:

• Overeating or inactivity as a result of depression can cause weight gain.
• Some people lose weight as part of their depression. In turn, an improved appetite associated with improved mood may result in increased weight.
• Adults generally tend to gain weight as they age, regardless of the medications they take.

If you gain weight after starting an antidepressant, discuss the medication’s benefits and side effects with your doctor. If the benefits outweigh the side effect of weight gain, consider managing your weight by eating healthier and getting more physical activity while enjoying an improved mood due to the medication.

You can also ask your doctor if adjusting the dose or switching medications might be helpful — but again, be sure to discuss the pros and cons before making such a decision.

Which antidepressants cause the fewest sexual side effects?

Sexual side effects are common with antidepressants in both men and women, so your concern is understandable. Effects on sexual function can include:

• A change in your desire for sex
• Erectile problems
• Orgasm problems
• Problems with arousal, comfort and satisfaction

The severity of sexual side effects depends on the individual and the specific type and dose of antidepressant. For some people, sexual side effects are minor or may ease up as their bodies adjust to the medication. For others, sexual side effects continue to be a problem.

Antidepressants with the lowest rate of sexual side effects include:

• Bupropion (Wellbutrin XL, Wellbutrin SR, Aplenzin, Forfivo XL)
• Mirtazapine (Remeron)
• Vilazodone (Viibryd)
• Vortioxetine (Trintellix)

Antidepressants most likely to cause sexual side effects include:

• Selective serotonin reuptake inhibitors (SSRIs), which include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil, Paxil CR, Pexeva) and sertraline (Zoloft).
• Serotonin and norepinephrine reuptake inhibitors (SNRIs), which include venlafaxine (Effexor XR), desvenlafaxine (Pristiq, Khedezla) and duloxetine (Cymbalta).
• Tricyclic and tetracyclic antidepressants, such as amitriptyline, nortriptyline (Pamelor) and clomipramine (Anafranil).
• Monoamine oxidase inhibitors (MAOIs), such as isocarboxazid (Marplan), phenelzine (Nardil) and tranylcypromine (Parnate). However, selegiline (Emsam), a newer MAOI that you stick on your skin as a patch, has a low risk of sexual side effects.

If you’re taking an antidepressant that causes sexual side effects, your doctor may recommend one or more of these strategies:

• Waiting several weeks to see whether sexual side effects get better.
• Adjusting the dose of your antidepressant to reduce the risk of sexual side effects. But always talk with your doctor before changing your dose.
• Switching to another antidepressant that may be less likely to cause sexual side effects.
• Adding a second antidepressant or another type of medication to counter sexual side effects. For example, the addition of the antidepressant bupropion may ease sexual side effects caused by another antidepressant.
• Adding a medication to improve sexual function, such as sildenafil (Viagra), tadalafil (Cialis) or vardenafil (Levitra, Staxyn). These medications are approved by the Food and Drug Administration only to treat sexual problems in men. Limited research suggests sildenafil may improve sexual problems caused by antidepressants in some women, but more information is needed on its effectiveness and safety in women.

Stopping medication because of sexual side effects is a common problem, and for most people this means depression returns. Work with your doctor to find an effective antidepressant or combination of medications that will reduce your sexual side effects and keep your depression under control. If you’re pregnant or trying to become pregnant, tell your doctor, as this may affect the type of antidepressant that’s appropriate.

Be patient. Everyone reacts differently to antidepressants, so it may take some trial and error to identify what works best for you.

Antidepressants for anxiety

Antidepressants are a common treatment for depression and anxiety. Antidepressants might also help people with anxiety-related disorders like generalized anxiety disorder (GAD), eating disorders, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD).

Selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs) are medications sometimes used in treating anxiety.

Antidepressants can help, but they might not be enough on their own. Many people find they feel better faster with a combination of antidepressants and psychological therapy.

Antidepressants can help to improve your mood, or if you have lost interest in activities you once enjoyed. They can also help improve sleep, thinking and concentration.

Antidepressants don’t help everybody who takes them. They are more likely to help people with moderate or severe depression than those with mild depression.

References

1. Williams JW, Mulrow CD, Chiquette E, Noël PH, Aguilar C, Cornell J. A Systematic Review of Newer Pharmacotherapies for Depression in Adults: Evidence Report Summary: Clinical Guideline, Part 2. Ann Intern Med. ;132:743–756. doi: 10.7326/0003-4819-132-9-200005020-00011
2. NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE. CG90: Depression in adults: treatment and management (update) https://www.nice.org.uk/guidance/cg90/documents/cg90-depression-in-adults-update-surveillance-review-decision2
3. Gartlehner G, Hansen RA, Morgan LC, et al. Second-Generation Antidepressants in the Pharmacologic Treatment of Adult Depression: An Update of the 2007 Comparative Effectiveness Review [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 Dec. (Comparative Effectiveness Reviews, No. 46.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK83442