What You Need to Know to Make an Informed Treatment Decision
When you’re suffering from deep, disabling depression, the idea that a pill can give you your life—and hope—back is incredibly appealing. But are antidepressants always the best treatment option? Is there solid evidence that they work in the long-term? What are the potential side effects and safety concerns? And are there any truly effective non-drug alternatives? These are some of the important questions to consider when considering antidepressant treatment. Learning the facts about what antidepressant can (and can’t) do will help you weigh the benefits against the risks and make a more informed decision.
Do antidepressants cure a chemical imbalance in the brain?
You’ve seen it in television ads, read it in newspaper articles, maybe even heard it from your doctor: depression is caused by a chemical imbalance in the brain that medication can correct. The truth is that there is very little—if any—research to support this theory. It’s a triumph of pharmaceutical marketing over science.
While antidepressant drugs increase serotonin levels in the brain, this doesn’t mean that depression is caused by a serotonin shortage. After all, aspirin may cure a headache, but that doesn’t mean headaches are caused by an aspirin deficiency.
When it comes to depression, serotonin is just one small part of the story
Mental health researchers agree that the causes of depression are much more complex than the chemical imbalance theory suggests. A growing body of research points to other physiological factors, including inflammation, elevated stress hormones, immune system suppression, abnormal activity in certain parts of the brain, nutritional deficiencies, and shrinking brain cells. And these are just the biological causes of depression. Social and psychological factors—such as loneliness, lack of exercise, poor diet, and low self-esteem—also play an enormous role.
How effective are antidepressants?
So now we know that depression isn’t simply a matter of having too little serotonin. But that doesn’t mean that antidepressants don’t work. Going back to our aspirin analogy, even though headaches aren’t caused by an aspirin deficiency, they still go away when you pop a couple of pills. Is the same true with antidepressant and depression? Again, the evidence may surprise you.
When depression is severe, medication may be helpful—even lifesaving. However, research shows that very few people become symptom-free on antidepressants, and some become worse. Furthermore, many who respond initially to medication soon slip back into depression, despite sticking with drug treatment.
Other studies show that the benefits of antidepressants have been exaggerated, with a growing number of researchers concluding that—when it comes to mild to moderate depression—antidepressants are no more effective than placebos.
I’m depressed and need relief. Where does this leave me?
Medication may be right for you if depression is interfering with your ability to function in an important part of your life—work, school, or in your relationships, for example. However, many people use antidepressants when therapy, exercise, or self-help strategieswould work just as well or better—minus the side effects. Even if you decide to take medication, it’s a good idea to pursue therapy and lifestyle changes that can help you get to the bottom of your underlying issues and develop the tools to beat depression for good. See Coping with Depression and Depression Treatment
What are the side effects of antidepressant medication?
There are many different types of drugs used in the treatment of depression, including selective serotonin reuptake inhibitors (SSRIs), atypical antidepressants, tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs). Side effects are common in all antidepressants. For many people, the side effects are serious enough to make them stop taking the medication.
Side effects of SSRIs (selective serotonin reuptake inhibitors)
The most widely prescribed antidepressants come from a class of medications known as selective serotonin reuptake inhibitors (SSRIs). The SSRIs include drugs such as Prozac, Zoloft, and Paxil.
The SSRIs act on a chemical in the brain called serotonin. Serotonin helps regulate mood, but it also plays a role in digestion, pain, sleep, mental clarity, and other bodily functions. As a result, the SSRI antidepressants cause a wide range of side effects.
Common SSRI side effects include:
- Decreased sex drive
- Weight gain
- Sleepiness or fatigue
- Dry mouth
The SSRIs can also cause serious withdrawal symptoms, especially if you stop taking them abruptly.
Side effects of atypical antidepressants
There are a variety of newer depression drugs, called atypical antidepressants, which target other neurotransmitters either alone or in addition to serotonin. Some of the brain chemicals they affect include norepinephrine and dopamine. The atypical antidepressants include:
- Bupropion (Wellbutrin)
- Venlafaxine (Effexor)
- Duloxetine (Cymbalta)
- Mirtazapine (Remeron)
- Trazodone (Desyrel)
- Nefazodone (Serzone)
The side effects vary according to the specific drug. However, many of the atypical antidepressants can cause nausea, fatigue, weight gain, sleepiness, nervousness, dry mouth, and blurred vision.
Side effects of older depression drugs
Tricyclic antidepressants and MAOIs (monoamine oxidase inhibitors) are older classes of antidepressants. Their side effects are more severe than those of the newer antidepressants, so they are only prescribed as a last resort after other treatments and medications have failed.
Antidepressants and suicide risk
There is a danger that, in some people, antidepressant treatment will cause an increase, rather than a decrease, in depression. In fact, the U.S. Food and Drug Administration requires that all depression medications include a warning label about the increased risk of suicide in children and young adults. The suicide risk is particularly great during the first month to two months of treatment.
Anyone taking antidepressants should be closely watched for suicidal thoughts and behaviors. Monitoring is especially important if this is the person’s first time on depression medication or if the dose has recently been changed. Signs that medication is making things worse include anxiety, insomnia, hostility, and extreme agitation—particularly if the symptoms appear suddenly or rapidly deteriorate. If you spot the warning signs in yourself or a loved one, contact your doctor or therapist immediately.
Antidepressant suicide warning signs
- Suicidal thoughts or attempts
- New or worse depression
- New or worse anxiety
- New or worse irritability
- Feeling agitated or restless
- Difficulty sleeping
- Aggression and anger
- Acting on dangerous impulses
- Extreme hyperactivity
- Other unusual changes in behavior
If you are concerned that a friend or family member is contemplating suicide, see Suicide Prevention.
What are the risk factors of antidepressants?
Anyone who takes antidepressants can experience side effects, but certain individuals are at a higher risk:
People over 65. Studies show that SSRI medications may increase the risk for falls, fractures, and bone loss in older adults.
Pregnant women. The use of SSRIs late in pregnancy may lead to short-term withdrawal symptoms in newborns after delivery. Typical symptoms include tremor, restlessness, mild respiratory problems, and weak cry.
Teens and young adults. The U.S. Food and Drug Administration requires all depression medications to include a warning label about the increased risk of suicide in children and young adults.
People who may have bipolar disorder. Antidepressants can actually make bipolar disorder worse or trigger a manic episode; there are other treatments available for those with bipolar disorder.
Is depression medication right for you?
If you’re considering antidepressants as a treatment option, the following questions may help you make your decision.
Questions to ask yourself and a mental health professional
- Is my depression adversely affecting my life enough to require drug treatment?
- Is medication the best option for treating my depression?
- Am I willing to tolerate unwanted side effects?
- What non-drug treatments might help my depression?
- Do I have the time and motivation to pursue other treatments such as therapy and exercise?
- What self-help strategies might reduce my depression?
- If I decide to take medication, should I pursue therapy as well?
Questions to ask your doctor
- How much mental health care training have you had?
- Are there any medical conditions that could be causing my depression?
- What are the side effects and risks of the antidepressant you are recommending?
- Are there any foods or other substances I will need to avoid?
- How will this drug interact with other prescriptions I’m taking?
- How long will I have to take this medication?
- Will withdrawing from the drug be difficult?
- Will my depression return when I stop taking medication?
Medication isn’t your only option for depression relief
Remember, antidepressants aren’t a cure. Medication may treat some symptoms of depression, but can’t change the underlying issues and situations in your life that are making you depressed. That’s where exercise, therapy, mindfulness meditation, social support and other lifestyle changes come in. These non-drug treatments can produce lasting changes and long-term relief.
Guidelines for taking antidepressants
The more you know about your antidepressant, the better equipped you’ll be to deal with side effects, avoid dangerous drug interactions, and minimize other safety concerns.
See a psychiatrist, not a family physician. Your family physician might help you or your loved one first realize that you may need depression treatment. But although any medical doctor can prescribe medications, psychiatrists are doctors who specialize in mental health treatment. They are more likely to be familiar with the newest research on antidepressants and any safety concerns. Your health depends on your doctor's expertise, so it's important to choose the most qualified physician.
Follow instructions. Be sure to take your antidepressant according to the doctor's instructions. Don't skip or alter your dose, and don't stop taking your pills as soon as you begin to feel better. Stopping treatment prematurely is associated with high relapse rates and can cause serious withdrawal symptoms.
Beware of drug interactions. You should avoid drinking alcohol when taking SSRIs since it can lessen the effects of the medication. Dangerous drug interactions can occur when SSRIs are taken with antihistamines, found in many over-the-counter cold and allergy medicines and sleep aids, or with prescription painkillers. Always talk to your doctor or pharmacist before combining medications.
Monitor side effects. Keep track of any physical and emotional changes you’re experiencing and talk to your doctor about them. Contact your doctor or therapist immediately if your depression worsens or you experience an increase in suicidal thoughts. See your doctor on a regular basis.
Be patient. Finding the right drug and dosage is a trial and error process. It takes approximately four to six weeks for antidepressant medications to reach their full therapeutic effect. Many people try several medications before finding one that helps.
Once you’ve started taking antidepressants, stopping can be tough. Many people have severe withdrawal symptoms that make it difficult to get off of the medication. If you decide to stop taking antidepressants, it’s essential to consult a doctor and taper off slowly.
Antidepressant withdrawal symptoms
When you stop taking antidepressants, you may experience a number of unpleasant—even disabling—withdrawal symptoms, including:
- Anxiety, agitation
- Depression, mood swings
- Flu-like symptoms
- Irritability and aggression
- Insomnia, nightmares
- Extreme restlessness
- Nausea and vomiting
- Dizziness, loss of coordination
- Stomach cramping and pain
- Electric shock sensations
- Tremor, muscle spasms
Tips for stopping your antidepressant safely
Reduce your dose gradually. In order to minimize antidepressant withdrawal symptoms, never stop your medication “cold turkey.” Instead, gradually step down your dose (many experts recommend reducing in 10% increments), allowing for at least two to six weeks or longer between each dosage reduction.
Don’t rush the process. The antidepressant tapering process may take from several months to years, and should only be attempted under a doctor's supervision. Be patient. If at any time you experience difficulties, consider spending more time at your current dose before attempting any further reductions.
Choose a time to stop that isn’t too stressful. Withdrawing from antidepressants can be difficult, so it’s best to start when you’re not under a lot of stress. If you’re currently going through any major life changes or significantly stressful circumstances, you may want to wait until you’re in a more stable place.
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Resources and references
General information about antidepressants and side effects
Understanding Antidepressant Medications – Covers types of antidepressants and their effectiveness, side effects, and serious risks. (U.S. Food and Drug Administration)
The Hidden Harm of Antidepressants – Reveals the issue of secrecy in antidepressant clinical trials and the widespread underreporting of dangerous side effects. (Scientific American)
SSRI Antidepressant Medications: Adverse Effects and Tolerability – Explores adverse effects during long-term use of SSRIs (Journal of Clinical Psychiatry)
Antidepressant risk factors
Antidepressants Can Raise the Risk of Suicide – A large review of 70 clinical trials found that antidepressant use in people under 18 doubles the risk of suicide and aggressive behavior. (The Telegraph)
Suicide and Antidepressants – Learn more about studies linking suicidal behavior and antidepressants. (DrugWatch)
Now Antidepressant-Induced Chronic Depression Has a Name: Tardive Dysphoria – Explore new research that suggests that antidepressants may worsen long-term treatment outcomes. (Psychology Today)
The chemical imbalance theory of depression
What causes depression? Research suggests that depression doesn’t spring from simply having too much or too little of certain brain chemicals. (Harvard Health Publications)
Is Depression Just Bad Chemistry? Article about how a complex disorder has so far eluded a simple biological explanation. (Scientific America)
Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study – Information about a major study conducted to determine the effectiveness of different treatments for people with depression. (National Institute of Mental Health)
Going off antidepressants – Steps to minimize or avoid the discontinuation symptoms that can occur if medications are withdrawn too quickly. (Harvard Women’s Health Watch)
Stopping SSRI Antidepressants Can Cause Long, Intense Withdrawal Problems – A recent systematic review of SSRI withdrawal problems found that withdrawal symptoms can be significant and can last for months and even years. (Mad in America)
Choosing an antideprssant
Antidepressants: Comparing Effectiveness, Safety, Side Effects, and Price (PDF) – Report helps consumers assess whether antidepressants are right for them, and if so, which one. (Consumer Reports)
Antidepressants: Selecting One That's Right for You – Introduction to the various types of antidepressants and how to find the right one for you. (Mayo Clinic)
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