How Doctors Choose the Best Antidepressant for You

Side Effects and Double Uses for Antidepressants

female student looking at depression pills
How can you choose the best antidepressant for you alone?. Istockphoto.com/Stock Photo©Ximagination

Choosing an Antidepressant

The selection of an antidepressant medication is not nearly so "hit or miss" as it might feel. There is a definite logic behind the sequence of antidepressants that a doctor recommends as she seeks the one that will be best for you as an individual. One tool available to help in selection is what's called an "algorithm," which is a flow chart that provides the best antidepressant selection based upon the answers provided to certain questions.

These selections are based upon current knowledge in the field of psychiatry about what antidepressant is best for which type of depression. 

Your Opinion Comes First

Just as important as whether a drug relieves depression is how good a fit a drug is for the individual. A patient may find that a particular drug makes them feel the best they have in years, but the side effects are intolerable. What happens now? This is the point when physician and patient must work as a team to find a solution that the patient can live with. Options might include accepting the side effect as a trade off for depression relief, augmenting with other medications (using more than one medication together to control depression and/or relieve side effects), or trying a new medication. The important thing is for the patient to be open about their expectations, but also realistic. One should try to find the drug which gives the best depression relief with the fewest antidepressant side effects, but keep in mind that, unfortunately, no drug is going to be perfect.

Factors to Consider

there are many factors that are considered when choosing an antidepressant beyond simply the type of depression you are living with. Some of these include learning what has worked for you in the past, what may have worked for other members of your family, other medications you are taking, and much more.

Some side effects may be welcomed by some people but intolerable for others, And some medications may work for other conditions you have in addition to depression; your choice may be a proverbial way to kill two birds with one stone. It is very important that you work together with your doctor as a team in making these choices. Nobody knows your body better than you do or understands your preferences as well as you.

Worst Offenders List - The Most Annoying Side Effects

There are two side effects that people seem to find the most troubling: sexual dysfunction and weight gain.

Sexual dysfunction

One of the classic symptoms of depression is loss of sex drive. Rather ironically, many of the medications used to treat depression can also potentially cause sexual side-effects. If these problems affect you, Serzone (nefazodone), Wellbutrin (bupropion) and Remeron (mirtazipine) are medications which have fewer sexual side-effects. Of course, these medications may have side effects that are more bothersome to you than sexual dysfunction.

Weight gain

Weight gain on antidepressants is another commonly complained about side-effect. In this department, Paxil and Remeron (mirtazipine) are a few of the worst offenders. Effexor (venlaxafine), Wellbutrin (bupropion), and Prozac (fluoxetine) are antidepressants that are not as likely to cause weight gain, and many people even lose a few pounds. But again, everyone is different, and some people gain weight on medications unlikely to cause weight gain and lose weight on those that often cause weight gain.

Side Effects Can Be a Good Thing

Believe it or not, side effects are not necessarily a bad thing. They can be good or bad, depending upon other illnesses or conditions that the patient has. If a patient has an eating disorder and is too thin, a drug like Prozac that suppresses appetite may not be desirable. However, if a patient is diabetic and overweight, this same side effect may be helpful in controlling their diabetes because they will have fewer cravings for forbidden foods. Conversely, if you need to put on some weight, Paxil (paroxetine) or Remeron (mirtazipine) might be the best antidepressants to use.

This good and bad with respect to weight scenario is similar when it comes to antidepressants that are stimulating and those that are sedating. An antidepressant that tends to be stimulating such as Wellbutrin (bupropion) may be helpful for someone with vegetative depression or who seems to have no energy, but could be the wrong choice for someone living with an anxiety disorder in addition to depression. On the other side, a sedating antidepressant such as Remeron (mirtrazapine) could work well for someone who is anxious and unable to sleep, but may be the wrong choice for someone who is already feeling a total lack of energy with their depression.

Again, it is important to note that every person is different. An antidepressant which is stimulating for one person could have a sedative effect for another, and vice versa.

Pulling Double Duty - When Antidepressants Help with Other Conditions

Certain antidepressants have been found to be effective for conditions other than depression. If you have another condition along with depression that might be benefited by a particular antidepressant, a doctor may opt to try that medication.

It's important to note that in prescribing an antidepressant, the first goal should be the best control of the depression. Sometimes this may mean choosing an antidepressant which is more likely to cause weight gain even in someone who is overweight, and that does not cover another condition he is suffering from, even if that option appears to be available.

It's also important to make a distinction between on-label and off-label uses of medications. On label use means that the medication has received FDA approval for that indication. Off label use does not mean that a medication is not useful—and may even have been found useful to treat a condition—but that it does not yet have FDA approval for that indication. It's also important for people to know that some physicians are more willing than others to consider prescribing medications for off-label reasons.

Examples in which antidepressants may have double duty functions include:

  • Smoking cessation - Wellbutrin (bupropion) is actually the same drug as the popular stop-smoking medication Zyban (bupropion). For a smoker, Wellbutrin may pull double duty and be the logical choice by helping with depression and also helping with smoking cessation.
  • PMS/OCD/Social anxiety disorder/panic disorder - Some antidepressants are also effective in helping with symptoms ranging from social anxiety disorder to panic disorder to PMS. Talk to your doctors about medications that may serve a dual purpose.
  • Chronic pain/fibromyalgia/neuropathy - Both tricyclic antidepressants and the serotonin norepihephrine reuptake ihibitors (SNRIs) Cymbalta (duloxetine) and Effexor (venlafaxine) have been found to be helpful for those living with chronic pain.
  • Sleep issues - If you are battling insomnia, a more sedating antidepressant taken at night may attack two problems at once. In contrast, a stimulating antidepressant taken at night may magnify the problem.
  • Bedwetting -  Though tricyclic antidepressants tend to be used less often than some of the newer formulations, for those who are struggling with bedwetting, imipramine may help with both problems.
  • Learning disabilities - It's thought that some of the antidepressants may have a secondary benefit of helping with some learning disabilities. If this is you, talk to your physician about whether or not one of these medications may work for you.

Ease of Taking and Discontinuing the Medication

It may sound like a minor problem, but it is not. Taking a medication on a regular schedule is difficult for many people, even physicians. When it comes to timing, some antidepressants are very forgiving of a forgotten dose—they have a long half life or stay in the body for a long time—whereas some pass out of your system quickly due to a short half life, reminding you of their absence quickly with recurrent symptoms or withdrawal symptoms. How long an antidepressant will "last" in your body is dependent on the "half life" of the medication. Medications that have a short half life are fairly unforgiving of a missed dose, whereas others, such as Prozac, have long half life which delay any significant discontinuation symptoms. Make sure to talk to your doctor about any problems with sticking with a medication regimen so that she can take this tendency into account in choosing the best drug to manage your symptoms.

Sources:

Carvalho, A., Sharma, M., Brunoni, A., Vieta, E., and G. Fava. The Safety, Tolerability and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature. Psychotherapy and Psychosomatics. 2016. 85(5):270-88.

Nosengo, N. Can You Teach Old Drugs New Tricks?. Nature. 2016. 534:7607.

Prus, A., and J. Porter. The Discriminative Stimulus Properties of Drugs Used to Treat Depression and Anxiety. Current Topics in Behavioral Neuroscience. 2016 Jun 29. (Epub ahead of print).

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