Medications

SSRIs can cause agitation, nausea, and low sex drive. Over time, many SSRI-treated patients gain weight, although the degree of weight gain varies depending on the drug. (For example, paroxetine poses a greater risk for weight gain than citalopram.) Elderly people taking these drugs should take the lowest effective dose possible, and those with heart problems should be monitored closely.

There have been many concerns about SSRIs and increased risk for suicidal behavior. Both adults and children who are treated with SSRIs should be carefully monitored for any worsening of depressive symptoms or changes in behavior. This is especially important during the first few months of antidepressant treatment.

Paroxetine has been linked to heart-related birth defects when women took this drug during the first trimester of pregnancy. Experts are also advising caution in prescribing other types of SSRIs to pregnant women. A 2006 study in the New England Journal of Medicine indicated that babies born to women who take SSRIs during the second half of pregnancy have an increased risk for persistent pulmonary hypertension, a serious lung condition. Other studies suggest that babies born to women who take SSRIs late in pregnancy may have more problems with irritability and difficulty feeding. Women who are pregnant or who are considering becoming pregnant should discuss the potential risks of these drugs with their doctors.

Designer Antidepressants. A number of newer antidepressants that target other neurotransmitters alone or in addition to serotonin are proving to be very promising for anxiety, including generalized anxiety disorder. They include nefazodone (Serzone), venlafaxine (Effexor), and mirtazapine (Remeron).

• Venlafaxine (Effexor) works well for both short- and long-term treatment of generalized anxiety disorder. It may have some benefits for social anxiety. In 2005, it was approved for treatment of panic disorder in adults. As with the SSRIs, and unlike other newer antidepressants, venlafaxine impairs sexual function. Of concern are reports of changes in blood pressure and heart conduction abnormalities, which may cause serious problems in elderly patients. Some patients report severe withdrawal symptoms, including dizziness and nausea. Venlafaxine can cause fatal overdose, especially if taken in combination with alcohol or other drugs. Venlafaxine should not be taken during the last trimester of pregnancy because the drug can cause complications in newborn infants.
• Nefazodone (Serzone) has shown some benefit in patients with GAD, social phobias, and panic disorder. The drug is more rapidly effective and has fewer distressing side effects, including sexual dysfunction, than SSRIs. Nefazodone is one of the only antidepressants that has a positive effect on sleep efficiency, which may particularly benefit patients with insomnia. The drug may cause an abrupt drop in blood pressure after standing up suddenly. Nefazodone has been linked with increased risk for liver failure.
• Mirtazapine (Remeron) may be an effective treatment for panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder. It may work faster than other SSRIs and have stronger early actions against anxiety in patients who also suffer depression. It may cause less sexual dysfunction than some other antidepressants. It interacts with histamine, a chemical involved in allergic responses. These actions can cause drowsiness, which may make it a useful drug for patients who suffer from insomnia. The drug also causes blurred vision. The drug has been associated with weight gain, although in one study it was not significant. It does not appear to have the adverse acute effects on the heart that other newer antidepressants have, although it may slightly raise cholesterol and triglyceride levels.