Antidepressants and Drug Treatment Guidelines
Major Classes of Antidepressants and General Treatment Guidelines
Major classes of antidepressants include:
- Selective serotonin-reuptake inhibitors (SSRIs). These have become the standard antidepressants. They target the brain chemical (neurotransmitter) serotonin. They are effective and have very moderate side effects. Some may be beneficial in treating anxiety and certain subtypes of depressive disorders unresponsive to previous drugs, including premenstrual dysphoric disorder and seasonal affective disorder, atypical depression, and recurrent brief depression.
- "Designer antidepressants." These drugs target neurotransmitters other than or in addition to serotonin, such as norepinephrine. Many are being proving to be effective in patients who do not respond to standard antidepressants or in specific patients, such as smokers who want to quit or patients with chronic pain.
- Tricyclic antidepressants (TCAs). These drugs are effective but can have severe adverse effects, particularly in older people.
- Monoamine oxidase inhibitors (MAOIs). These drugs include newer selective MAOIs. MAOIs are the most effective antidepressants for atypical depression, but have some severe side effects and require restrictive dietary rules.
- St. John's wort and other herbal remedies are included in the Lifestyle section of this report.
A great deal of leeway exists in choosing an appropriate antidepressant. Overall, they seem to be equally effective, although cost, individual responses, and side effects vary widely.
Approach and Duration of Initial Treatment. The guidelines for the duration of an initial antidepressant regimen is as follows:
- Patients should start at a low dose, which is increased over a period of 5 - 10 days.
- Patients should see their doctor every 1- 2 weeks until substantial improvement occurs. It may take 4 - 8 weeks before a patient experiences the effects of any antidepressant.
- Side effects usually diminish within 1 - 4 weeks. (Exceptions may be weight gain and sexual dysfunction.)
- If no improvement occurs, an alternative drug may be tried. More than 80% of patients respond to some antidepressant, although specific drugs are helpful for only about half of patients. This suggests that if one medication fails, another has a good chance of being helpful. However, according to important results from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trials, the fewer drug treatment strategies required, the better a patient’s chances of recovering completely from depression. Patients who become symptom-free have the best chance for complete recovery compared to patients whose symptoms merely improve.
- In general, patients should continue taking antidepressants for at least 6 months after symptom relief to help prevent relapse. (Patients who improve within 2 weeks of taking medications may not require lengthy treatment.)
Previous Section
