Drugs Expert

Depression is an illness that causes you to feel sad, to lose interest in activities that you’ve always enjoyed, to withdraw from others, and to have little energy. It’s different from normal feelings of sadness, grief, or low energy. Depression can also cause people to feel hopeless about the future and even to think about suicide.

Many people, and sometimes their families, feel embarrassed or ashamed about having depression. Don’t let these feelings stand in the way of getting treatment. Remember that depression is a common illness. Depression affects the young and old, men and women, all ethnic groups, and all professions.

If you think you may be depressed, tell your doctor. Treatment can help you enjoy life again. The sooner you get treatment, the sooner you will feel better.

What causes depression?

Depression is a disease. It’s not caused by personal weakness and is not a character flaw. When you have depression, chemicals in your brain called neurotransmitters are out of balance.

Most experts believe a combination of family history (your genes) and stressful life events may cause depression. Life events can include:

• Childbirth, a death in the family, work, or relationships.
• Finding out you have a long-term health problem, such as arthritis, heart disease, or cancer.
• Health problems, such as anemia and an underactive thyroid gland (hypothyroidism). Treating the health problem can usually cure the depression.

Just because you have a familymemberwith depression or have stressful life events doesn’t mean you’ll get depression.

You also may get depressed even if there is no reason you can think of.

What are the symptoms?

The symptoms of depression may be hard to notice at first. They vary among people, and you may confuse them with just feeling “off” or with another health problem.

The two most common symptoms of depression are:

• Feeling sad or hopeless nearly every day for at least 2 weeks.
• Losing interest in or not getting pleasure from most daily activities nearly every day for at least 2 weeks.

A serious symptom of depression is thinking about death or suicide. If you or someone you care about talks about this or feeling hopeless, get help right away.

You also may:

• Lose or gain weight. You also may feel like eating more or less than usual almost every day.
• Sleep too much or not enough almost every day.
• Feel restless and not be able to sit still, or you may sit quietly and feel that moving takes great effort. Others can easily see this behavior.
• Feel tired or as if you have no energy almost every day.
• Feel unworthy or guilty nearly every day. You may have low self-esteem and worry that people don’t like you.
• Find it hard to focus, remember things, or make decisions nearly every day. You may feel anxious about things.

If you have some of these symptoms for at least 2 weeks, talk to your doctor. Treatment may be right for you.

How is it treated?

Depression can be treated in various ways. Counseling, psychotherapy, and/or antidepressant medicines are all used. Lifestyle changes, such as getting more exercise, also may help. Your doctor or mental health professional will help you find the best treatment.

If you have mild or moderate depression, your family doctor or a mental health professional, such as a counselor or psychologist, may treat you. If you have severe depression or if treatment is not helping, you may need to see a psychiatrist. Some people need to be treated in the hospital, especially if they have thoughts of suicide.

Work with your health care team to find the best treatment for you. It may take a few tries, and it can take several weeks for the medicine to start working. Try to be patient and keep following your treatment plan.

Depression can return (relapse). How likely you are to get depression again increases each time you have a bout of depression. Taking your medicines and continuing some types of therapy after you feel better can help keep that from happening. Some people need to take medicine for the rest of their lives. This does not stop them from living full and happy lives.

Let your doctor know if you think you are depressed. Depression is easy to overlook. The earlier you are treated, the more quickly you will get better.

Types of medication

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are a class of antidepressants considered the current standard of drug treatment. A possible cause of depression is an inadequate amount of serotonin, a chemical used in the brain to transmit signals between neurons. SSRIs are said to work by preventing the reuptake of serotonin (also known as 5-hydroxytryptamine, or 5-HT) by the presynaptic neuron, thus maintaining higher levels of 5-HT in the synapse. Chemists Klaus Schmiegel and Bryan Molloy of Eli Lilly discovered the first SSRI, fluoxetine. This class of drugs includes:

• Citalopram (Celexa)
• Escitalopram (Lexapro, Cipralex)
• Fluoxetine (Prozac, Sarafem, Selfemra)
• Fluvoxamine (Luvox CR)
• Paroxetine (Paxil, Pexeva)
• Sertraline (Zoloft)

Theseantidepressants typically have fewer adverse effects than the tricyclics or the MAOIs, although such effects as drowsiness, dry mouth, nervousness, anxiety, insomnia, decreased appetite, and decreased ability to function sexually may occur. Some side effects may decrease as a person adjusts to the drug, but other side effects may be persistent. Though safer than first generation antidepressants, SSRIs may not work on as many patients as previous classes of antidepressants, suggesting the role of norepinephrine in depression is still important.

Work by two researchers has called into question the link between serotonin deficiency and symptoms of depression, noting that the efficacy of SSRIs as treatment does not in itself prove the link. Research indicates that these drugs may interact with transcription factors known as “clock genes,” which may play a role in the addictive properties of drugs (drug abuse), and possibly in obesity.

Randomized controlled trials published in the Archives of General Psychiatry showed that up to one-third of the effect of SSRI Treatment can be seen in the first week. These early effects have also been shown to increase the absolute reduction in HRSD scores by 50%.

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

Serotonin-norepinephrine reuptake inhibitors (SNRIs) are a newer form of antidepressant that work on both norepinephrine and 5-HT. They typically have similar side effects to the SSRIs, though there may be a withdrawal syndrome on discontinuation that may necessitate dosage tapering. These include:

• Desvenlafaxine (Pristiq)
• Duloxetine (Cymbalta)
• Milnacipram (Ixel)
• Venlafaxine (Effexor XR)

Noradrenergic and specific serotonergic antidepressants (NaSSAs)

Noradrenergic and specific serotonergic antidepressants (NaSSAs) form a newer class of antidepressants which purportedly work to increase norepinephrine (noradrenaline) and serotonin neurotransmission by blocking presynaptic alpha-2 adrenergic receptors while at the same time blocking certain serotonin receptors. Side effects may include drowsiness, increased appetite, and weight gain.Examples include:

• Mianserin (Tolvon)
• Mirtazapine (Remeron, Avanza, Zispin)

Norepinephrine (noradrenaline) reuptake inhibitors (NRIs)

Norepinephrine (noradrenaline) reuptake inhibitors (NRIs) act via norepinephrine (also known as noradrenaline). NRIs are thought to have a positive effect on the concentration and motivation in particular. These include:

• Atomoxetine (Strattera)
• Mazindol (Mazanor, Sanorex)
• Reboxetine (Edronax)
• Viloxazine (Vivalan)

Norepinephrine-dopamine reuptake inhibitors (NDRIs)

Norepinephrine-dopamine reuptake inhibitors inhibit the neuronal reuptake of dopamine and norepinephrine (noradrenaline). These include:

• Bupropion (Wellbutrin XL, Aplenzin, Budeprion XL, Budeprion SR, Zyban)

Selective serotonin reuptake enhancers (SSREs)

• Tianeptine (Stablon, Coaxil, Tatinol)

Melatonergic agonists

• Agomelatine (Valdoxan, Melitor, Thymanax)

Tricyclic antidepressants (TCAs)

Tricyclic antidepressants are the oldest class of antidepressant drugs. Tricyclics block the reuptake of certain neurotransmitters such as norepinephrine (noradrenaline) and serotonin. They are used less commonly now due to the development of more selective and safer drugs. Side effects include increased heart rate, drowsiness, dry mouth, constipation, urinary retention, blurred vision, dizziness, confusion, and sexual dysfunction. Toxicity occurs at approximately ten times normal dosages; these drugs are often lethal in overdoses, as they may cause a fatal arrhythmia. However, tricyclic antidepressants are still used because of their effectiveness, especially in severe cases of major depression. These include:

TERTIARY AMINE TRICYCLIC ANTIDEPRESSANTS:

• Amitriptyline (Elavil, Endep)
• Clomipramine (Anafranil)
• Doxepin (Adapin, Sinequan)
• Imipramine (Tofranil)
• Trimipramine (Surmontil)

SECONDARY AMINE TRICYCLIC ANTIDEPRESSANTS

• Desipramine (Norpramin)
• Nortriptyline (Pamelor, Aventyl)
• Protriptyline (Vivactil)

Monoamine oxidase inhibitor (MAOIs)

Monoamine oxidase inhibitors (MAOIs) may be used if other antidepressant medications are ineffective. Because there are potentially fatal interactions between this class of medication and certain foods (particularly those containing tyramine), red wine, as well as certain drugs, classic MAOIs are rarely prescribed anymore. However, this does not apply to Emsam, the transdermal patch form of selegiline, which due to its bypassing of the stomach has never been reported to induce such events. MAOIs work by blocking the enzyme monoamine oxidase which breaks down the neurotransmitters dopamine, serotonin, and norepinephrine (noradrenaline). MAOIs can be as effective as tricyclic antidepressants, although they can have a higher incidence of dangerous side effects (as a result of inhibition of cytochrome P450 in the liver). A new generation of MAOIs has been introduced; moclobemide (Manerix), known as a reversible inhibitor of monoamine oxidase A (RIMA), acts in a more short-lived and selective manner and does not require a special diet. As one of the side effects is weight gain and could be extreme. These include:

• Isocarboxazid (Marplan)
• Moclobemide (Aurorix, Manerix)
• Phenelzine (Nardil)
• Selegiline (Eldepryl, Emsam)
• Tranylcypromine (Parnate)

Augmenter drugs

Some antidepressants have been found to work better in some patients when used in combination with another drug. Such “augmenter” drugs include:

• Buspirone (Buspar)
• Gepirone (Ariza)
• Nefazodone (Serzone)
• Tandospirone (Sediel)
• Trazodone (Desyrel)

Tranquillizers and sedatives,typically thebenzodiazepines, areprescribedtoease anxiety and promote sleep. Because of the high risk of dependency, these medications are intended only for short-term or occasional use. Medications are often used not for their primary functions, but to exploit what are normally side effects. Quetiapine fumarate (Seroquel) is designed primarily to treat schizophrenia and bipolar disorder, but frequently causes somnolence because of its affinity for histamine (H1 and H2) receptors, exploiting the same side effects as diphenhydramine (Benadryl).

Antipsychotics such as risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel) are prescribed as mood stabilizers and to treat anxiety. Their use as mood stabilizers is a recent phenomenon, and controversial among some patients. Antipsychotics, whether typical or atypical, may also be prescribed to augment an antidepressant, to increase the blood concentration of another drug, or to relieve the psychotic or paranoid symptoms that often accompany clinical depression. However, they can cause serious side effects, particularly at high dosages, including blurred vision, muscle spasms, restlessness, tardive dyskinesia, and weight gain.

Psychostimulants are sometimes added to an antidepressant regimen if the patient suffers from anhedonia, hypersomnia and/or excessive eating as well as low motivation. These symptoms are common in atypical depression, and can be resolved by adding low to moderate doses of amphetamine (Adderall) or Methylphenidate (Ritalin, Methylin) as these chemicals can enhance motivation and social behavior, and suppress appetite and sleep. They can also restore sex drive. Extreme caution must be used however with certain populations. Stimulants are known to trigger manic episodes in people suffering from bipolar disorder. Close supervision of those with substance abuse disorders is urged. Emotionally labile patients should avoid stimulants, as they exacerbate mood shifting.

Lithium remains the standard treatment for bipolar disorder and is often used in conjunction with other medications, depending on whether mania or depression is being treated. Lithium’s potential side effects include thirst, tremors, light-headedness, nausea, and diarrhea. Some of the anticonvulsants, such as carbamazepine (Tegretol), sodium valproate (Epilim), and lamotrigine (Lamictal), are also used as mood stabilizers, particularly in bipolar disorder. Both lithium and lamotrigine have also been studied and used to augment antidepressants in treatment-resistant unipolar depression.

Drugs rating:

	Title	Votes	Rating
1	Tranylcypromine	2		(9.5/10)
2	Sarafem (Fluoxetine)	26		(9.3/10)
3	Xanax (Alprazolam)	1189		(8.7/10)
4	Nefazodone	11		(8.7/10)
5	Selegiline	7		(8.6/10)
6	Symbyax (Fluoxetine and Olanzapine)	89		(8.2/10)
7	Parnate (Tranylcypromine)	62		(8.2/10)
8	Serzone (Nefazodone)	35		(8.2/10)
9	Nardil (Phenelzine)	82		(8.0/10)
10	Endep (Amitriptyline)	71		(8.0/10)
11	Marplan (Isocarboxazid)	1		(8.0/10)
12	Clomipramine	30		(7.7/10)
13	Adderall (Amphetamine and Dextroamphetamine)	932		(7.6/10)
14	Imipramine	26		(7.6/10)
15	Citalopram	510		(7.5/10)
16	Fluoxetine	187		(7.5/10)
17	Doxepin	86		(7.5/10)
18	Fluvoxamine	19		(7.5/10)
19	Pexeva (Paroxetine)	11		(7.5/10)
20	Sertraline	236		(7.4/10)
21	Amitriptyline	228		(7.4/10)
22	Escitalopram	198		(7.4/10)
23	Emsam (Selegiline)	70		(7.4/10)
24	Effexor XR (Venlafaxine)	1273		(7.3/10)
25	Sinequan (Doxepin)	68		(7.3/10)
26	Lamictal (Lamotrigine)	1492		(7.2/10)
27	Venlafaxine	214		(7.2/10)
28	Bupropion HCl	178		(7.2/10)
29	Vivactil (Protriptyline)	5		(7.2/10)
30	Trazodone	706		(7.1/10)
31	Methylphenidate	426		(7.1/10)
32	Paroxetine	190		(7.1/10)
33	Desvenlafaxine	129		(7.1/10)
34	Nortriptyline	88		(7.0/10)
35	Zyban (Bupropion)	26		(7.0/10)
36	Lexapro (Escitalopram)	3659		(6.9/10)
37	Seroquel (Quetiapine)	1157		(6.9/10)
38	Wellbutrin XL (Bupropion)	601		(6.9/10)
39	Luvox CR (Fluvoxamine)	18		(6.9/10)
40	Celexa (Citalopram)	1264		(6.7/10)
41	Prozac (Fluoxetine)	1139		(6.7/10)
42	Desyrel (Trazodone)	557		(6.7/10)
43	Pristiq (Desvenlafaxine)	525		(6.7/10)
44	Tofranil (Imipramine)	136		(6.7/10)
45	Norpramin (Desipramine)	31		(6.7/10)
46	Zoloft (Sertraline)	1585		(6.6/10)
47	Anafranil (Clomipramine)	155		(6.6/10)
48	Cymbalta (Duloxetine)	1832		(6.5/10)
49	Desipramine	2		(6.5/10)
50	Risperdal (Risperidone)	285		(6.4/10)
51	Mirtazapine	105		(6.4/10)
52	Paxil (Paroxetine)	1091		(6.3/10)
53	Remeron (Mirtazapine)	547		(6.3/10)
54	Zyprexa (Olanzapine)	444		(6.3/10)
55	Budeprion SR (Bupropion)	51		(6.3/10)
56	Pamelor (Nortriptyline)	134		(5.9/10)
57	Aplenzin (Bupropion)	12		(5.9/10)
58	Elavil (Amitriptyline)	682		(5.7/10)
59	Buspar (Buspirone)	540		(4.8/10)
60	Budeprion XL (Bupropion)	52		(4.3/10)
61	Adapin (Doxepin)	0		(0/10)
62	Eldepryl (Selegiline)	0		(0/10)
63	Sanorex (Mazindol)	0		(0/10)
64	Maprotiline	0		(0/10)
65	Surmontil (Trimipramine)	0		(0/10)
66	Selfemra (Fluoxetine)	0		(0/10)
67	Mazanor (Mazindol)	0		(0/10)

What can you do if a loved one has depression?

If someone you care for is depressed, the best thing you can do is help the person get or stay in treatment. Learn about the disease. Talk to the person and gently encourage him or her to do things and see people. Don’t get upset with the person. The behavior you see is the disease, not the person.

Is suicide a concern?

Many people who have depression have thoughts of death or thoughts of suicide, and depression can lead to suicide. Learn the warning signs of suicide, which include talking a lot about death, givingthings away, or usinga lot ofalcohol or drugsorboth. If you see these signs in yourself or a loved one, get help.