Which Antidepressant Medication Is Best?
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Introduction
Antidepressant medications are some of the most commonly prescribed medications in the United States. According to the Centers for Disease Control and Prevention, in 2018, over 13% of the adult population in the United States reported using antidepressants in the past 30 days. These trends have only increased with time, especially in a world where mental health awareness remains on the rise.
Antidepressants treat much more than just depression
While antidepressants are primarily used to treat depression, these medications are very versatile, and have also been used to treat a wide variety of conditions besides depression. Antidepressants are first-line treatments for most anxiety disorders as well, including generalized anxiety disorder and panic disorder. They are also used to treat obsessive-compulsive disorder, post-traumatic stress disorder, eating disorders, and even conditions such as chronic pain, fibromyalgia, stroke recovery, and enuresis (bedwetting) in children. Their versatility and efficacy helps explain the enduring popularity of these medications.
While many people are happy with their antidepressant medication, however, some are disappointed; whether due to side-effects or a lack of response. As a result, psychiatrists often get asked “which antidepressant medication is best?” or “am I on the right antidepressant medication?
There are several different classes of antidepressant medication
Firstly, it's crucial to acknowledge that what works for one individual may not work for another. Each person's brain chemistry is unique, and what alleviates symptoms for one person might exacerbate them for another. Additionally, the severity of depression, potential side effects, personal preferences, cost, and medical history all play significant roles in determining the most suitable medication.
That being said, let's delve into some of the commonly prescribed antidepressants and their characteristics.
Selective Serotonin Reuptake Inhibitors (SSRIs):
SSRIs are often the first line of treatment for depression due to their efficacy and relatively low risk of severe side effects compared to older antidepressants. Examples of SSRIs include Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Celexa (citalopram), and Lexapro (escitalopram). These medications work by increasing the levels of serotonin in the brain, which is thought to regulate mood. Please note that this is a very simplified explanation of the mechanism of action.
SSRIs are generally well-tolerated, but common side effects may include nausea, insomnia, sexual dysfunction, and weight gain. It's important to note that while SSRIs can be effective, they may take several weeks to reach their full therapeutic effect. Additionally, finding the right SSRI and dosage may require some trial and error.
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):
SNRIs, such as Cymbalta (duloxetine), Effexor (venlafaxine), Pristiq (desvenlafaxine), Savella (milnacipran), and Fetzima (levomilnacipran) work by increasing the levels of both serotonin and norepinephrine in the brain. This dual mechanism of action may provide additional benefits for some individuals, but this is not always the case.
Like SSRIs, SNRIs can cause side effects such as nausea, insomnia, and sexual dysfunction. Some people believe that SNRIs may offer improved efficacy compared to SSRIs in certain individuals, although this is controversial.
Serotonin modulators
Some newer antidepressants are marketed as “serotonin modulators”, including vortioxetine (Trintellex) and vilazodone (Viibryd). These medications are very similar to SSRI medications, however. For example, vortioxetine’s primary mechanism of action is to inhibit serotonin reuptake - same as SSRI medications. These serotonin modulators are believed to have similar efficacy and side effects as SSRIs.
Tricyclic Antidepressants (TCAs):
TCAs, such as amitriptyline and nortriptyline, are older antidepressants that also work by blocking the reuptake of serotonin and norepinephrine. While TCAs can be effective for treating depression, they are generally reserved for cases where other medications have been ineffective due to their higher risk of side effects.
TCAs can cause a range of side effects, including dry mouth, constipation, blurred vision, dizziness, and weight gain. They also carry a higher risk of overdose compared to newer antidepressants. Due to these factors, TCAs are generally not used as first-line antidepressants anymore.
Monoamine Oxidase Inhibitors (MAOIs):
MAOIs, such as Nardil (phenelzine) and Parnate (tranylcypromine), are among the oldest classes of antidepressants. They work by inhibiting the enzyme monoamine oxidase, thereby increasing the levels of neurotransmitters like serotonin, norepinephrine, and dopamine. MAOIs are typically reserved for cases of treatment-resistant depression due to their potential for serious side effects and interactions with certain foods and medications.
MAOIs require strict dietary restrictions to avoid a dangerous rise in blood pressure known as a hypertensive crisis. Additionally, they can interact with a wide range of medications, including over-the-counter cold remedies and many other prescription drugs. Due to these limitations, MAOIs are generally not used as first-line antidepressants anymore.
Atypical Antidepressants:
Atypical antidepressants encompass a diverse group of medications that don't fit neatly into the categories mentioned above. Examples include Wellbutrin (bupropion), Remeron (mirtazapine), and trazodone. These medications may work through various mechanisms, such as dopamine and norepinephrine reuptake inhibition or modulation of serotonin receptors.
Atypical antidepressants may offer advantages such as different side effect profiles compared to traditional SSRIs and SNRIs. For example, Wellbutrin is less likely to cause sexual dysfunction but may increase the risk of seizures in certain individuals. Remeron is sometimes prescribed for its sedating effects, which can be beneficial for individuals with insomnia or anxiety. It is also possible to combine an atypical antidepressant with SSRI or SNRIs under the careful supervision of a psychiatrist.
Many antidepressants share similar side effects
Here is a chart from whatmedicine.org comparing side effects of commonly prescribed antidepressant medications.
But please note that any antidepressant can cause any of the side-effects listed on the table, and that side effects from antidepressants are highly variable and individualized!
Conclusion
So, which antidepressant is the best? The truth is, there's no one-size-fits-all answer. All antidepressants are effective for treating depression (compared to either placebo or no treatment at all), but what works best for one person may not work for another. It often takes time and patience to find the right medication and dosage that provides relief with manageable side effects. If there was a “best” antidepressant, then everyone would already be taking that medication!
Moreover, medication alone is rarely sufficient for treating depression. Psychotherapy, lifestyle changes, social support, and other interventions are often essential components of a comprehensive treatment plan. Furthermore, some people experience treatment-resistance, a poorly understood phenomenon where their depressive symptoms do not respond well to antidepressants. It's crucial for individuals experiencing depression to work closely with a healthcare provider to explore all available options and tailor a treatment approach that meets their specific needs and preferences.
In conclusion, while the question of which antidepressant is best may not have a definitive answer, there are many effective options available. By understanding the different classes of antidepressants, their mechanisms of action, and potential side effects, individuals can make informed decisions with the guidance of their healthcare providers. Ultimately, the goal is to find a treatment regimen that improves mood, enhances quality of life, and supports long-term mental well-being.
Want to talk with someone about your medications?
If you would like to speak with someone about your medications, and you live in the Dallas-Fort Worth (DFW) areas, click here to request an appointment with one of Prestonwood Health's board-certified psychiatrists. After a thorough evaluation, we will talk with you about your treatment options to begin your return to wellness. You may also e-mail us or call us at 214-810-1898.
