TREATMENTS FOR DEPRESSION

Drugs known as antidepressants

CLASS:- "SPECIFIC SEROTONIN RE-UPTAKE INHIBITORS"
(SSRIs or sometimes the "5-HT RE-UPTAKE BLOCKERS")

(1) These two drugs are included here for convenience (see below)

(2) Escitalopram is a cleaner version of citalopram. Citalopram is a mixture of two molecules, which are identical except that they are mirror images of each other. Escitalopram is the molecule that actually has the antidepressant action and is now available in UK without the other molecule, which had no action. The result is the same, but escitalopram may have slightly fewer side effects and may even be slightly more effective.

What are the SSRI's used for ?

SSRIs are antidepressants which are used to help to improve mood in people who are feeling low or depressed. Fluoxetine ("Prozac") may also be used to help treat the eating disorder "Bulimia nervosa". In addition to this, the SSRIs are now widely used to help a variety of other symptoms. These include anxiety (where a lower starting dose often helps), social phobia and social anxiety, obsessive-compulsive disorder, post-traumatic stress disorder, panic, pre-menstrual syndrome and agoraphobia. Some drugs are "licensed" (ie officially approved) for some of these conditions (e.g. paroxetine for social phobia) but this does not necessarily mean the others do not help, just one manufacturer can prove it and has applied for a licence.

Trazodone ("Molipaxin") and nefazodone ("Dutonin") are not strictly pure "SSRIs" but have many of the same effects and so are included in this group for convenience.

The SSRIs are now one of the most commonly prescribed antidepressants but there are many other similar drugs. All these antidepressants seem to be equally effective at the proper dose but have different side effects to each other. Apart from nausea, the SSRIs generally have less side effects than the older drugs. If one drug does not suit you, it may be possible to try another. Starting with a lower dose for a week or so may also help the drugs to be more tolerable or have less side effects.

How do the SSRI's work ?

The brains has many naturally occurring chemical messengers. One of these are called serotonin (sometimes called 5-HT) and is important in the areas of the brain that control mood and thinking. It is known that this serotonin is not as effective or active as normal in the brain when someone is feeling depressed. The SSRI antidepressants increase the amount of this serotonin chemical messenger in the brain. This can help correct the lack of action of serotonin and help to improve mood. For a more detailed explanation, click here.

How should I take them ?

Tablets and capsules:

Tablets and capsules should be swallowed with at least half a glass of water whilst sitting or standing. This is to make sure that they reach the stomach and do not stick in your throat.

Trazodone modified release tablets ("Molipaxin CR") should be swallowed whole and not chewed. This is because they are made so that they release the drug over a longer period of time. This can help to reduce side-effects or reduce the number of times a day you need to take your medicine. Crushing or chewing these will cause the drug to be released too quickly.

Liquids:

Your pharmacist should give you a medicine spoon or oral syringe. Use it carefully to make sure you measure the correct amount. Ask your pharmacist for a medicine spoon if you do not have one.

When should I take the SSRI ?

Take your medication as directed on the medicine label. Try to take it at regular times each day. If you are told to take your dose once a day this will usually be best in the morning, except with fluvoxamine, which is probably best in the evening. If you feel sick when you first start taking your SSRI, this should only last for a few days, but this can be helped by taking your medicine with or after food. Also, taking them at mealtimes may make it easier to remember as there is no problem about taking any of these drugs with or after food. They are not sleeping tablets.

How long will the SSRI take to work ?

It may take as long as two weeks or more before the SSRIs start to have any effect on your mood, and a further three or four weeks for this effect to be reaching its maximum. Unfortunately in some people the effect may take even longer to occur e.g. several months, especially if you are older.

How long will I need to keep taking the SSRI for ?

This should be discussed with your doctor, as people respond differently. To help you make a decision, it may be useful for you to know that research has shown that:

• for a first episode of major depression, your chances of becoming depressed again are much lower if you keep taking the antidepressant for six months after you have recovered (longer if you have risk factors for becoming depressed again)
• for a second episode, your chances of becoming depressed again are lower if you keep taking the antidepressant for one or two years after you have got better
• for depression that keeps coming back, keeping taking an antidepressant has been shown to have a protective effect for at least five years.

Are the SSRIs addictive ?

They are not addictive, but if you have taken them for eight weeks or more you may experience some mild "discontinuation" effects if you stop them suddenly. These do not mean that the antidepressant is addictive. For a drug to be addictive or produce dependence, then it must have a number of characteristics:

• should produce craving for the drug when the last dose "wears off"
• should produce tolerance ie you need more drug to get the same effect
• there should be an inability to cut down or control use
• should produce withdrawal symptoms
• there should be continued use of the drug despite knowing of harmful consequences

Thus antidepressants, if stopped suddenly, may produce some "discontinuation" symptoms but these are more of an "adjustment" reaction from sudden removal of a drug rather than withdrawal. For further discussion, click here.

Can I stop taking the SSRI suddenly ?

It is unwise to stop taking them suddenly, even if you feel better. Two things could happen. Firstly, your depression can return if treatment is stopped too early (see "How long will I need to keep taking them for?"). Secondly, you might also experience some mild "discontinuation" symptoms (see also above). At worst, these could include dizziness, vertigo/light-headedness, nausea fatigue, headache, "electric shocks in the head", insomnia, abdominal cramps, chills increased dreaming, agitation and anxiety. They can start shortly after stopping or reducing doses, are usually short lived, will go if the antidepressant is started again and can even occur with missed doses. These effects have been reported for all the SSRIs, but it seems that they occur more often with paroxetine than the others.

If you get these discontinuation symptoms, you have a number of options:

• If they are not severe, you can wait for the symptoms to go - they usually only last for a few days or weeks
• Ask for something to help your symptoms in the short-term e.g. a sedative or sleeping tablet
• Start the medication again (the symptoms should go) and then try reducing the dose more slowly over a longer time e.g. reduce the dose by about a quarter (25%) every 4-6 weeks. Another system that works for some people is to use the syrup; everytime you take a dose, add some diluent (e.g. syrup or water) and then the syrup gradually (rather than suddenly) gets more and more dilute.
• Switch to another antidepressant - this sometimes helps e.g. fluoxetine has a long "half-life" and is easier to stop than is e.g. paroxetine

When the time comes your doctor should withdraw the drug slowly e.g. by reducing the dose gradually every few weeks. You should discuss this with your doctor.

What should I do if I forget to take a dose ?

Start again as soon as you remember unless it is almost time for your next dose, then go on as before. Do not try to catch up by taking two or more doses at once as you may get more side-effects. You should tell your doctor about this next time you meet.

If you have problems remembering your doses (as very many people do) ask you pharmacist, doctor or nurse about this. There are some special packs, boxes and devices which can be used to help you remember.

What sort of side-effects might occur ?

Table adapted from UK Psychiatric Pharmacy Group leaflets, with kind permission (www.ukppg.org.uk )

Do not be worried by this list of side effects. You may get none at all. There are other rare side-effects. If you develop any unusual symptoms ask your doctor about them next time you meet.

There has been much in the newspapers and magazines about people who are supposed to have become more aggressive or suicidal whilst taking fluoxetine (‘Prozac’). There has also been much which implies that ‘Prozac’ is somehow a "wonder drug". It might be worth noting that;-

• All antidepressants can cause a very few people to become more aggressive or suicidal. There is now plenty of evidence to show that fluoxetine (‘Prozac’) is the same as (and certainly no worse than) any other antidepressant in this respect.
• There is no particular evidence that fluoxetine or any other drug in this group is a wonder drug. It is just that they generally have less side effects than the older antidepressants and are much less toxic than the older antidepressants.

Will the SSRI cause me to put on weight ?

Fluoxetine ("Prozac") may cause you to lose weight. You tend to lose more the heavier you are so this "side effect" is not usually one which people complain about! The other drugs in this group tend to have less of an effect on body weight. If, however, you do start to have problems with your weight tell your doctor next time you meet as he or she can arrange for you to see a dietician for advice. It may be that in the long term (ie several years), there may be tendency to gain a little weight.

Will it affect my sex life?

Drugs can affect desire (libido), arousal (erection) and orgasmic ability. The SSRIs are know to affect all three stages in some people. Delayed orgasm is known to occur in many people. Indeed some of these drugs are now widely used to help treat premature ejaculation. If this does seem to have happened, you should discuss this with your doctor, as a change in dose, when you take the dose or drug may help reduce any problem.

With trazodone, a serious condition known as priapism has been reported very rarely. Priapism occurs in men and is defined as a persistent painful erection without sexual stimulation. It is no joke and should be treated as an emergency, as it can cause permanent damage. If this should happen, you should go to a hospital accident and emergency department as soon as possible, and certainly within a couple of hours.

Will the SSRI make me drowsy ?

These drugs may make you feel drowsy, although this effect is less than with other antidepressants. You should not drive (see below) or operate machinery until you know how they affect you. You should be careful as they may affect your reaction times or reflexes. They are not, however, sleeping tablets, although if you take them at night they may help you get to sleep.

Can I drink alcohol while I am taking the SSRI ?

You should avoid alcohol except in moderation while taking these drugs as they may make you feel more sleepy. This is particularly important if you need to drive or operate machinery and you must seek advice on this. Also, the effects of alcohol can be increased if it is taken while you are taking fluvoxamine ("Faverin").

Are there any foods or drinks that I should avoid ?

You should have no problems with any food or drink other than alcohol (see above).

Will the SSRI affect my other medication ?

If you are taking "Faverin" (fluvoxamine) tablets do not take indigestion remedies at the same time of day. This is because these tablets are 'enteric coated'. Indigestion remedies contain alkalis, substances which can break down the coating of the tablet before it reaches the stomach. You might then get more side effects. If you need to take something for indigestion wait for at least 2 hours after taking your "Faverin" tablets.

You should have no problems if you take any other medications although a few problems can occur. The SSRIs can "interact" with "MAOI's", lithium, tricyclic antidepressants (e.g. amitriptyline, clomipramine, dothiepin etc.) and anticoagulants e.g. warfarin, although your doctor should know about these. This also does not necessarily mean the drugs can not be used together, just that you may need to follow your doctors instructions very carefully. Make sure your doctor knows about all the medicines you are taking. Some other medicines e.g. some of the antihistamines used for hay fever can make you drowsy. Combined with your SSRI this could make you even drowsier. There has been much concern about the safety of St. John's wort with antidepressants. Until more information is available, you should avoid taking St. John's wort along with any other antidepressant. You should tell your doctor before starting or stopping these or any other drugs.

If I am taking a contraceptive pill, will this be affected ?

It is not thought that the contraceptive pill is affected by any of these drugs, although if you suffered diarrhoea and vomiting this might reduce the effectiveness of the oral contraceptive.

What if I want to start a family or discover I'm pregnant?

It is important to consider that there will be a risk to you and your child from taking a medicine during pregnancy but also a possible risk from stopping the medicine e.g. getting ill again. Unfortunately, no decision is risk-free. It will be for you to decide which is the least risk. All we can do here is to help you understand some of the issues, so you can make an informed decision. For your information, major malformations occur "spontaneously" in about 2-4% of all pregnancies, even if no drugs are taken. The main problem with medicines is termed "teratogenicity" i.e. a medicine causing a malformation in the unborn child. A medicine causing teratogenicity is called a "teratogen". Since a baby has completed it's main development between days 17 and 60 of the pregnancy (the so-called "first trimester") these first 2-16 weeks are the main concern. After that, there may be other problems e.g. some medicines may cause slower growth. The infant may also be affected after birth e.g. withdrawal effects are possible with some drugs.

If possible, the best option is to plan in advance. If you think you could become pregnant, discuss this with your doctor and it may be possible to switch to medicines thought to carry least risk, and take other risk-reducing steps e.g. adjusting doses, taking vitamin supplements etc. If you have just discovered you are pregnant, don't panic, but seek advice from your GP within the next few days if possible. He or she may also want to refer you on to someone with more specialist knowledge of your medicine.

Very few medicines have been shown to be completely safe in pregnancy and so no manufacturer or advisor can ever say any medicine is safe. They will usually advise not to take a medicine during pregnancy, unless the benefit is much greater than the risk. In the UK, there is the NTIS (National Teratology Information Service) who offer individual risk assessments. However, their advice should always be used to help you and your doctor decide what is the risk to you and your baby. There is a risk from taking the medicine and a risk should you stop a medicine e.g. you might become ill again and need to go back on the medication again. The advice offered here is just that i.e. advice, but may give you some idea about the possible risks and what (at the time of writing) is known through the medical press.

It may be helpful to know that in the USA, the FDA (Food and Drug Administration) classifies medicines in pregnancy in five groups:

The SSRIs are classified as "B" or "C" (fluoxetine, paroxetine and sertraline are "B", citalopram and fluvoxamine are "C"). The SSRIs are not teratogenic in animals, and most human data is for fluoxetine. No major abnormalities have been reported to date with paroxetine, but some "discontinuation" effects (such as increased breathing rate and jitteriness) have been seen in a few infants for a couple of days after birth, so it may be wise to reduce the dose a little before your due date. Fluoxetine is the most widely studied SSRI in pregnancy. Information on over 2000 pregnancies indicates that the risk of "spontaneous abortion" may be slightly higher than normal but that the number of abnormalities is the same as the general population and so fluoxetine did not appear to be a major risk. A recent study has shown no evidence of any short or long-term effects on intelligence and language development, although there was a slight reduction in the length of pregnancy (by about 6 days). You should, however, still seek personal advice from your GP, who may then if necessary seek further specialist advice.
Trazodone and nefazodone are both classified as "C". There is no evidence of a teratogenic effects, and animal tests show a low risk of danger but you should seek personal advice from your GP, who may then if necessary seek further specialist advice.

Will I need a blood test ?

You will not need a blood test to check on your SSRI.

Can I drive while I am taking the SSRI ?

You may feel drowsy at first when taking any of these drugs. Until this wears off or you know how your drug affects you do not drive or operate machinery. You should be careful as they may affect your reaction times.

It is against the law to drive, attempt to drive or be in charge of a vehicle when unfit, either through illness or from the side effects of medication. Under UK law, it is the drivers responsibility to let the DVLA and insurance company know if you may be "unfit" to drive. If you do not, and you have an accident, it could effect your insurance cover. Your doctor will be able to advise you, and may wish to access the UK Driver and Vehicle Licensing Agency (DVLA) guidelines website, which has the current DVLA guidelines on anxiety/depression, psychotic disorders, mania and other conditions. If your doctor advises you not to drive, and you continue to do so, the doctor can inform the DVLA directly, as he or she would be lawfully responsible were you to have an accident. Once told, the DVLA may wish to carry out an enquiry, but you are entitled to drive until a decision is made.

Email your comments or feedback.
Several developments have been as a result of feedback from visitors.

No site can be entirely bias-free. No matter how hard someone tries, training and background will always influence your outlook. We have, however, tried to eliminate bias, and we hope you take these pages in the spirit in which they are provided i.e. a genuine attempt to inform, educate and support.

Information here is based on published data. References include the UK British National Formulary (BNF, published by the British Medical Association and Royal Pharmaceutical Society of Great Britain), Martindale (the extra pharmacopoea, published by RPSGB Pharmaceutical Press), Psychotropic Drug Directory (latest edition), Data Sheet Compendium (UK Manufacturers Data Sheets, published by the Association of British Pharmaceutical Industry), MicroMedex (an independent and extensive CD-ROM based drug information source), UK Psychiatric Pharmacy Group leaflets, Royal College of Psychiatrists advice and guidelines and the current medical literature. Thanks also to all those people who left e-mail comments, suggestions and requests, who have helped shape the site.  

Email your comments or feedback.
Many developments have been as a result of feedback from visitors.

No site can be entirely bias-free. No matter how hard someone tries, training and background will always influence your outlook. We have, however, tried to eliminate bias, and we hope you take these pages in the spirit in which they are provided i.e. a genuine attempt to inform, educate and support.

Information here is based on published data. References include the UK British National Formulary (BNF, published by the British Medical Association and Royal Pharmaceutical Society of Great Britain), Martindale (the extra pharmacopoea, published by RPSGB Pharmaceutical Press), Psychotropic Drug Directory (latest edition), Data Sheet Compendium (UK Manufacturers Data Sheets, published by the Association of British Pharmaceutical Industry), MicroMedex (an independent and extensive CD-ROM based drug information source), UK Psychiatric Pharmacy Group leaflets, Royal College of Psychiatrists advice and guidelines and the current medical literature. Thanks also to all those people who left e-mail comments, suggestions and requests, who have helped shape the site.