Psychopathology Sum-Up: Types of Antidepressants

Weekly series! As per previous discussion, I will be publishing a big information blog on each Friday. Unfortunately, it’s midterms for me, which means a shorter post for you. Blame the paper(s) and exams and readings and stuff. I promise to be back on schedule next week. Also, I’ve commissioned a post on bulimia from Tetyana, who runs the spectacular Science of Eating Disorders blog, a skeptical look at research on ED’s.

Anyways, today we look at the types of antidepressants.

Selective Serotonin Reuptake Inhibitors (SSRI’s)

[Note to neurobiologists: I am simplifying massively here. I know that.]

These are the most popular medications for depression, and include a bunch of names you probably recognize: Zoloft, Prozac, Paxil, Celexa, Lexapro.

How do they work?

A general sketch of two neurons.
A general sketch of two neurons.

Neurons don’t connect directly to each other–they have a very tiny space (the synaptic cleft) between each end of one and beginning of the next. Neurotransmitters (like serotonin, dopamine, GABA, etc) are released from the presynaptic neuron, and partially absorbed by the postsynaptic neuron. The neurotransmitter that isn’t absorbed is mainly taken back by the presynaptic neuron. SSRI’s work by blocking the reuptake mechanism for serotonin, leaving more available serotonin in the brain, which seems to relieve depression in some people.

But, this is grossly oversimplified, and depression is not as basic as not having enough serotonin. In the words of Ozy, brain chemicals are not fucking magic.

Side effects of SSRI’s can include lack of sex drive, hyperactivity or lowered energy, etc. In some, these are so life-disrupting that other medications are preferred.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRI’s)

SNRI’s include Cymbalta, Effexor, and Pristiq. They work very much like SSRI’s, except they inhibit both the reuptake mechanism for norepinephrine and serotonin.

The effectiveness of SSRI’s lends support to the Monoamine Hypothesis–an incomplete explanation for depression, suggesting that several neurotransmitter systems (including serotonergic) are responsible.  The hypothesis does hold up to scrutiny, but doesn’t explain why many antidepressants also help with anxiety and obsessive-type disorders.

Tricyclic Antidepressants

Color me happy to have done my research before publishing–turns out I didn’t have all of my facts straight. Tricyclics are antidepressants that operate somewhat like SSRI’s by inhibiting the reuptake of serotonin–but they also have a laundry list of possible side effects, and, like MAOI’s, are used more and more rarely.

Monoamine Oxidase Inhibitors (MAOI’s)

MAOI’s can be super effective! However, they come with hefty diet restrictions, and resultingly, are used rarely–mostly as a last resort.

People taking MAOI’s need to avoid all sorts of things, like pickled foods, most cheeses, wine, decongestants, and SSRI’s. Failure to do so can cause a stroke–the result of buildup of tyramine in the brain. Since other antidepressants are available, MAOI’s have fallen out of favor.

Norepinephrine and dopamine reuptake inhibitors (NDRIs)

Wellbutrin! NDRI’s are good because they usually don’t have the sexual side effects. They too, lend support to the Monoamine Hypothesis, by altering the dopaminergic and norandronergic pathways.

St. Johns Wort

Okay. This is alt-med, but it’s been gaining mainstream popularity. It’s one of those that might work on mild to moderate depression. And if taken without doctor supervision and with other medications it can cause you all sorts of problems. In combination with SNRI’s, it can cause Serotonin Syndrome–an excess of the neurotransmitter which overloads the central nervous system. It also appears to decrease the effectiveness of oral contraceptives, might cause problems if you’re breast-feeding, and oh, right, as an herbal supplement, isn’t all that regulated. What I’m saying is, self-prescribing this stuff is not a great idea, and right now, there’s not evidence that it works for major depression. But some people do use it, so I’ll include it.

Psychopathology Sum-Up: Types of Antidepressants

20 thoughts on “Psychopathology Sum-Up: Types of Antidepressants

    1. 1.1

      I actually only know people who’ve used Wellbutrin and Prozac–and usually they love it. I think Wellbutrin skews heavily towards the younger ages because docs don’t want to prescribe anything that could reduce sex drive.

      1. I demanded it and they thought of it as a second line treatment at the time and were reluctant until I said, “I will not take your weight-gain, sex-killing drugs!” Of course, I benefited greatly from having “ED-NOS” rather than “AN” written down, cuz people don’t take that seriously. Another rant for another time.

    2. 1.2

      I’ve quit multiple SSRIs that I was taking for depression and anxiety because they had unacceptable side effects. The sad part is that my list of unacceptable side effects actually didn’t include the libido-killing effects. Then I went on Cymbalta and eventually I got so tired of the withdrawal side effects (headaches, dizziness), which I would get in-between doses, that I went off it, too. I started taking Wellbutrin for depression and because I wanted to try medicating my ADHD (I hadn’t been on meds for it since I’d been a kid), and it was the first antidepressant I’d ever taken that worked without unacceptable side effects or the sex drive deadening. It also seems to be helping my ADHD. It hasn’t done anything for my anxiety, but you can’t win them all. Here’s hoping it keeps working.

  1. 2

    I briefly took a new anti-depressant (Cymbalta?) but I quickly felt chemically castrated. It neutered my sex drive totally. I never knew how incredibly boring life could be until then.

    But I was given them for chronic fatigue, not depression, so the doctor quickly put an end to that experiment.

  2. 3

    Fuck yeah, Effexor! Going on it was terrible, but I’m all functional and stuff! My depression, OCD and PTSD are pretty well managed.

    Downsides for me: I am among the very small number of people who become super photosensitive on it. I sunburn painfully in less than 15 minutes in the shade during non-peak UV time. On the other hand, I’m still a big goth at heart, so sanity > sunshine.

    I tried Celexa first, and I got nasty gastrointestinal issues, I broke out, I had some serious side effects and a constant feeling of an alien presence in my head. Which would have been depressing on their own.

    Team SNRI all the way.

  3. 4

    Something else showing promise are atypical antipsychotics (such as abilify) when used in conjunction with SSRIs I was in a phase 2 (long-term side-effects, everyone was on the study drug) trial of an atypical antipsychotic in conjunction with the SSRI I’ve been taking for years and although it had some pretty pronounced side-effects, for the first time in my life, I was free of dysthymia.

    AFAIK, they work as dopamine inhibitors.

  4. 6

    Effexor, to me, is one of the scary ones. A friend is on it and it works great for him – it seriously does the trick, so I’m not bashing Effexor when I say that when I was put on it the result was awful. (It’s weird how differently people can react to stuff). It worked in that I was no longer seriously depressed, but I wasn’t anything at all either. I was numb, living life in cotton balls. I didn’t stay on it long for that reason, and coming off it was scary because even though I was careful to wean myself off it soooo slowly I was getting “brain zaps” that would sometimes black me out a little and make my lips feel numb and tingly.

  5. 7

    My experience, for what it’s worth: I’ve been fighting depression on & off (mostly on) for about 35 years. The first antidepressant I took was Elavil (amitriptyline). Its side effects were bothersome but tolerable, & it alleviated my symptoms (insomnia, extreme pessimism, ruminations, & obsessive thoughts about death) quite effectively. After a couple of years on the Elavil, I was off antidepressants for a few years. At some point, I don’t remember exactly when, I tried St. John’s Wort. It made me feel like I had taken a massive dose of caffeine, & I didn’t stay on it long enough to assess its effectiveness as an antidepressant. The next prescription antidepressant I took was Remeron. After some unpleasant side effects the first few weeks, it alleviated my depressive symptoms more effectively than anything else I’ve taken. I’ve never been in a better place mentally & emotionally before or since. It reduced my libido, but I was willing to accept that trade-off. I would have stayed on Remeron indefinitely if not for the weight gain: I packed on 40 pounds in a couple of years. In an effort to stop that, my therapist switched me to Wellbutrin. I’ve taken it for about 15 years. It works pretty well against the depression, & the weight gain has slowed down a lot, although it has not completely stopped (blame that on my lifestyle, not the medicine). Antidepressants are not a miracle cure for depression, but they have helped me.

  6. 8

    Sercee — I took Effexor, and while it helped, it made me sweat like a pig all the time, made me intolerent to heat (and I lived in Florida). So I tapered off it.

    It was horrible (experience here, I hope you don’t mind the blog posting, it’s no longer active so I’m not trolling for readers!

    They saved my sanity, but oh getting off them was terrible. I was shocked at this as I’d taken several SSRIs before without any problem, and didn’t think the SNRI would be that different.

    I’m having much better luck with Cymbalta. It helps my longtime depression, anxiety, mild OCD, and chronic pain, so it’s win-times-four.

  7. 9

    May I add noradrenergic and specific serotonergic antidepressants (NaSSAs) to this list? Mirtazapine was a great choice for me: I sleep better than ever and there are no sexual side effects.

  8. 10

    I’m a psychiatrist, so I just wanted to add a few tricks of the trade. Effexor is a short acting medicine so it can be painful to come off of for some people. I have patients taper off of it and then have them take 10 mg of prozac a day for a week. It can also be used to come off of Paxil as well. If someone can’t tolerate prozac, then I will try zoloft.

    Sometimes adding wellbutrin to an SSRI can decrease sexual side effects.

    In terms of eating disorders, wellbutrin really is only a problem if someone is vomiting a lot or using laxatives. Purging can affect your electrolytes which can decrease seizure threshold. Wellbutrin also increases the risk of seizure. So having an eating disorder or if you have had one in the past doesn’t mean you can’t take Wellbutrin. It is important to be honest with your doctor, which, of course, can be hard to do sometimes.

    Just some ideas people can take to their doctors

  9. 12

    St John’s wort does bad things when combined with a number of drugs, including a lot of drugs for non-psychiatric issues. Don’t forget to include it when telling your doctor what your meds are. Herbal does not mean safe.

  10. 13

    Serena touches on an important issue. I’ve been lucky enough to have good health insurance all my adult life. It’s frightening to imagine the effect that depression might have had on my life otherwise. I know a young woman, a recent college graduate, who suffers from OCD and irrational fears. She is struggling to get out of a vicious cycle in which unemployment and the attendant lack of health insurance make it difficult to get therapy, and her untreated psychiatric symptoms make it difficult to get a job with decent benefits. It’s heartbreaking.

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