Psychiatric reference for writers: Medications used to help antidepressants work better

Sometimes an antidepressant alone aren’t enough to get depression under control.  Psychiatrists see this often: the patient has had a partial response to the medication (at an adequate dose over an adequate amount of time), but there’s definite room for improvement in the individual’s mood.  Treatment options at that point include switching the antidepressant to something else, adding a second antidepressant, or adding an augmenting agent to help jumpstart the first antidepressant.  Here is a partial list of augmenting medications. 

Thyroid hormone.  People who have too little thyroid hormone in their body have a tendency to feel depressed.  They are mentally and physically slowed.  It turns out that thyroid medication at low doses can help relieve these same symptoms in people without thyroid problems.  Thyroid hormone is also effective in treating bad mood swings.  Side effects can include anxiety, loss of appetite, dizziness, and sensitivity to heat.  Chest pain and osteoporosis are rare.

Stimulants.  Stimulants include amphetamines as well as wakefulness-promoting medications like Modafinil (Provigil).  Stimulantss are especially helpful in patients who sleep too much, have little energy, and exhibit slowed thinking/concentration problems.  They should be avoided in people with anxiety issues, as well as heart problems. Side effects can include high blood pressure, fast heart rate, weight loss, anxiety, fidgetiness, jerking movements, and poor sleep.  Some stimulants are addicting.  These medications are usually avoided in patients with substance abuse issues.

Lithium.  Typically used in bipolar disorder, Lithium exhibits an anti-depressant effect even in people who don’t have bipolar disorder.  The dose is typically much lower than one would use in people with bipolar disorder.  Side effects can include weight gain, shakes, problems during pregnancy, acne, diarrhea, thirst, excessive urination, and rarely thyroid and kidney problems.

Lamotrigine, or Lamictal.  Lamictal is often used in patients with bipolar depression.  It has been shown to be very helpful for depressed people without bipolar disorder, especially for those with mood swings.  The most concerning side effect is rare: a life-threatening rash.  It is important to start this medication at a low dose and increase it very slowly.

Atypical antipsychotics (AAP).  AAP’s can be helpful for depression, and some are FDA indicated for depression in people with only partial response to an antidepressant.  Examples include Quetiapine (Seroquel) and Aripiprazole (Abilify).  Some atypical antipsychotics exhibit antidepressant effects on their own, but they’re especially helpful when depression is accompanied by agitation, confused thinking, racing thoughts, insomnia, or hallucinations.  Side effects can include sleepiness or insomnia, weight gain, sugar or cholesterol problems, movement problems, and very seizures, heart problems, or coma.  Atypical antipsychotics should be used with care in patients with dementia.

Benzodiazepines (BZ).  BZ’s are helpful when depression presents with anxiety or insomnia.  Examples include Lorazepam (Ativan) and Clonazepam (Klonopin).  Side effects include sedation, loss of impulse control, and at high doses, breathing problems and coma.  These medications can be very addictive, so doctors try to avoid using them in people with substance abuse problems.  Usually BZ’s are used on a short-term basis.

Over-the-counter (OTC) augmentation strategies.  The major concern with OTC treatments include medication interactions and potential to worsen physical problems, especially if treatment isn’t discussed with the physician.  Some work directly on mood (SAM-E, 5-HTP, Omega-3 Fatty Acids).  Others target sleep or pain.

Alex Natalian is a pseudonym for psychiatrist KRR.

Psychiatric Database for Writers: Antidepressants

Antidepressants are used for the treatment of depression and other disorders, like anxiety, pain, and difficulty with attention.  The following is a very general overview of antidepressant groups.

Tricyclics Antidepressants (TCA) were the first group of medications to emerge on the market for depression.  They are used for depression, anxiety, obsessive compulsive disorder, chronic pain, sleep, bedwetting, and other problems.  Examples include Imipramine (Tofranil) and Amitriptyline (Elavil). These medications are often quite sedating.  They’re often used in depressed patients with insomnia.  Side effects can include dry mouth, blurred vision, constipation, urinary retention, forgetfulness, and less common, confusion, low blood pressure, heart problems, seizures.  They are very dangerous in overdose.

Like TCA’s, Monoamine Oxidase Inhibitors (MAOI) have been on the market for many years.  They are very effective medications for depression and anxiety but are rarely prescribed due to potential interactions with food and other medications.  Examples include Tranylcypromine (Parnate) and Phenelzine (Nardil).  Side effects include weight gain or loss, sleepiness, low blood pressure, high blood pressure, and rarely coma.  Most newer psychiatrists don’t have experience prescribing these antidepressants.

With the discovery of Prozac in the 1990’s, Selective Serotonin Reuptake Inhibitors (SSRIs) are perhaps the most-used antidepressant group on the market.  They are used for depression & anxiety/panic attacks, as well as obsessive-compulsive disorder, mood disorder related to menstruation, and many other conditions.  This group includes Celexa, Lexapro, Luvox, Paxil, Prozac, and Zoloft. These medications are well-tolerated and are typically safe in overdose.Side effects can include slight tremor, stomach upset, diarrhea or nausea, problems sleeping, sleeping too much, and sexual problems. Individually, Prozac is perhaps the most activating.  Most cause weight loss except Luvox.  Paxil is particularly effective for panic attacks.  Celexa, Lexapro, and Zoloft are good choices for medically complicated or older patients, due to fewer medication interactions.

Serotonin Norepinephrine Reuptake Inhibitors (SNRI’s) are similar to SSRI’s, except they influence both Serotonin and Norephinephrine, which means they’re a little more likely to cause high blood pressure than SSRI’s and are typically more effective for treatment of pain than medications like Prozac.  Examples include Venlafaxine (Effexor) and Duloxetine (Cymbalta).  They are used for depression, anxiety, and sometimes for pain conditions, like fibromyalgia.  Side effects are similar to SSRI’s, apart from blood pressure changes.  They are very rarely fatal in overdose.  Cymbalta is considered better for pain management than Effexor.

Buproprion (Wellbutrin) is a “novel” antidepressant, in that it’s very unusual.  While most antidepressants work on Serotonin and Norepinephrine, Bupropion affects a chemical called dopamine.  It is used for depression and concentration, as well as smoking cessation, but isn’t good for anxiety.  Major side effects include shakiness/anxiety, problems sleeping. It is rarely associated with visual hallucinations and (especially at high doses) seizures.

When it comes to depression in people with insomnia, doctors often turn to sedating antidepressants. Mirtazapine (Remeron) is moderately sedating and can promote appetite, which can be helpful in underweight patients.  Trazodone is a very sedating antidepressant, so sedating in fact that most people can’t take a high enough dose for the antidepressant effect to kick in.  Trazodone is used mostly for sleep.  Side effects can include daytime sleepiness or slowing, painful erection of the penis (rare), and dizziness; it doesn’t usually cause weight gain.  Nefazodone, also called Serzone, is a sedating antidepressant that can cause mild weight gain, sleepiness, and rarely liver disease.  It isn’t used all that often due to risk of liver problems.

Alex Natalian, Psychiatrist and Author     Alex Natalian is a pseudonym for psychiatrist KRR.