Medication for Severe Depression

Severe depression, also known as major depressive disorder (MDD) is characterized by experiencing at least five or more depressive symptoms for two weeks or more. This can be treated most effectively by combining psychotherapy with antidepressants which can help relieve some of the symptoms of depression. There are four main categories of antidepressant medication, all of which effect the levels of neurotransmitters in the brain. These include selective serotonin reuptake inhibitors (SSRIs); atypical antidepressants; monoamine oxidase inhibitors (MAOIs); and tricyclic antidepressants (TCAs).

Selective serotonin reuptake inhibitors

• SSRIs effect the brain's ability to re-absorb the neurotransmitter serotonin into the pre-synaptic cell. This causes an increase in the levels of serotonin in the brain. These include citalopram (Celexa, Cipram), escitalopram (Lexapro, Cipralex), fluoxetine (Prozac, Fluox), fluvoxamine (Luvox, Fevarin), paroxetine (Paxil, Seroxat), sertraline (Zoloft, Lustral), or zimelidine (Zelmid, Normud). SSRIs should not be taken with MAOIs or certain TCAs. This may cause severe serotonin syndrome which can be fatal. Drugs such as alcohol, Sudafed, Meridia, Ambien, or dextromethorphan can make the effects of SSRIs more toxic and should be avoided.

Tricyclic antidepressants

• Tricyclic antidepressants include amitryptiline (Elavil), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), nortryptiline (Aventyl), protryptiline (Vivactil), and trimipramine maleate (Surmontil). Most of these act as serotonin-norepinephrine reuptake inhibitors (SNRIs), increasing the levels of these neurotransmitters in the brain. These have been used since the 1950s, but have been superseded by SSRIs and more recently developed SNRIs.

Atypical antidepressants

• Atypical antidepressants are more often used for people who have major depression combined with another psychological disorder such as panic, anxiety or bipolar disorder, or when SSRIs and TCAs have not been effective. These medications effect different combinations of the neurotransmitters serotonin, norepinephrine and dopamine. These include bupropion (Wellbutrin), desvenlafaxine (Prestiq), duloxetine (Cymbalta), mirtazapine (Remeron), trazodone (Desyrel), or venlafaxine (Effexor).

Monoamine oxidase inhibitors

• Monoamine oxidase inhibitors have been in use since the 1950s but have recently been supplanted by SSRIs and SNRIs, which are more selective. MAOIs effect the levels of all the neurotransmitters - serotonin, norepinephrine, dopamine and tyramine - by blocking the activity of monoamine oxidase which is used to destroy the neurotransmitters. MAOIs are now used as a last resort when other medications do not have enough of an effect or have undesired side effects. This is because MAOIs usually have more side effects and potentially fatal interactions with foods that are high in tyramine and other drugs. Increased levels of tyramine can cause a fatal spike in blood pressure. Some examples of MAOIs are isocarboxazid (Marplan), nialamide (Niamid), benmoxin (Nerusil), hydralazine (Apresoline), iproniazid (Marsilid, Iprozid), mebenazine (Actomol) and safrazine (Safra).

Side effects

• Side effects vary depending on the specific medication taken, but can include weight loss or gain, changes in appetite, nausea, constipation, diarrhea, dizziness, dry mouth, sexual dysfunction, problems sleeping, confusion, tremors, seizures, liver or urinary tract impairment, heart arrhythmias, or blood pressure problems. These medications may need to be taken for 6-12 months to have an effect. They should not be stopped suddenly as withdrawal-like symptoms are likely to occur.