Antidepressants are among the most prescribed medications in the United States. This is partly because the number of people diagnosed with depression and anxiety has been increasing, and prescriptions have increased dramatically among some age groups during the pandemic.
Despite the prevalence of these medications, some patients have “significant misconceptions” about how they work, said Dr. Andrew J. Gerber, a psychiatrist and president and medical director of Silver Hill Hospital in New Canaan, Connecticut.
About 80 percent of antidepressants are prescribed by primary care doctors who have not had extensive training in managing mental illness.
Dr. Paul Nestadt, an associate professor of psychiatry at Johns Hopkins School of Medicine, said patients tell him, “‘You know, Doctor, I’ve tried everything.'” But often, he said, “they never got to a good dose, or they only took it for a week or two.”
Below are some answers to frequently asked questions about antidepressants.
How do antidepressants work?
There are many types of antidepressants and they all work a little differently.
Generally, they initiate a change in the way brain cells (and different regions of the brain) communicate with each other, said Dr. Gerard Sanacora, a professor of psychiatry at Yale School of Medicine.
Clinical trials have shown that antidepressants are generally more effective in moderate, severe, and chronic depression than in mild depression. Even then, it is a modest effect compared to placebo.
The largest study of multiple antidepressants, dubbed the STAR*D trial, found that half of the participants had improved after using the first or second medication they tried, and nearly 70 percent of people had stopped having symptoms with the fourth antidepressant.
Unfortunately, there is no way to know in advance how an individual will respond to a given medication, so there may be a period of trial and error.
More research is needed to better understand how antidepressants work and their effectiveness, especially when taken over several years.
How do I know which one to take?
The most commonly prescribed antidepressants are selective serotonin reuptake inhibitors, or SSRIs, such as Prozac or Zoloft, and serotonin and norepinephrine reuptake inhibitors, or SNRIs, such as Cymbalta and Effexor. These two types tend to have fewer side effects than tricyclic antidepressants such as clomipramine or monoamine oxidase inhibitors such as phenelzine.
Generally speaking, SSRIs and SNRIs are equally effective.
But for some people, the differences between these medications, even those in the same class, don’t seem subtle at all. If a medication is not right for you, there are other options. Experts recommend working with your doctor to find the best option.
How long do antidepressants take to work?
A common myth is that antidepressants are “quick fixes,” said Dr. Kao-Ping Chua, a pediatrician and health policy researcher at the University of Michigan Medical School. “They definitely aren’t.”
In general, experts say it can take one to two months to start seeing positive effects. And that’s assuming you’re taking the optimal amount.
At first, doctors tend to perform more frequent checkups so that they can monitor patients.
“It may take some time to identify the correct dosage,” Dr. Chua said. If the dose is adjusted and it still doesn’t work, “switching to a different antidepressant might be reasonable,” he said.
If you are experiencing acute or debilitating symptoms of depression, including thoughts of self-harm, seek immediate help by calling the Suicide and Crisis Lifeline by dialing 988.
Are side effects inevitable?
No.
Unlike older antidepressants, SSRIs and SNRI medications typically don’t have many short-term side effects, and if they do, they are usually mild.
Some of the most common, which can occur within a few days of starting the medication, are decreased libido, headache, dry mouth, and upset stomach. But many people don’t experience any side effects, experts said.
Short-term side effects often go away as the body adjusts to the medication; You should know which ones are most likely to persist within about two to three weeks of starting the medication, Dr. Nestadt said.
Decreased libido can be persistent, which can be a “dealing factor,” he said. At that point, doctors might try treating the problem with an additional medication or switching to a different antidepressant.
Long-term use may cause other side effects, such as weight gain or emotional dullness.
Finally, antidepressants can interact with other drugs. An SSRI combined with ibuprofen, for example, increases the risk of gastrointestinal bleeding. Additionally, it is generally not recommended to drink alcohol while taking antidepressants.
Should I do anything else besides taking the medication?
Yeah.
Therapy remains one of the first recommended treatments for depression. Antidepressants don’t make problems go away, but they can make them easier to cope with, Dr. Chua said.
Lifestyle changes can also help, experts said. Research has shown that exercise can reduce symptoms of depression. And eating a heart-healthy diet can be beneficial, although more research is needed on how foods affect mood. Getting too much or too little sleep also affects how we feel, so it’s important to get enough rest.
Are antidepressants used for anything other than depression?
Yeah.
They can also treat chronic pain conditions such as shingles and migraines, as well as anxiety, social phobia, post-traumatic stress disorder, and obsessive-compulsive disorder.
What’s up with the “black box” warning?
In 2004, the Food and Drug Administration issued a “black box” warning that said use of certain antidepressants may be linked to suicidal ideation and behavior in adolescents. Three years later, the warning was expanded to include people between 18 and 24 years old.
The warning was based on an analysis of drug trials in which there were no suicides. However, the researchers found a significant risk of suicidal thoughts. Other studies have found that SSRIs reduce suicide rates and suicidal behavior among young people, leading some experts to call for the warning to be reevaluated.
How do I know when it is time to stop antidepressants?
Psychiatrists generally recommend discussing whether to stop the medication after experiencing benefits for at least six months.
Studies show that “patients who do well on antidepressants are more likely to experience depression relapses if they stop taking them,” Dr. Chua said.
But that’s not the case for everyone, he added, so check with your provider to decide if you should stop taking your medication.
Psychotherapy can help people successfully stop antidepressants. But it is always important to gradually reduce the medication under the supervision of a doctor.
In some cases, if the taper is not done slowly enough, patients may experience what is commonly called brain shocks, which feel like electric shocks, or other side effects such as nausea, said Dr. David J. Hellerstein, professor of clinical medicine. psychiatry at Columbia University Irving Medical Center.
Slow tapering is especially important with an antidepressant that has a short half-life like Effexor or Paxil, he added. When patients stop medications like those, the amount of medication in the body “builds up very quickly,” she added.
Some people with chronic, recurrent depression may need to take antidepressants indefinitely, Dr. Hellerstein said.
This is generally considered safe, he said, adding that it is significantly riskier for people without treatment.
If you are having suicidal thoughts, call or text 988 to reach the 988 Suicide and Crisis Lifeline or visit SpeakingOfSuicide.com/resources for a list of additional resources. Go here to obtain resources outside the United States.