How to Manage Antidepressant Side Effects

Depression is a common disorder in the U.S., affecting roughly 10% of the nation and disrupting family lives, the work place, and social activities. But there is no reason to suffer through the difficulties of depression; there are very effective treatment options for this medical condition. In this slideshow, learn about recognizing depression, common adverse effects you might experience, and the pros and cons of various treatments to help you avoid these bothersome side effects.

What is Major Depressive Disorder (MDD)?

Depression is not a trivial illness. In fact, according to the U.S. Centers for Disease Control and Prevention (CDC), an estimated 1 in 10 U.S. adults report depression. Depression, also referred to as major depressive disorder (MDD), can result in difficulties with family life, work, and social activities. Depression is not just feeling blue occasionally. Depression affects daily feelings, thoughts, and actions over a longer period of time. Medical conditions such as arthritis, cancer, and diabetes may worsen, too. The good news is that depression is treatable with a high rate of success using treatment options such as prescription medications and psychotherapy (talk therapy).

What Are the Symptoms of Depression?

Many people with depression have a severe low mood, tearfulness, or a sense of hopelessness that has lasted for at least 2 weeks. Other symptoms may include irritability, anxiety, or short-tempers. Participation in enjoyable activities declines and many people may withdrawal from family or friends. Changes in sleeping or eating habits, constant self-criticism, or drug and alcohol abuse may also surface. One may attempt to hurt themselves or commit suicide. Signs that someone is thinking about suicide might include talking about death and dying, or engaging in self-destructive or risky behaviors. View these suicide prevention guidelines for adults.

Could I Be at Risk for Depression?

Depression does not play favorites. Anyone from any age group, socioeconomic status, or ethnic background is subject to depression. Some groups that tend to have a higher incidence of depression include:

  • People between 45 to 64 years
  • Elderly
  • Women
  • Blacks, hispanics, and non-hispanics of other color
  • Education less than high school degree
  • Those who are divorced
  • Unemployed
  • People without health insurance

Do We Know What Causes Depression?

Depression probably involves changes in brain chemicals (neurotransmitters like serotonin and norepinephrine) that control our mood, although the exact causes of depression are not known. Depression may involve multiple factors, such as:
  • Genetics or family history
  • Chronic or acute health conditions
  • Situations like job loss, workplace stress, or physical or mental abuse
  • Severe grief due to death of a loved one
  • Prescription drug side effects
  • Abuse of alcohol or drugs
  • Hormonal changes in women

Are There Different Types of Depression?

Absolutely. There are many different types of depression, but all are amenable to some form of treatment. The most common types of depression include:

If you suffer from symptoms resembling depression, consider talking to a healthcare provider.

What Kind of Treatments Are Available for Depression?

The mainstays of treatment for depression revolve around two different approaches: prescription medications and talk therapy (psychotherapy) with a trained specialist like a mental health counselor. Often, these two approaches are effectively used together. There are different types of psychotherapy and this treatment can help you to:
  • Set realistic and daily goals
  • Work through a crisis situation
  • Develop coping and problem solving skills
  • Learn to develop positive relationships
  • Replace negative thoughts with positive ones

What Types of Medications are Used for Depression?

No single antidepressant is the best for everyone. Patients have different responses to antidepressants, such as effectiveness and side effects. Most antidepressants take 4 to 6 weeks for a full effect, and about 50% of patients respond to the first treatment. Examples of antidepressant classes include:

Antidepressants: How To Cope With Side Effects

When you start an antidepressant, many initial side effects like upset stomach, headache or anxiety may go away after a short period, usually in two to three weeks. It takes about 4 to 6 weeks for the full effect of many antidepressants to kick in, too. So, it is important to stick with your medicine for at least a month, taking it as prescribed by your doctor. If your side effects seem intolerable, do not stop taking your antidepressant without speaking to your doctor. Abruptly stopping some antidepressants may cause withdrawal-like symptoms or worsen your depression and mood. Speak with your doctor. You may just need a dose adjustment.

Managing Antidepressant Side Effects: Nausea and Vomiting

It is important to remember you will not experience every antidepressant side effect. For those who do have side effects, coping mechanisms can help until the side effect subsides. Nausea can start fairly quickly after beginning treatment with an antidepressant, usually within the first week, but it may go away within a month. If you experience nausea or vomiting, check with your doctor or pharmacist to see if you can take your medicine with food, or if you can use an antacid or Pepto Bismol. Be sure to drink plenty of noncarbonated fluids, and eat smaller but more frequent meals. If your nausea does not subside, talk to your doctor about a temporary dose reduction.

Managing Antidepressant Side Effects: Sexual Problems

Sexual dysfunction, including decreased libido (sexual drive), inhibited orgasm, erectile dysfunction, and ejaculatory failure, is a common side effect of many antidepressants, especially the selective serotonin reuptake inhibitors (SSRIs). Consult with your doctor; some strategies to cope with sexual side effects include:
  • Switch to another antidepressant with lower sexual side effects
  • Add or change to an antidepressant, such as bupropion, to counteract sexual dysfunction
  • For men, consider use of ED drugs such as sildenafil (Viagra), vardenafil (Levitra, Staxyn), or tadalafil (Cialis).

Managing Antidepressant Side Effects: Weight Gain

Weight gain while taking antidepressants can be due to many different factors. When your mood improves, you may have a better appetite, and this can lead to unexpected weight gain. In addition, lack of physical activity or water retention can also lead to weight gain. Some antidepressants that may be less likely to result in weight gain include:

Managing Antidepressant Side Effects: Drowsiness, Insomnia, Headaches

Drowsiness can be a temporary antidepressant side effect early in treatment, and may subside after a few weeks. It may be possible to take your antidepressant before bed, so that you feel less drowsy in the daytime. Do not drive when you are drowsy. If drowsiness persists, talk to your doctor. If your antidepressant causes insomnia, ask if you can take it in the morning or add a low dose of a sedating antidepressant (like trazodone) at bedtime. Avoid caffeine. Be sure to engage in regular exercise which can boost your mood and help with insomnia, too. Mild headaches are common with initial therapy and should subside in a few weeks; if not, contact your doctor.

The Selective Serotonin Reuptake Inhibitors (SSRIs): Pros and Cons

Names of common SSRIs include citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil), fluoxetine (Prozac), and sertraline (Zoloft). Side effects among this class can vary. Paroxetine has been associated with more weight gain and more sexual side effects than the other options. Fluoxetine is linked with lower rates of withdrawal-type side effects, and sertraline may lead to diarrhea in some patients. With long-term (> 24 month) use of paroxetine or venlafaxine, studies have shown an increased risk for diabetes. As a class, SSRIs can increase the risk for stomach bleeding, so caution should be advised in patients with a history of ulcers or taking a blood thinner.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Pros and Cons

Venlafaxine (Effexor), desvenlafaxine (Pristiq, Khedezla) and duloxetine (Cymbalta) are effective SNRIs that inhibit reuptake of several brain neurotransmitters to treat depression. Common side effects may include: nausea (especially with venlafaxine), dry mouth, insomnia or drowsiness, anxiety, sexual problems, headache and sweating. The SNRIs can usually be given once-a-day, and venlafaxine may be useful in patients who have hard-to-treat depression. Duloxetine is also used for painful conditions like osteoarthritis, neuropathic pain, and fibromyalgia, but may increase blood pressure and worsen sweating.

Miscellaneous (Atypical) Antidepressants: Pros and Cons

Other antidepressants include trazodone (Oleptro), nefazodone (Serzone), mirtazapine (Remeron), vilazodone (Viibryd), and bupropion (Wellbutrin XL, others). Bupropion, vilazodone, trazodone or nefazodone may result in less sexual dysfunction, and bupropion may lead to weight loss. Trazodone, nefazodone, and mirtazapine can be sedating, which may be a plus in depressed patients with insomnia. Bupropion has been added to SSRIs to help reverse sexual dysfunction; it can also help boost patients who feel fatigued. Bupropion must be avoided in patients with a risk for seizures, and higher doses of bupropion can increase this risk.

Monoamine Oxidase Inhibitors (MAOIs): Pros and Cons

MAOIs include selegiline transdermal (Emsam), phenelzine (Nardil), isocarboxazid (Marplan), and tranylcypromine (Parnate). Side effects such as lightheadedness (especially when standing up), weight gain, drowsiness, headache, insomnia, nausea, constipation, dry mouth, or sexual dysfunction may occur. MAOIs are not used as first-line depression treatment as there are more tolerable antidepressants with fewer food and drug interactions. Tyramine found in dried fruit, aged cheeses, pickles, smoked meats, fava beans, and red wine can lead to a spike in blood pressure, headache, nausea, and other serious effects.

Tricyclic Antidepressants (TCAs): Pro and Cons

The TCAs are a large class of older antidepressants that include amitriptyline, amoxapine, desipramine, imipramine, doxepin, nortriptyline, protriptyline, and trimipramine. TCA side effects include dry mouth, dizziness, constipation, blurred vision, sedation, urine retention, fast heart rate, and weight gain; many of these side effects are due to anticholinergic action of the TCAs. Like the MAOIs, TCAs are rarely used first-line; however, they may be used in adults for other indications, including pain and migraine headache prevention. A TCA overdose can be fatal. Heart rhythm disturbances, seizures, and depressed breathing are serious overdose complications.

Brintellix: A New Serotonergic Antidepressant

In October 2013 the FDA approved Brintellix (vortioxetine) to treat adults with major depressive disorder (MDD). Brintellix’s proposed mechanism of action is to enhance serotonin activity in the brain by blocking serotonin reuptake. Brintellix has several other actions at serotonin receptors, and is the only agent with this combination of serotonergic activity. More than 7,500 patients aged 18 to 88 years old were enrolled in clinical trials demonstrating Brintellix effectiveness, but there are no head-to-head trials with other SSRIs. Roughly 5 to 8 percent patients who received Brintellix stopped treatment due to a side effect, the most common ones being nausea, constipation, and vomiting.

Fetzima: A Newer SNRI Approved for Depression in Adults

Fetzima (levomilnacipran extended-release capsules), a once-daily serotonin and norepinephrine reuptake inhibitor (SNRI) was FDA-approved for treatment of Major Depressive Disorder (MDD) in adults in 2012. Levomilnacipran is the active enantiomer of milnacipran (Savella) which is approved only for fibromyalgia. In Phase III studies of adults with MDD, a significant improvement in depression was seen with Fetzima given once daily compared to placebo. Common side effects occurring in greater than 5 percent of patients included nausea (>10%), constipation, and sweating. Patent protection for Fetzima runs until 2023.

Serious Antidepressant Class Effect: Risk of Suicide

The FDA requires labeling on all depression drugs to include strong warnings about risks of suicidal thinking and behavior, known as suicidality, in children, adolescents and young adults. This risk may be higher during the initial few months of treatment, or with a personal or family history of bipolar disorder or suicidal action. Initially high doses of antidepressants in children have been linked with elevated suicide risk. However, it is important to remember that untreated depression itself is also linked with suicide. Caregivers and healthcare providers should closely monitor patients for suicidal signs and symptoms within the first few months of treatment initiation and with dose changes.

SSRI Use in Children: The FDA's Overview

In an FDA review, no suicides occurred among 2,200 children treated with SSRI medications, according to the National Institutes of Mental Health. However, about 4 out of 100 of those children taking SSRIs experienced suicidal thinking, including attempts, at twice the rate of those taking placebos. Due to this increased risk, the FDA requires a "Boxed Warning" about the risk for suicide or attempted suicide in children and adolescents on all antidepressant labels. Some studies suggest that the benefits of antidepressants may outweigh the risks to children with major depression and anxiety disorders. Only fluoxetine is currently approved to treat depression in children.

How to Manage the Risk of Suicide

It is important that family members, caregivers, and healthcare providers are aware of this risk of suicide. To better understand this risk, patients and caregivers are strongly encouraged to discuss this concern with their physician, and review the FDA Medication Guide available for all antidepressants. Your pharmacist will also give you this handout. According the scientific data in patients taking antidepressants, the risk for suicide is not increased in adults older than 24. Adults 65 years and older taking antidepressants actually have a decreased risk of suicidality. It is not known if any one antidepressant is more or less likely to result in suicidal thoughts or action.

Do Not Abruptly Stop Taking Antidepressants

Do not stop taking your antidepressant without first talking to your doctor, even when you have a side effect. Abruptly stopping an antidepressant can lead to a host of unpleasant withdrawal symptoms such as: anxiety, worsened depression, moodiness, irritability, fatigue, headaches, dizziness, nausea/vomiting, and diarrhea. Paroxetine (Paxil) and venlafaxine (Effexor) are especially prone to cause these symptoms when abruptly stopped; fluoxetine (Prozac) is less likely to cause this problem. Your doctor may recommend that the antidepressant be slowly discontinued to help prevent withdrawal side effects, and will tell you how you can best taper the medication dose.

Serotonin Syndrome: A Rare But Serious Effect

Many antidepressants alter the levels of neurotransmitters like serotonin in the brain. Serotonin helps to facilitate chemical messages in the brain and it is thought this helps with the symptoms of depression. Taking multiple drugs that boost serotonin levels can lead to an overload of serotonin in the body and unpleasant, dangerous and potentially fatal side effects such as:
  • Confusion
  • Hallucinations
  • Nausea-vomiting
  • Rapid heart rate
  • High fever
  • Incoordination

Drug Interactions Can Lead to Serotonin Syndrome

Serotonin syndrome can occur rarely when two drugs that increase brain serotonin are taken together. Do not start new medicines without first checking with your healthcare provider. Examples of drugs that may cause serotonin syndrome include:

Antidepressants and Cost Concerns

Prescription medications can be costly for many, especially those without adequate health insurance. However, many of the most effective and well-tolerated antidepressants are now available in generic forms. Generic formulations can save a patient literally hundreds of dollars per month. Talk to your doctor or pharmacist about available generic alternatives, which include:

What if My Antidepressant Does Not Work?

If the first antidepressant you try does not work or results in intolerable side effects, there are other options, so do not give up. If you have no improvement in your symptoms after four to six weeks, talk to your doctor about switching to a different antidepressant or adding another lower dose antidepressant in a different class. Quite often, lower doses of two different antidepressants may have a better effect for you and can resolve bothersome side effects. If you prefer to stop your antidepressant, speak with your doctor first so that a tapering schedule can be started. Finally, consider talk therapy with a trained professional who can offer methods to help lessen your depression and increase your quality of life.

Finished: How to Manage Antidepressant Side Effects

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Sources

  • Centers for Disease Control and Prevention (CDC). CDC Features. An Estimated 1 in 10 U.S. Adults Report Depression. April 20, 2012. Access May 25, 2014 at http://www.cdc.gov/features/dsdepression/.
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  • Mayo Clinic. Depression (Major Depressive Disorder). Antidepressants: Get tips to cope with side effects. Last updated July 9, 2013. Accessed May 25 at http://www.mayoclinic.org/diseases-conditions/depression/in-depth/antidepressants/art-20049305.
  • Drugs.com. Winter Depression May Require Plan. December 26, 2012. Accessed May 29, 2014 at http://www.drugs.com/news/winter-depression-may-require-plan-42227.html.
  • U.S. Food and Drug Administration (FDA). Antidepressant Use in Children, Adolescents and Adults. Last updated 8/10/2010. Accessed 5/27/2014. Available at: http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/UCM096273
  • National Institute of Mental Health. Antidepressant Medications for Children and Adolescents: Information for Parents and Caregivers. Accessed May 28, 2014 at http://www.nimh.nih.gov/health/topics/child-and-adolescent-mental-health/antidepressant-medications-for-children-and-adolescents-information-for-parents-and-caregivers.shtml.
  • Mayo Clinic. Depression (Major Depressive Disorder). Antidepressants: Selecting one that's right for you. Last updated November 8, 2011. Accessed May 24, 2014 at http://www.mayoclinic.org/diseases-conditions/depression/in-depth/antidepressants/art-20046273
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