Antidepressants are among the most prescribed medications in the United States. That’s partly because the number of people diagnosed with depression and anxiety has increased and prescriptions rose sharply among some age groups during the pandemic.
Despite the prevalence of these medications, some patients have significant misconceptions about how the drugs work, said Dr. Andrew J. Gerber, a psychiatrist and president and chief medical officer of Silver Hill Hospital in New Canaan, Connecticut.
About 80 percent of antidepressants are prescribed by primary care physicians who have not had extensive training in the management of mental illness.
Dr. Paul Nestadt, associate professor of psychiatry at the 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 only stayed there for a week or two.
Here 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.
In general, they initiate a change in the way brain cells and different brain regions 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 for moderate, severe, and chronic depression than for mild depression. Still, it’s 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 drug they tried, and nearly 70 percent of people had remained free of symptoms with the fourth antidepressant.
Unfortunately, there is no way to know in advance how an individual will respond to any medication, so there may be a period of trial and error.
More research is needed to better understand how antidepressants work and how effective they are, 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-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 drugs, even those in the same class, don’t feel subtle at all. If a medication doesn’t feel right, there are other options. Experts advise working with your doctor to find the best fit.
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, it can take a month or two to start seeing positive effects, experts say. And that’s assuming you’re taking the optimal amount.
In the beginning, doctors usually make more frequent visits to be able to monitor patients.
It can take time to identify the right dose, said Dr. Chow If the dose is adjusted and it still doesn’t work, switching to a different antidepressant might be reasonable, he said.
If you experience 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 SNRIs typically don’t have many short-term side effects, and if they do, they’re often mild.
Some of the most common, which can appear in the days of starting the medication, are a decrease in libido, headache, dry mouth and upset stomach. But many people experience no side effects, experts said.
While short-term side effects often fade as the body adjusts to the medication, you should know which ones are most likely to stick around for two to three weeks after starting the medication, said Dr. Nestadt.
Decreased libido can be persistent, which can be a deal breaker, he said. At this point, doctors may try to treat the problem with an additional medication or switch to a different antidepressant.
Long-term use can cause other side effects, such as weight gain or emotional dulling.
Finally, antidepressants can interact with other drugs. An SSRI combined with ibuprofen, for example, increases the risk of gastrointestinal bleeding. Also, drinking alcohol while taking antidepressants is generally not recommended.
Do I need to do anything else besides taking the medication?
Yes.
Therapy remains one of the first recommended treatments for depression. Antidepressants don’t make problems go away, but they can make it easier to deal with problems, said Dr. Chow
Lifestyle changes can also help, experts said. Research has shown that exercise can reduce symptoms of depression. And eating a heart-healthy diet may be beneficial, although more research is needed on how foods affect mood. Sleeping too much or too little also affects how we feel, so it’s important to get the right amount of rest.
Are antidepressants used for anything other than depression?
Yes.
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 about the black box warning?
In 2004, the Food and Drug Administration issued a black box warning that the use of certain antidepressants may be linked to suicidal ideation and behavior in adolescents. Three years later, the notice was expanded to include 18- to 24-year-olds.
The warning was based on an analysis of drug trials in which there were no suicides. The researchers, however, found a significant risk of suicidal thoughts. Other studies have found that SSRIs decrease suicide rates and suicidal behavior among young people, leading some experts to call for the warning to be re-evaluated.
How do I know when it’s time to stop taking antidepressants?
Psychiatrists usually recommend discussing whether to go off the medication after you’ve been experiencing benefits for at least six months.
Studies show that patients on antidepressants are more likely to experience relapses of depression if they stop taking antidepressants, said Dr. Chow
But that’s not the case for everyone, he added, so check with your provider to decide whether to stop taking your medication.
Psychotherapy can help people successfully come off antidepressants. But it is always important to reduce the medication under the supervision of a doctor.
In some cases, if the taper is not done slowly enough, patients may experience what are commonly called brain zaps, which feel like electric shocks, or other side effects such as nausea, said Dr. David J. Hellerstein, a professor of in clinical psychiatry at Columbia University Irving Medical Center.
The slow taper is especially important with an antidepressant that has a short half-life like Effexor or Paxil, he added. When patients stop taking drugs like these, the amount of drugs in the body closes very quickly, he 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 more risky for people to go without treatment.
If you are having suicidal thoughts, call or text 988 to contact the 988 Suicide and Crisis Lifeline or go to SpeakingOfSuicide.com/resources for a list of additional resources. go here for resources outside the United States.
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