Considering Treatment 

What are antidepressants used for? 

Antidepressants are a class of medications that treat symptoms of depression and anxiety. Some antidepressants also treat other conditions, such as obsessive-compulsive disorder, bulimia, chronic pain and posttraumatic stress disorder. 
  

Do I need treatment? 

If you have been feeling depressed or anxious for a long time, you may wonder whether you need treatment. Despite growing conversations about mental health, stigma is still common and can cause people to discount or minimize these feelings. Some people believe they should be able to “just shake it off,” so they don’t seek treatment. As a result, many live with depression or anxiety for years without getting the support they need. 

If you feel sadness, despair and hopelessness for more than two weeks, or if you have lost interest in things you used to enjoy, see a doctor for an assessment of your symptoms and to discuss treatment and support options. 

Most people with depression eventually respond well to treatment. Getting treatment early also makes it more likely that the antidepressant will help. 
  

How do antidepressants work? 

Antidepressants work by increasing certain natural chemicals in the brain called neurotransmitters. These chemicals are serotonin, norepinephrine and dopamine. If your levels of these chemicals are low, you may feel depressed or anxious. By raising these levels, antidepressants can improve mood and reduce anxiety. However, the brain is very complex, and researchers are still learning exactly how these medications produce their effects. 

We do know that these medications reduce depression and anxiety in up to 70 per cent of people who try them. The rate can be even higher when people who do not get relief with an antidepressant try a second one. Finding the best antidepressant for you may take some trial and error. Working with your doctor will give you a better chance at finding the medication that works for you. 
  

Are antidepressants the only treatment option? 

Antidepressants are one way of treating depression or anxiety. They often work best when they are combined with other kinds of support, such as talking with a therapist. Examples of these treat.ments include cognitive-behavioural therapy and interpersonal therapy. For people with mild to moderate depression, talk therapy on its own can be just as effective as antidepressants. 

Other non-medication options include getting support from family and friends, and making lifestyle changes like exercising regularly, eating well and getting enough sleep. Peer support, school and job counselling, and housing and employment supports can also help people deal with problems that can cause depression or anxiety, or make it worse. Refer to the back of this pamphlet for more resources. 

For people who do not get better with antidepres.sants, newer therapies like transcranial magnetic stimulation can help. 
  

Types of Antidepressants

There are several classes (or types) of antidepressants, and each class includes different medications. Overall, all antidepressants work well, but people may respond better to some medications than others. This is especially true in depression, where symptoms can vary from person to person. Your prescriber might try another type of antidepressant or a combination of antidepressants to help with your symptoms. 

Antidepressants are referred to in two ways: by their generic name and by their brand name. The different classes of antidepressants are listed below, starting with the ones that are prescribed most often. The examples are the generic names, with brand names available in Canada in brackets. 
  

SSRIs—Selective serotonin reuptake inhibitors 

SSRIs are usually the first choice of medication for treating depression and anxiety. They have milder side effects than some other antidepressants. 

Examples: citalopram (Celexa), escitalopram (Cipralex), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft),  vilazodone (Viibryd), vortioxetine (Trintellix) 
  

SNRIs—Serotonin and norepinephrine reuptake inhibitors 

SNRIs can be used to treat depression, anxiety and chronic pain. 

Examples: desvenlafaxine (Pristiq), duloxetine (Cymbalta), levomilnacipran (Fetzima), venlafaxine (Effexor) 
  

NDRIs—Norepinephrine and dopamine reuptake inhibitors 

The medication in this class is bupropion (Wellbutrin, Zyban). When used to treat depression, bupropion is often chosen for its energizing effects, sometimes in combination with other antidepressants. It is also attention-deficit/hyperactivity disorder. 
  

NaSSAs—Noradrenergic and specific serotonergic antidepressants 

The medication in this class is mirtazapine (Remeron). It is the most sedating antidepressant, making it a good choice for people with insomnia or severe anxiety. This medication stimulates appetite and has fewer side effects that involve sexual function. NaSSAs can be used in com.bination with a second antidepressant. 
  

TCAs—Tricyclic antidepressants 

This is an older class of antidepressants. These medications have more side effects than newer options, so they are not often a first choice for treatment. However, they may help people with severe depression who have not responded to other medications. 

Examples: amitriptyline (Elavil), clomipramine  (Anafranil), desipramine (Norpramin),  imipramine (Tofranil), nortriptyline (Aventyl) 
  

MAOIs—Monoamine oxidase inhibitors 

MAOIs were the first class of antidepressants. They are effective, but they are not used often because they do not mix well with certain medications and food. People who take MAOIs must follow a special diet, which includes avoiding some cheeses, as well as cured meats and fermented products. Similar to TCAs, a doctor may prescribe this type of medication if first-line antidepressants do not work. 

A newer MAOI called moclobemide (Manerix) has fewer drug interactions and dietary restrictions, but it may not work as well as other MAOIs. 

Examples: moclobemide (Manerix), phenelzine (Nardil), tranylcypromine (Parnate) 
  

Starting Antidepressants 

How long does it take for antidepressants to start working? 

Antidepressants usually take four to eight weeks to start having their full effect, once you are on the right dose. Early signs that the medication is helping include better sleep, improved appetite and more energy. Improvement in mood often takes longer to appear. 
  

How long should I take antidepressants? 

If your medication is helping, your prescriber will usually recommend continuing it for at least six to 12 months after you start feeling the benefits. Continuing your medication as advised gives you the best chance of a lasting recovery. 

Stopping antidepressants too soon or abruptly can cause depression or anxiety symptoms to return, and can lead to withdrawal. Most people need to take antidepressants for at least a year. If your depression keeps coming back, your prescriber may suggest taking the medication for a longer period, switching to a different anti.depressant or adding another medication to your treatment plan. 
  

Side Effects 

Are side effects common? 

All medications can have side effects, but each person can have a different experience. You may not have any side effects at all. Some antidepres.sants are more likely than others to cause certain side effects. The table on page 4 lists common side effects that can occur with different types of antidepressants. 

Side effects are usually more noticeable when you first start the medication. For most people, they improve or go away over time. Some side effects are reviewed in more detail throughout this pamphlet. To help reduce side effects, your prescriber will usually start you on a low dose and slowly increase it to give your body a chance to adjust. The goal is to find the right dose for you— one that gives you the most benefit while causing the fewest side effects. 
  

Can antidepressants cause unexpected changes in mood? 

Antidepressants can sometimes cause a shift from depression to mania, but this is rare. Let your prescriber know if you need less sleep than usual and have an unusual amount of energy, or if your mood changes from feeling depressed to feeling very happy or irritable. Your doctor may prescribe a mood stabilizing medication, either on its own or in combination with antidepressants. 
  

Do antidepressants increase the risk of suicide? 

Depression itself can cause thoughts of suicide or suicidal behaviour. For some people, the risk of suicide increases when they start using medication treatment for depression. One reason may be that antidepressants can improve energy and motivation before they improve mood. This means a person may feel more able to act on suicidal thoughts that were already there. 

Antidepressants can also cause agitation, restless.ness and detachment (not feeling like yourself). These feelings may resemble symptoms of anxiety and may add to, rather than relieve, feelings of hopelessness and despair. In a small number of people (about four per cent), these effects can make suicidal thoughts worse. The risk is highest in the first few weeks after starting or stopping treatment, especially in children and youth. 

You can take steps to get ready in case you feel worse before you start feeling better. For example, know who can support you and make a list of people you can call for help. When you begin treatment, pay close attention to changes in your thoughts and mood. If you have thoughts of hurting yourself or others, contact your prescriber or a crisis line, or go to the nearest emergency department. You do not have to manage this alone. Help is also available through the resources listed at the end of this pamphlet. 

Will antidepressants affect my sex drive and sexual function? 

Depression and the medications that treat it can lower interest in sex. Antidepressants, especially those that affect serotonin, can also cause sexual side effects, such as taking longer to ejaculate or being unable to reach orgasm. 

Many factors affect sex drive and sexual function. When antidepressants relieve depression or anxiety, you may feel more interested in your partner and in sex. If your medication is affecting your sex life, your prescriber may be able to help by changing your dose, switching your medication or adding other medications. 
  

Are antidepressants addictive? 

Antidepressants are not addictive. Unlike addictive drugs, they do not cause euphoria, strong cravings or the need to take more to get the same effect. 

However, like many addictive drugs, antidepres.sants can cause withdrawal when you stop taking them. After taking them for months or years, your body becomes used to the medication. 

Stopping, especially suddenly, can lead to withdrawal effects such as muscle aches, electric-shock sensations, dizziness, headache, nausea, chills and diarrhea. These symptoms are most common with paroxetine (Paxil) and venlafaxine (Effexor), but they can occur with any antidepres.sant. Some people find these symptoms distressing and have difficulty withdrawing from these medi.cations. Your prescriber can help make the experience as comfortable as possible. 
  

Are there things my prescriber can do to reduce side effects? 

Side effects are a common reason people stop taking antidepressants. Review any information your prescriber or pharmacist provided about potential side effects for your medication. If you experience bothersome side effects, let your prescriber know as soon as possible but continue taking your medication as prescribed. 

Your prescriber may use different approaches to help manage side effects, such as: 

• encouraging you to wait a little longer for the side effects to fade 
• adjusting your dose 
• suggesting that you take the medication at a different time of day 
• adding other medications that help manage certain side effects 
• changing your medication 
• stopping medication and suggesting a different type of treatment, such as talk therapy 
    

Are there things I can do to reduce side effects? 

Yes. There are practical steps you can take to ease many side effects: 

• Get regular exercise. 
• Eat a diet rich in fibre, fruit and vegetables, lean protein and healthy fats. Cut down on refined carbohydrates and saturated fats. Research shows that a Mediterranean diet can reduce depression. 
• Use sugarless candy or gum, drink plenty of water and brush your teeth regularly to help your mouth produce more saliva and keep it from feeling dry. 
• Get up slowly from a sitting or lying position to prevent dizziness. 
    

Safety Considerations for Different Situations 

Can antidepressants interact with other medications or food? 

Antidepressants can interact with other prescription medications and over-the-counter products such as cold and allergy medications. They can also interact with natural health products and herbal remedies, such as St. John’s wort, or foods such as grapefruit. 

These interactions can affect how your antidepres.sant works or increase side effects. Always check with your prescriber or pharmacist before starting a new medication or supplement, or making a major dietary change. 
  

Is it safe to drink alcohol or coffee while taking antidepressants? 

Alcohol can make symptoms of depression or anxiety worse. It can also make antidepressants less effective and increase side effects such as feeling sleepy, dizzy and lightheaded. 

But if you have been taking antidepressants for more than a few weeks and you are feeling well, it should be okay to have one or two drinks occasionally—remember, though, that one drink could have the effect of two or even three drinks because mixing alcohol with antidepressants may worsen both side effects and your overall mental health. 

The caffeine in coffee and other beverages can cause problems if you experience depression or anxiety. Depression can disrupt sleep, so caffeine, which is a stimulant, can make the problem worse. It is better to choose decaffeinated drinks or cut back on how much caffeine you consume. 
   

Is it safe to use cannabis or street drugs while taking antidepressants? 

Using cannabis or other recreational drugs while on antidepressants can change how your medication works. These substances can make the effect of the medication unpredictable. They can make your medication less effective or increase side effects. 

Always talk with your prescriber or pharmacist before using any substances to understand potential interactions and stay safe. 
  

Is it safe to drive while taking antidepressants? 

Some antidepressants can make you feel sleepy or drowsy. If you experience these effects, it is import.ant to avoid driving or using heavy machinery. If your medication affects your daily activities, talk with your prescriber because they can help adjust your treatment safely. 
  

Is it safe to use antidepressants during pregnancy and breastfeeding? 

If you are planning to become pregnant or think you may be pregnant, talk with your prescriber about your medication. It is important to take care of your mental health during pregnancy and anti.depressants may help you do that. Make sure you also talk with your prescriber about the risks and benefits of antidepressants. 

Antidepressants may affect the developing fetus, but research shows mixed results. Many anti.depressants are relatively safe to use during pregnancy and your prescriber and pharmacist will help you decide what is best for you. 

If you decide to breastfeed, the amount of anti.depressant passed through breast milk is very small and is not considered to be a risk to the baby, especially when weighed against the benefits of breastfeeding. 

Postpartum depression is a type of depression that can occur after having a baby. There are specific medications that treat this condition. Talk with your prescriber if you begin to have symptoms of depression after giving birth. 
  

Is it safe for youth to use antidepressants? 

Most antidepressants are not officially approved for children and teens by Health Canada. For young people, treatment usually starts with counselling and support to address challenges in their lives. However, if symptoms are severe or counselling does not help, a prescriber may consider antidepressants. 
  

Is it safe for older adults to use antidepressants? 

Antidepressants are an effective treatment for depression in older adults. However, older adults may be more sensitive to side effects. This is because they often have other medical conditions or take other medications that may interact with their antidepressant.