antidepressants · antidepressants depression is the most common of all mental illnesses. around...

Antidepressants

Depression is the most common of all mental illnesses.

Around one person in four is likely to be diagnosed

with it at some time. It is often associated with feelings

of anxiety. Experiences vary from ‘one off’, short

lived, spells of distress with transient symptoms like

loss of energy and sleep problems to that of a major

life-threatening illness, which runs a chronic course.

Individuals with severe depression may havesuicidal ideas. These can come on suddenly, ordevelop gradually. Recognising that feeling suicidalis a symptom of depression can be an importantprotection. However, individuals with mild ormoderate depression should not be labelled asmore likely to kill themselves than others. They mightnot always enjoy themselves as much as peoplewho do not get depressed. But their lives areunlikely to be cut short.

Unipolar depression (depressive disorders with noswings towards mania – individuals are ‘down’ ratherthan ‘up and down’ in cycles) is typicallycharacterised by feelings of sadness andworthlessness. Some think of depression in terms ofindividuals ‘punishing themselves’ for things that havehappened in their lives, or blaming themselves forfailing to meet unachievable gaols. Others distinguishbetween factors which can make someone vulnerableto depression (such as losing a parent early in life),those which precipitate it (like losing a job), and thosewhich can perpetuate it or promote recovery. Havingsupportive personal relationships, hope, and timelyaccess to good psychiatric and/or social care helpspeople to recover.

The relationship between anxiety and depressioncan be thought of as being like the responses of awild animal which has been trapped. At first itstruggles fiercely – the anxious phase. Then itdespairs and lies quietly – the depressed phase.Many of us experience a mixture of these feelingswhen facing problems in life. But in depressiveillness they are more intense than normal.

Depression – like all other mental states – isassociated with biochemical changes in the brain.Serotonin and noradrenaline are monoamineneurotransmitters involved in the regulation ofmood, emotion, sleep and appetite. They arereleased from nerve endings to activate adjacentnerve cells. In order to ‘switch off’ this processmonoamines are reabsorbed and broken down byan enzyme, monoamine oxidase.

In the 1950s researchers noticed that imipramine, adrug once investigated as a treatment forschizophrenia, has an antidepressant effect. It wasrealised that this was due to it preventing thereuptake of noradrenaline and serotonin. Similarly,a drug developed to treat tuberculosis, iproniazid,was also found to have mood lifting properties. Itwas later realised that this was due to the inhibitionof monoamine oxidase. Other pharmaceuticalswere found to cause depressive symptoms,apparently by reducing the levels of monoamineneurotransmitters in the brain.

The ‘monoamine theory of depression’ suggests thatit is in part caused by insufficient amounts ofsubstances such as noradrenaline being made, orby too much being reabsorbed back into the nerveendings. Related ideas suggest that depression islinked to levels of serotonin and noradrenalinebecoming imbalanced; by changes in the numbersof ‘receptors’ for such chemicals on nerve cellsurfaces; or by other abnormalities associated withthe way they are transported to and away from siteswhere they are active. These variations may beassociated with both genetic variations and theimpact of life events.

It also appears that prolonged stress can result in thehypothalamic and pituitary glands in the brain andthe adrenal glands, found over the kidneys,interacting in ways which lead to a long term over-production of cortisol. This helps the body preparefor shocks. But in the long term high cortisol levelsseem to be linked to depression.

It is important not to be fatalistic about either thebiochemical or the social causes of depression.Recovery is helped by knowing that both physical

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and environmental problems can be overcome. Inmild depression there is little evidence that takingmedicines is of value. Social and psychologicalsupport is normally more important. In more severeillness there is good evidence that antidepressantsaid recovery, but here again this should not obscurethe value of other forms of help and treatment.

All the main antidepressants have actions that seemto be consistent with the ‘monoamine theory’. Yettheir use normally increases the levels of such brainchemicals two or more weeks before the symptomsof depression are alleviated. This indicates thatother complex changes are going on. These mightinclude the growth of new cells, the formation ofnew connections between cells in key parts of thebrain, or changes in the numbers of activeneurotransmitter receptors.

The main groups of antidepressant are:

• monoamine oxidase inhibitors (MAOIs)which inhibit the enzyme monoamine oxidase,leading to increased levels of monoamines inthe brain;

• tricyclic antidepressants, which can betermed monoamine reuptake inhibiting (MARI)drugs; and

• the selective serotonin reuptakeinhibitors (SSRIs) and related drugs.SSRIs specifically reduce the rate of serotoninbeing reabsorbed back into the nerve endingsin certain brain areas. Raised serotonin levelsmay subsequently facilitate noradrenalinerelease. Some other modern antidepressantsmay have a selective effect on noradrenaline aswell as, or instead of, serotonin reuptake.

The side effects of antidepressants can vary fromsexual dysfunction (including losing desire and notbeing able to ‘come’ normally) to precipitatingfeelings of panic. When inappropriately prescribedthey can be dangerous. But in the rightcircumstances they help people recover fromdepression, which should be taken just as seriouslyas conditions like heart disease. That is why theirside effects can be worth risking.

The use of electro convulsive therapy is not covered

in this medicines guide. Today ECT is not as widely

used as in the past. But it can now be given without

causing pain. Despite side effects such as memory

loss it can relieve serious depression when other

treatments fail.

For help lines and other information sources see the Contacts and Resources Information Sheet. This guide cannot provide all the factsyou may need to know about your medicines – it is a starting point, not the last word.

Antidepressants

Monoamine oxidase inhibitors

General information

Monoamine oxidase inhibitors (MAOIs) prevent

monoamine neurotransmitters being broken down

by inhibiting the enzyme monoamine oxidase. This

increases levels of substances such as serotonin and

noradrenaline in the brain. MAOI medicines, which

were first introduced in the 1950s, include:

• phenelzine (Nardil)

• moclobemide (Manerix)

They are now much less widely used than in the1960s and 1970s, partly because of side effects.The original MAOIs, like isocarboxacid andphenelzine, interact with foods containing achemical called tyramine. This can have harmfulconsequences. Examples of such foods includecheeses, broad beans, yeast products (like Marmite)and wines such as chianti. Small amounts oftyramine cannot be avoided. But if people takingthese MAOIs do not guard against eating anddrinking significant amounts of tyramine they mayexperience dangerous rises in blood pressure.

MAOIs also inhibit enzymes in the liver, whichbreak down insulin, local anaesthetics and someother drugs. Caution must be taken when changingfrom an MAOI to another form of antidepressantand vice versa, because residues in the body maycause a ‘double effect’ on neurotransmitter levels. Adrug-free break of two weeks or more shouldnormally be allowed before starting a new courseof antidepressants. Prescribers are told that specialcaution must also be taken in the cases of:

• individuals with diabetes, epilepsy, or heart orliver problems; and

• pregnant women, and those who arebreastfeeding.

However, for some individuals MAOIs work whenother antidepressants do not. Their beneficial effectsmay take several weeks – or even a month or two –to become apparent. Yet for people with depressionwhich has proved difficult to relieve it may well beworth persevering with taking them.

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Why hasmoclomebemidebeen prescribedfor me?

How muchshould I take?

What willhappen when Istart taking it?

What are theside effects ofthis drug?

Antidepressants

Moclomebemide (Manerix)

What should I doif I get any sideeffects?

Moclobemide is prescribed for depression, normally after other treatments havenot relieved their symptoms. It is what is called a reversible monoamine oxidaseinhibitor (sometimes referred to as a RIMA). It might have side effects when takenwith foods containing tyramine, like cheeses, yeast products and chianti. Hencethey are best avoided. If you have not taken an antidepressant before you mightwant to ask why moclobemide is being recommended for you.

Most people will initially be prescribed 300 milligrams per day, taken in two orthree doses. This may gradually be increased.

People starting antidepressants such as Manerix/moclomebemide often do notnotice any improvement for two or three weeks. Side effects – see below – mayappear sooner. You may, for example, feel tense or anxious in the first week orso. However, persevering can be worthwhile. It often takes some time before thecorrect dose of the correct drug is found for someone with a less responsive formof depression.

If too much moclobemide is taken, users may experience nausea, drowsiness andslurred speech.

• Relatively common side effects include: sleep disturbances; dizziness; nausea;headaches; agitation; dry mouth.

• Less common effects include: bowel disturbances; confusion; tiredness; blurredvision; skin rashes.

Prescribers are told to be careful about giving Manerix to individuals withconditions such as Parkinson’s disease, and women who may be pregnant or whoare breast feeding. Some medicines that can be bought from pharmacies shouldbe avoided, such as those containing codeine. The advice is always tell anypharmacist you contact to purchase over the counter medicines if you are takingthis or any other prescribed medicine.

Medicine takers are often advised to tell their doctor of pharmacist immediately ifthey begin to get side effects, not to stop taking the medicine. You will have tojudge when you need to do this, and ultimately whether you should go on using themedicine or not. Ideally, medicine takers and their professional advisers decidetogether whether side effects can be coped with, whether the dose needs changing,or if it would be best to move on to another treatment.

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What willhappen if Idon’t take themedicine asrecommended?

Is thereanything else Ishould know?

Are there anyadditionaltherapies thatmay be able tohelp me?

Questions youmight like to askabout yourmedicationinclude:


The standard line is that people who fail to take antidepressants will forgo theirbenefits, and may relapse if they stop them too soon after they feel better. Themore severe the depression the more this is likely to be true. Solving personalproblems or coming to terms with losses is often vital. But medicines can helppeople overcome disabling symptoms caused by physical changes in the brainassociated with sadness and loss.

Moclobemide can have an adverse effect on blood pressure when taken withtyramine-rich foods (yeast products, including home brewed beer, cheese etc) andit is recommended that they are avoided whenever possible. (See the generalleaflet on MAOIs, and information in every medicine pack.) As with otherantidepressants people are normally advised not to drink. But once you areestablished on it careful, moderate, use of alcohol should not be harmful. Expertssay you don’t need to stop taking meclobemide just because you want anoccasional drink, but at the same time the advice is be careful with driving andother risky activities.

There are many other therapies or activities which can help with depression.Medicines are not the only answer. Counselling or psychotherapy can bevaluable. There is good evidence that structured cognitive and problem solvingtherapies are effective for many people.

Research has also shown that exercise can decrease feelings of anxiety anddepression. Some find it also helps relaxation and sleeping. Exercise of moderateintensity such as walking or cycling for half an hour a day can produce these effects.Yoga and other forms of meditation can also be relaxing. Additional forms of therapythat some people find helpful include acupuncture. The use of herbal remedies suchas St Johns Wort is more controversial. You may want to try it, but it should not betaken at the same time as any MAOI – or other – antidepressant.

• Why are you recommending this particular antidepressant to me?

• How long should it take for it to start working?

• What happens if I still don’t feel any better after then?

• What side effects might I experience, and are any dangerous?

• How do you want me to contact you if there is an emergency?

• Is there anything else I can do to cope with my depression?

Antidepressants

What should I do if I get any side effects?

Tricyclic antidepressants (TCAs)

General information

Tricyclic antidepressants stop the reuptake of

monoamine neurotransmitters such as

noradrenaline and serotonin, and so raise their

levels within the brain. Better known examples of

tricyclic antidepressant generic (official) and brand

(commercial) names include:

• amitriptyline (Elavil; Lentizol)

• chlomipramine (Anafranil)

• imipramine (Tofranil)

There are many other TCAs, with generic namessuch as lofepramine, trimipramine and dothiepin.Their properties vary to a limited degree. It has,for example, been suggested that dothiepin(marketed as Prothiadin) may have a stronger anti-anxiety effect than other tricyclic antidepressantsand that lofepramine has fewer side effects for theaverage user.

Like all other antidepressants, the TCAs’ maintherapeutic effects are likely to take at least twoweeks – and often longer – to become apparent.These medicines are in overall terms less safe andmore difficult to go on taking than newer (and untilrecently much more expensive) treatments such as theSSRIs. They have been associated – especially wheninappropriately prescribed – with heart attacks, sexproblems and a wide range of other difficulties.

It is said that sometimes people do not respond toTCAs because the dose they have beenrecommended is too low. Against this, some recentwork has suggested that relatively small doses oftricyclics can be as effective as higher ones. But thisview is not widely accepted. What is clear is thatfor people who tolerate them well and can takesufficient doses TCAs generally seem to be aseffective in relieving depressive illness as otherantidepressants. TCAs are normally consideredinappropriate for a number of service user groups,including people who:

• have epilepsy, diabetes or glaucoma;

• suffer from heart, liver, kidney or prostateproblems;

• are pregnant, breastfeeding or who wish tobecome pregnant.

They also interact with some other medicines,including over-the-counter products such as Tagamet(cimetidine – used to reduce stomach acid levels).There is no evidence of tricyclics being addictive inthe formal medical sense. However, on occasionspeople experience withdrawal symptoms if theysuddenly stop taking them. Professionals say suchproblems are not usually difficult to manage.

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Antidepressants

Why hasamitriptylinebeen prescribedfor me?


What willhappen when Istart takingamitriptyline?



Amitriptyline (Elavil; Lentizol)

Amitriptyline has a sedative and an antidepressant effect. It may therefore beuseful for individuals who have feelings of anxiety as well as depression. It hasalso been given to children who have problems with bed wetting, and toindividuals with pain associated with nerve damage.

A relatively low dose (up to 75 milligrams a day in an adult of working age) maybe prescribed at first. It might later be increased, so that the best balance of sideand treatment effects is found.

Improved sleep may be enjoyed within a few days. But the antidepressant effectcan take several weeks or a month to take full effect, while side effects can beexperienced almost immediately. This can naturally be discouraging. Yet for thosewho continue to take the medicine the benefits may ultimately outweigh the costs.When you have depression it often takes some time before the most acceptabledose of the most effective drug is identified.

• More common side effects include: blurred vision; constipation; drowsiness; drymouth; weight gain; urinary retention; dizziness on standing.

• Less common side effects include: insomnia; racing heart beat; seizures; skinrashes.

Sometimes (normally only when given in high doses) amitriptyline can adverselyaffect the cardiovascular system and may cause more significant changes in bloodpressure, or heart rhythm abnormalities. People with manic depression mayexperience manic episodes if they take amitriptyline (or other antidepressants) at thewrong stage in their illness. If you drink alcohol it can make you sleepy.

The standard advice to service users is contact your doctor, talk over the issuesand then decide together whether or not you can cope with the side effects andwant to stay on the medication, if the dose you are taking needs to be altered, orwhether you need a different treatment.

You might also want to talk to your pharmacist, and/or check the web and otherinformation sources. If this is the first antidepressant you have tried you mightwant to ask why you have been prescribed it. Why does the personrecommending it think it is likely to be the best medicine for you, given the otheroptions available?

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Some people who stop taking TCAs (or other antidepressants) before they haverecovered for long enough and moved on in their lives find that their symptomscome back. If amitriptyline users stop taking it abruptly they may experience somewithdrawal symptoms, like anxiety or insomnia. Stopping antidepressanttreatment should normally be a planned, gradual, process.

This drug is toxic in overdose. You will have to judge the situation, but the bestadvice is that if you or someone else has taken a TCA in excess of therecommended amount, get medical help quickly.

You can take amitriptyline without food. It is very unlikely that you will becomeaddicted to amitriptyline

Due to its sedative effect, people using this medicine should consider the safety ofactivities such as driving, operating machinery and other tasks that requirealertness and good physical coordination. It is always sensible to be careful, forexample, about drinking and driving, especially if you are taking a psychotropicmedicine. Experts such as pharmacists specialising in mental health say youshould avoid alcohol when you start using drugs like amitriptyline, and laterexperiment carefully if you feel you would like a drink. TCAs taken with alcoholsometimes cause extreme drowsiness.

There are many other therapies or activities which can help to relieve depression.Counselling or psychotherapy are useful for some people, and recent research hasshown that exercise can decrease feelings of anxiety and depression. Some find italso helps relaxation and sleeping. Moderate exercise such as walking or cycling,even just for half an hour a day, can have good effects. Yoga and meditationtechniques may also prove relaxing. Other forms of therapy which some people findhelpful include acupuncture and herbal drugs such as St Johns Wort. However, yourare advised not to experiment with the latter while taking a prescribed drug or drugs,because of possible interactions.

• How long should take for this medicine to start working?

• Why has amitriptyline been prescribed for me?

• What happens if I still don’t feel any better in a few weeks time?

• What side effects should I watch out for, and what should I do if I think I amgetting them?

• How do I contact you if I feel I need help urgently?

• Is there anything else I can do to recover from this depression?



Why hasclomipraminebeen prescribedfor me?





Antidepressants

Clomipramine (Anafranil)

Clomipramine can relieve symptoms of depression. It has a mild sedative effectand may also help control anxiety, which often accompanies depression. It canbe used for treating phobic and obsessional disorders. (While medicines are still‘in patent’ and able to attract high prices their manufacturers often invest in trialsof their use in specific circumstances. If these provide evidence of their value insuch contexts this should inform prescribers’ choices. Yet other medicines in thesame class might in fact have similar effects.)

It is likely that a low dose (say 10 milligrams daily) of clomipramine will beprescribed initially. This will often be increased over time, to balance the benefitsand possible side effects as effectively as possible. Taking clomipramine atbedtime may help to avoid drowsiness during the day.

The antidepressant effect can take several weeks to become apparent. Bettersleep may be enjoyed more quickly, although side effects can be experiencedeven faster. Taking a medicine that doesn’t seem to be working is naturallydisappointing. However, it is worth keeping the potential benefits in mind. It oftentakes time before an effective treatment for depression, tailored to the needs ofthe individual, is found.

• More common side effects include: constipation; dry mouth; nausea;dizziness; weight gain; drowsiness.

• Less common side effects include: insomnia; racing heart beat; seizures; skinrashes.

The side effects of clomipramine are like those of amitriptyline. People who havemanic depression may experience manic episodes if they take TCAs. Medicines likeclomipramine can also bring on seizures amongst individuals with a history ofconvulsive disorders. In some cases they adversely affect the cardio-vascular system.However, when prescribed properly to people without heart problems the risk is low.

The standard advice to service users is contact your doctor, talk over the issues andthen decide together whether you can cope and stay on the medicine, or if the doseyou are taking needs to be altered, or whether you want a different treatment. Youmight also want to talk to your pharmacist, or check the web and other informationsources like the package leaflet. If this is the first antidepressant you have tried youmight want to ask why you have been prescribed it. Why is it likely to be the bestmedicine for you?

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Some people who stop taking TCAs (or other antidepressants) before they havecompletely recovered – which may be well after they feel better – find that theirsymptoms come back. If clomipramine is stopped abruptly withdrawal symptomssuch as nausea, anxiety or insomnia can occur. If you decide to end treatmentwith this or any other antidepressant medicine it is best to plan this as a gradualprocess, with professional advice.

This drug is toxic in overdose. Like other TCAs it should be stored carefully, andthe best advice is that anyone who has taken a significant overdose should getmedical advice quickly.

Clomipramine is better taken after food.

Responses to alcohol can be exaggerated. Due to its sedative effect, peopleusing this medicine should consider the safety of their daily activities such asdriving, operating machinery and other tasks which require alertness andphysical coordination. Be careful, for example, about drinking and driving.Initially alcohol is best avoided altogether. After people have got used to usingclomipramine careful experimentation with taking a drink should be OK, if thatis what you decide is the best choice.

There are many treatments and activities which can help to relieve depression.Drugs are not the only answer. Counselling or psychotherapy are useful for somepeople, especially structured forms such as cognitive behavioural therapy. Recentresearch has shown that exercise can decrease feelings of anxiety anddepression. Some find it also helps relaxation and sleeping.

Moderate exercise, such as walking or cycling for half an hour a day, can producethese effects. Yoga and meditation techniques may prove relaxing. Other forms oftherapy, which some people find helpful, include herbal remedies such as St JohnsWort (although the advice is not to experiment with this while taking a prescribeddrug, because of possible interactions) and acupuncture.


• Why has clomipramine been prescribed for me?



• Is there anything I should do about recovering from depression in addition totaking this medicine?



Antidepressants

Why hasimipramine beenprescribed for me?





Imipramine (Tofranil)

Imipramine is a tricylclic antidepressant which is prescribed for the relief ofdepressive symptoms. It is like amitriptyline (see information sheet 9) but isconsidered to be less sedating.

A low dose (say 75 milligrams a day) is often prescribed initially, and thenincreased. The objective is to get the best balance between the antidepressanteffects and imipramine’s possible side effects. It may be taken once a day, usuallyat night.

The antidepressant effects of TCAs like imipramine typically take from two to fourweeks to become apparent. But side effects can appear almost immediately.Taking medication that doesn’t seem to be working helpfully is often difficult anddiscouraging, although this needs to be set against the possibility of longer termbenefits. In treating depression finding the best dose of the best drug for theindividual service user often takes time.

• More common side effects include: blurred vision; constipation; dry mouth;tremors; weight gain.

• Less common and rare side effects include: insomnia; racing heart beat;seizures; skin rashes.

All TCAs have side effects like those of amitriptyline, although imipramine is lesssedating. In some cases it may (as with other drugs in this class) cause seizures.Antidepressant medicines such as imipramine can make people feel they want tourinate but are unable to do so. Individuals with manic depression mayexperience manic episodes if they take medicines such as imipramine at thewrong time. It can adversely affect the cardiovascular system and result inproblems like hypotension (low blood pressure). It may be harmful if taken bypeople with heart disorders.

The standard advice is to contact your doctor at the first sign of trouble. He or sheshould be happy to talk over the issues, and then decide with you whether or notyou can cope with the side effects and stay on the medication, if the dose you aretaking needs to be altered, or whether you want a different treatment altogether.You might also want to talk to your pharmacist, and/or check the web and otherinformation sources. If this is the first antidepressant you have tried you mightwant to ask why you have been prescribed it – was it because its likely to be thebest medicine for you?

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Some people who stop taking TCAs (or any other antidepressant) before theyhave recovered and moved on in their lives – which may be well after they feelbetter – find that their symptoms come back. If imipramine is stopped abruptlywithdrawal symptoms can occur. Stopping treatment should normally be plannedwith professional advice.

Imipramine is toxic in overdose. It should, like all medicines, be stored safely. Ifanyone takes an overdose the best thing to do is to get immediate medical help.

Responses to alcohol can be exaggerated by TCAs. Even though imipramine isnormally less sedating than other drugs in this class, people using it shouldconsider the safety of their daily activities such as driving, operating machineryand other tasks that require alertness and physical coordination. Everyone shouldalways, of course, avoid drinking and driving, especially when taking apsychotropic medicine. When imipramine is first prescribed alcohol use is bestavoided. But later moderate drinking should be OK, provided you judge that it issensible.

There are many other therapies or activities which can help to relieve depression.Counselling or psychotherapy are useful for some people, although simply talkingabout problems in an unstructured way may not help. Recent research has shownthat exercise can decrease feelings of anxiety and depression. Some people findit also helps them to relax and sleep.

Exercise of moderate intensity, such as walking or cycling for just half an hour a day,can produce benefits. Yoga and meditation techniques may prove relaxing. Otherforms of therapy which some people find helpful include taking herbal drugs such asSt Johns Wort (the advice is do not experiment with this while taking a prescribedmedicine, because of possible interactions) and acupuncture.


• Why has imipramine been prescribed for me?



• What should I do if I start to feel worse?

• Is there anything else I can do to help me recover?



Antidepressants

Selective serotonin reuptakeinhibitors and related medicines

General information

It is still not clear why antidepressants often take

around a month to work, even though they increase

brain amine levels within hours. But during the

1960s a better understanding of the ways in which

antidepressant medicines work started to build up.

For instance, it was found that as drugs like TCAsbreak down they form secondary compounds,which themselves have psychotropic effects. Doctorsand research scientists began to think that if drugscould be used more selectively to adjust the levels ofsingle neurotransmitters in specific areas of thebrain, then it might be possible to treat depressiveillnesses in a more targeted way. Some of theunwanted side effects associated with tricyclicantidepressant use should then be avoided.

At the start of the 1970s techniques needed forpursuing such advances in a systematic waybecame available. At the same time – after a periodin which the role of noradrenaline depletion indepression had received the most attention – theeffects of changing serotonin levels emerged as atopic of special interest.

This lead in the late 1980s to the marketing of thefirst medicine intended to act as a selectiveserotonin reuptake inhibitor (SSRI), fluoxetine(Prozac). Despite their relatively high pricecompared to older off-patent drugs, medicines suchas Prozac in time displaced the TCAs as the mostwidely used type of antidepressant. Against thebackground of concerns about ‘tranquilliser’ over-use and addiction, the SSRI anti-depressants alsopartially replaced the minor tranquillisers in thetreatment of anxiety associated with depression. Ifused for this purpose it is now thought that they

should be prescribed in lower doses than thoserecommended for more typical depression.

Other widely prescribed SSRIs include:

• fluvoxamine (Faverin);

• paroxetine (Seroxat); and

• sertraline (Lustral).

There is good evidence that the SSRIs are onaverage safer, and for many individuals moreacceptable, than earlier drugs. Some have nowcome off patent, and are hence no longer muchmore expensive than the tricyclics. It does not seemthat they are inherently more effective, or faster toact, than TCAs. But their better side effect profileshelp people to go on taking them. However, theyare not risk free. SSRIs are not appropriate, forexample, for some people with:

• epilepsy

• diabetes; or

• liver or kidney problems.

If you have been given an SSRI or otherantidepressant and have such a condition it could beworth checking that the prescription is right. Womenwho are pregnant, wanting to become pregnant, orbreast feeding are normally advised to avoid takingthese medicines, as also are people taking, or whohave only just stopped taking, MAOIs – see HeritageCare Information Sheet 6.

Stopping taking SSRI medicines can causewithdrawal symptoms. For some individuals thismeans they should only be given up very gradually.As is also the case with anti-depressants like TCAs,paradoxical responses like feelings ofaggressiveness can occur amongst a minority of theindividuals who start taking them. There have been

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apparently rare but well publicised cases involvingviolence to others, or self-harm or suicide, in whichSSRIs have been said to be responsible.

Following the development of the first SSRIs a range ofother new antidepressants has become available.They include venlafaxine (Efexor – which is describedas having a combined action on both serotonin andnoradrenaline reuptake) and reboxetine (Edronax, anoradrenaline reuptake inhibitor). Bupropion (nowmarketed as Zyban for smoking cessation, rather thanas an antidepressant) also has selective effects onneurotransmitter levels in the brain, which in that casemay result in increased dopamine availability.Information about such medicines is available on theinternet, as well as from sources like the BritishNational Formulary (see www.bnf.org) and theinformation leaflets in each pack.

For some individuals, one particular SSRI or relatedtreatment designed selectively to alter serotinin and/ornoradrenaline levels can have unique benefits. But inoverall terms the advantages and possible drawbacksof all these treatments are broadly comparable. Thereis no reliable way – yet – of telling in advance whichis the best possible medical, or indeed other, treatmentfor someone who is experiencing depression.


Antidepressants

Why hasfluoxetine(Prozac) beenprescribed forme?




Fluoxetine (Prozac)

Fluoxetine is mostly prescribed for patients with depression. It can also be used totreat other mental health and allied problems, such obsessive-compulsive disorder(OCD) and bulimia nervosa. Fluoxetine is less toxic in overdose than many otherantidepressants. Fluoxetine, like other SSRIs, is relatively unlikely to cause significantheart and/or circulatory system problems, although its use can relatively often resultin stomach and bowel upsets.

Different medicine takers may need different doses. But a typical one for someonewith depression would be 20 milligrams a day. This drug stays in the body for arelatively long time, so dosage increases should be made carefully.

People vary, but you might not notice any improvement in depressive symptomsfor around a month. Other symptoms such as sleeping problems or anxiety mayimprove more quickly. Despite possible side effects during the time before yourdepression lifts it could well prove worth persevering. There is no reliable way offinding out who will benefit from a drug such as fluoxetine other than trying it forlong enough for it to have a chance to work.

• More common side effects include: stomach upsets, including nausea andvomiting; other gastro-intestinal disturbances, such as diarrhoea; sleepdisturbances, including insomnia; sexual dysfunction, like a loss of desire orfinding it difficult to ‘come’.

• Less common and rarer side effects include: drowsiness; weight loss;restlessness and sweating; headaches; constipation; skin rashes; tremors/twitching; and dry mouth.

Some side effects wear off if people continue to take fluoxetine. However, as with anymedicine it is probably sensible to tell your doctor if you think you are developing askin rash or other new problem. People who have manic depression may experiencean episode of mania if they take fluoxetine at the wrong time.

If you suffer from epilepsy, taking fluoxetine could make you more likely to have aseizure. If you have diabetes, you may find that the drug affects your blood sugarlevels. It also interacts with medicines for a number of other conditions, so it makessense to remind your doctor and your pharmacist what you are already taking.

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What willhappen if I don’ttake the medicineasrecommended?






People are normally told that if they begin to experience side effects they should notstop taking their medicine, but contact their doctor or pharmacist. If you have agood relationship you can then decide together whether or not you can cope withthe side effects and keep taking the medicine, whether the dose you are takingneeds to be altered, or whether you would like alternative treatment. Ultimately, ofcourse, you have to judge who you trust, and what advice you want to accept.

Not taking an antidepressant such as fluoxetine might mean that symptoms will persistlonger than would otherwise be the case, or return more rapidly. People with moresevere depression benefit more from drug treatments than individuals with moderateillness. If SSRI antidepressants are stopped abruptly users may experience withdrawalsymptoms like increased nervousness. However, they can normally be coped withwithout major problems if the withdrawal is gradual.

You can eat any normal food while taking fluoxetine, and take medicines likepainkillers, antibiotics and the contraceptive pill. Drinking alcohol should notcause major problems, but it is wise not to for a few days when you first starttaking SSRIs. Afterwards go carefully, and see how drowsy it makes you feel.Warnings about not drinking and driving should be taken even more seriouslythan normal.

Fluoxetine can come in liquid form, or in capsules.

There are many other therapies or activities which can help to relieve depression.Drugs are not the only answer. Counselling or psychotherapy are useful for somepeople. Recent research has shown that exercise can decrease feelings of anxietyand depression. Some find it also helps relaxation and sleeping. Even moderateactivities such as walking or cycling for half an hour a day may produce these effects.Yoga and meditation techniques can be relaxing. Other forms of therapy, which somepeople find helpful, include herbal remedies such as St Johns Wort (the advice is donot experiment with this while taking any prescribed drug for depression, because ofpossible interactions) or acupuncture.

• How long should it take for this medicine to start working?

• Why has fluoxetine been prescribed for me?



Why hasparoxetine beenprescribed for me?





Paroxetine (Seroxat)

Antidepressants

Paroxetine is prescribed primarily to relieve the symptoms of depression. It is alsolicensed for the treatment of other disorders, such as panic and obsessionalstates. It does not normally have a significant sedative effect. As with other SSRIs,it does not have cardiovascular side effects like those of the TCAs. However,problems such as withdrawal symptoms may be more common.

The most commonly prescribed dose is 20 milligrams per day. This initial amountmay be increased if symptoms are not reduced, although recently concerns aboutpeople feeling suicidal on very high doses have been raised (there may be a riskof feeling suicidal with all SSRIs, in rare circumstances). A once-daily dose taken inthe morning is common. It may take some time to find a drug which helps relievedepression, and to determine the best dose. Most doctors and pharmacists say that,depending on a person’s age and experience of depression, antidepressant treatmentcan appropriately continue for many months, or even years.

You may not notice any improvement for three or four weeks, although side effectsmay appear almost immediately.

• More common side effects include: nausea and vomiting; insomnia; sexualdysfunction (like finding it hard to ‘come’); and weight gain.

• Less common side effects include: sweating; tremor (shaking); dry mouth; skincomplaints; feeling on edge and sweating; diarrhoea.

If you suffer from epilepsy or convulsive disorders, you may be more likely to have aseizure. People with a history of manic depression are more likely to experience anepisode of mania if they take paroxetine, or any other antidepressant.

Service users are normally advised that if they experience side effects they shouldcontact their doctor or pharmacist, rather than just stopping their medicine. If youhave a good relationship you can then decide together whether or not you cancope with the side effects and keep taking the medicine, or the dose you aretaking needs to be altered, or whether you would like an alternative treatment.

14


What will happenif I don’t take themedicine asrecommended?




Not taking a prescribed antidepressant might mean that symptoms will persistlonger than would otherwise be the case, or return more rapidly. People with moresevere depression appear to benefit more from drug treatments than individualswith mild to moderate illness. If SSRIs such as paroxetine are stopped abruptly usersmay experience withdrawal symptoms like increased anxiety. However, they cannormally be coped with successfully if the withdrawal is gradual. If you have beenworried by media reports about medicines such as Seroxat it may be worthremembering that widely prescribed ‘best selling’ psychotropic medicines haveoften attracted critical attention, and that medicine safety is constantly monitoredand reviewed by government agencies across the world.

Paroxetine can be taken with or without food.

If you are using an anticoagulant to treat or prevent a heart or other vasculardisorder check with your doctor or pharmacist that you should also be takingparoxetine, because of possible interactions.

The effects of alcohol are not normally exaggerated by paroxetine. People withdepression are often advised to be careful about drinking, but there is no reason tostop taking this medicine if you decide you want to. However, drinking and driving isnot advisable for anyone, regardless of the medicines they are taking.

There are many other therapies or activities which can help to relieve depression.Counselling and/or psychotherapy are useful for some people, and recentresearch has shown that exercise can decrease feelings of anxiety anddepression. It may also help with relaxation and sleeping. Exercise of moderateintensity, such as walking or cycling for even half an hour a day, can bebeneficial.

Yoga and meditation techniques may prove relaxing. Other forms of therapywhich some people find helpful include herbal remedies such as St Johns Wort(but do not experiment with this while taking a prescribed drug for depressionbecause of possible interactions) and acupuncture.


• Why has paroxetine been prescribed for me in preference to other treatments?


• What side effects should I watch out for?

• What should I do if I think I am getting side effects or feeling worse?

Antidepressants

Why hasvenlafaxine beenprescribed for me?





Venlafaxine (Efexor)

Venlafaxine is prescribed for depression. Unlike the SSRIs which are claimed toinhibit the reuptake of serotonin selectively, venlaflaxine inhibits the reuptake ofboth serotonin and noradrenaline. This can have advantages for some users.

Most people are prescribed a total of 75 to 150 milligrams daily, taken in twodivided doses. This may be increased in cases of severe depression. It may takesome time to determine the best dose for you.

You may not notice an improvement for three to four weeks. Despite possible sideeffects before the drug starts to relieve your depression, it could be well worthpersevering. The only reliable way to find out if someone will benefit from takingvenlafaxine is, as with other antidepressants, to try it for long enough.

• More common side effects include: nausea; headache; sleep disturbance;drowsiness

• Less common and rare side effects include: dizziness; indigestion and loss ofappetite; anxiety; sexual dysfunction (decreased libido and/or difficulty inreaching orgasm); vomiting; blurred vision.

Many side effects wear off over time. However, it is sensible to tell your doctor ifyou develop a skin rash or any other new problem.

Venlafaxine can interact with medicines that can be prescribed or purchased fora number of physical conditions, so it makes sense to remind your doctor andpharmacist of what you are already taking.

People are usually told that if they begin to experience side effects they should notstop taking their medicine, but contact their doctor or pharmacist. If you have agood relationship you can then decide together whether or not you can cope withthe side effects and keep taking the medicine, whether your dose needs to bechanged, or whether you would like alternative treatment.

15


What will happenif I don’t take themedicine asrecommended?




Not taking an antidepressant such as venlafaxine might mean that symptoms willpersist for longer, or return more rapidly. There is evidence that people withsevere illness benefit from drug treatments more than those with moderatedepression. (Mild depression may respond to non-drug treatments better than itdoes to medicines, which in such cases often appear to have no positive effect.) Ifvenlafaxine is stopped suddenly you may experience nausea, dizziness, fatigueand/or headache. These symptoms are much less likely to occur if the drug iswithdrawn gradually.

People using venlafaxine should consider the safety of activities such as drivingand operating machinery, particularly when first taking the medicine. If the drugdoes not make you drowsy moderate drinking should not cause problems, afteryou have got used to taking it.

Pregnant and breastfeeding women are not normally prescribed venlafaxine. Ifyou are thinking of becoming pregnant it makes sense to discuss the risks andbenefits of continuing the medicine with your doctor. If you decide to stop takingthe drug it can then be withdrawn gradually.

There are many other therapies or activities which can help to relieve depression.Medicines are not the only answer. Counselling or psychotherapy are useful forsome people. Recent research has shown that exercise can decrease feelings ofanxiety and depression. Some find that exercise also helps relaxation andsleeping. Even mild activities such as walking for half an hour each day canproduce these effects.

Yoga and meditation techniques can also be relaxing. Other forms of therapy,which some people find helpful, include herbal remedies such as St John’s Wortor acupuncture. However, you would be well advised not to experiment withtaking St John’s Wort while taking a prescribed antidepressant, because ofpossible interactions.

• How long should it take for this medicine to start working?

• Why has venlafaxine been prescribed for me?


• What side effects should I watch out for?

• What should I do if I start to feel worse, or think I am getting side effects?

• Is there anything else I should be doing to overcome my illness?

antidepressants · antidepressants depression is the most common of all mental illnesses. around...

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