What Antidepressant Is Right for Me?

There is absolutely no “one-size-fits-all” when it comes to antidepressants, and the decision to choose the “best” anti-depressant for a patient is multi-factorial. An experienced psychiatrist or other mental health expert will discuss risks and benefits of a variety of medication options with patients, and also explain the logic between choosing one medication versus another. Making the decision to start an antidepressant trial can feel overwhelming, and working with a provider who takes the time to explain options, can make this process less anxiety provoking.

When treating patients for depression with anti-depressants, I’ll want to take several items into consideration:

• The Patient’s Diagnosis/ Co-occurring Anxiety: If a patient suffers from depression with anxiety, an SSRI or SNRI may be preferred. Selective Serotonin Reuptake Inhibitors (SSRI’s) and Selective Serotonin Norepinephrine Inhibitors (SNRI’s) treat both depression and anxiety symptoms (they’re considered “first line” treatment for both conditions). SSRI’s include Prozac (fluoxetine), Lexapro (escitalopram), Zoloft (sertraline) and others. SNRIs include Cymbalta (duloxetine), Effexor (venlafaxine) and others.
• Suspicion of Bipolar Disorder: If a patient has bipolar disorder (or  is suspected to have bipolar disorder), then anti-depressants such as SSRI’s or SNRI’s may not be appropriate (or must be used very cautiously). For patients with bipolar disorder, a mood stabilizing medication or Second Generation Anti-Psychotic (SGA) may be more appropriate. Many do not realize, that mood stabilizing medications and SGAs can have quite robust anti-depressant effects. Alternatively, there may be reasons to add an anti-depressant to a mood stabilizing regimen (or use an anti-depressant conservatively), but providers may prefer anti-depressants such as Wellbutrin (Buproprion) in these cases, as there may be less of a risk for mood destabilization or cycling.
• Side Effects: Certain anti-depressants are more, or less likely to have various side effects. For example, Prozac (fluoxetine) and Paxil (paroxetine) may be more likely to have fatigue and  sexual side effects than others, while Effexor (venlafaxine) and Paxil (paroxetine) may be more likely to have withdrawal or discontinuation side effects when stopped. Wellbutrin (buproprion) may improve libido/ sexual function (particularly if caused by other psychiatric medications, but it should be used very cautiously in patients with a history of seizure or eating disorders (as it can increase the risk of seizure, particularly at doses of 450 mg). If a patient suffers from insomnia and/or poor appetite as part of their depression, Remeron (mirtazepine) may be a good option, as it can help w/ both sleep and appetite. If a male patient suffers from pre-mature ejaculation, Prozac (fluoxetine) may be preferred, as it can treat this condition as a side effect.
• Family History & Pre-conceived Notions: If a family member has been successfully treated with a certain anti-depressant, for a similar condition, it’s conceivable that the same medication may be more likely to help a patient, given similar genes. Additionally, if a patient has family or acquaintances who did particularly well w/ a certain medication (or who had a particularly bad experience with a medication), taking this into consideration is also important, as it could affect compliance or willingness to go through a full trial.

While trial and error are unfortunately common when treating depression, explaining the above, and taking these items (and others) into consideration, can make trials more manageable, and increase the likelihood of successfully treating a patient’s depression.

It’s also important to keep in mind, that any medical decision making should occur between the patient, and their provider. The above is not medical advice, merely general information on the process of choosing an anti-depressant, and why it’s important to work with someone who is thoughtful and thorough about these decisions.

How Doctors Choose the “Right” Antidepressant

Psychiatrists and other mental health professionals, should also be applying evidenced-based guidelines to their shared decision-making, when prescribing anti-depressants, such as SSRI’s, SRNIs (or any psychiatric medication).

It’s not uncommon for patients to see a commercial on TV, read Reddit articles on psychiatric medications, or to perform their own Ai searches, and then come to the conclusion that they “need” a certain anti-depressant or other medication. Being assertive and educated about your medical care is important (and it’s very important that your Psychiatrist listens and considers your thoughts w/ shared decision-making), but it’s also important for the clinician to perform their own accurate evaluation / diagnosis, and to then utilize their medical knowledge and experience, to thoroughly discuss the patient’s preferences, along with additional options. It is not uncommon for a patient to request a certain medication, and then for me to explain that it’s 1) not indicated based on their diagnosis or 2) dangerous, and therefore I am not open to prescribing it. An open conversation is generally extremely well received, but if the provider doesn’t take time with the patient, rapport can suffer greatly (you never want a patient’s research to feel dismissed).

The clinician should also take into consideration past treatment response. This may seem obvious, but it’s unfortunately not uncommon for a patient to tell me that they had a severe side effect with a medication (such as an SSRI or SNRI), and then to tell me that their provider wrote them for a similar medication (with an even HIGHER risk of that same side effect) as their next trial. Alternatively, if a patient did well with a medication in the past (and is exhibiting similar symptoms), that may be a great place to start.

• If a patient had severe sexual side effects with an SSRI such as Prozac (fluoxetine) or Zoloft (sertraline), I may be more likely to recommend Wellbutrin (buproprion) or Trintellix (vortioxetine) as a possible trial.
• If a patient had increased anxiety when taking Wellbutrin (buproprion) or Trintellix (vortioxetine) in the past, I may be more likely to recommend an SSRI or SNRI for their next trial.

Medical conditions should also be considered when writing someone for an anti-depressant. For example, the experienced clinician should be ruling out thyroid conditions, anemia, vitamin deficiencies or medication side effects (such as beta blockers) as the cause of a patient’s depression – because anti-depressant treatment may not be needed at all!

Common Antidepressant Types and How They Differ

Selective Serotonin Reuptake Inhibitors (SSRI’s) include medications such as Prozac (fluoxetine), Zoloft (sertraline), Lexapro (escitalopram), Celexa (citalopram) and others. They are generally thought of as first line agents for patients with Major Depressive Disorder and other depressions (excluding patients with bipolar disorder). They are generally well tolerated, treat both anxiety and depression, and are relatively safe, with no (or minimal) routine lab monitoring for most. They replaced many older anti-depressants (such as Tricyclic Anti-depressants / TCAs and Monoamine Oxidase Inhibitors / MAOIs) as first line, as these older medications tend to have higher risk of side effects, and can be lethal in overdose. Common side effects include nausea, tiredness, headache, upset stomach, and a lower libido (these do not occur in all patients, and most/ all of these side effects are often transient).

Selective Serotonin Norepinephrine Reuptake Inhibitors (SRNIs) include medications such as Cymbalta (duloxetine), Effexor (venlafaxine) and Pristiq (desvenlafaxine). These medications are commonly utilized for patients suffering from Major Depressive Disorder, other depressive disorders and anxiety (excluding patients with bipolar disorder). These medications increase availability of not only serotonin, but norepinephrine as well, and therefore may provide additional benefit for mood, chronic pain and poor focus. I’ve found that they may be less likely than SSRIs to cause sexual side effects (for some).

Other Anti-depressants:

• Wellbutrin (buproprion) increases availability of Norepinephrine and Dopamine. It can be very effective for depression, and patients will often report improved energy, motivation and focus. It is used off label for ADHD for some patients. It does not increase serotonin, and therefore not only does not treat anxiety, but it can worsen anxiety (for some, very significantly). It can be dangerous to prescribe Wellbutrin to someone with a history of seizures, alcohol dependence, or an active eating disorder, as it can increase the risk of seizure.
• Remeron (mirtazepine) works on serotonin receptors in various ways (it is neither an SSRI or SNRI, but does increase availability of serotonin). It treats both anxiety and depression, and can be utilized as an appetite inducer, and treatment for insomnia as well. Weight gain may be more common with Remeron (mirtazepine) than many other anti-depressants. Alternatively, it may be less likely to cause sexual side effects than some other anti-depressants.
• Trintellix (vortioxetine) is a newer anti-depressant that may be particularly helpful in patients with executive dysfunction, cognitive slowing (in their depressions), low energy and poor motivation. It does NOT tend to cause sexual side effects. Of note, it does not treat anxiety, so if there is co-occurring anxiety, an SSRI or SNRI may be preferred.
• Tricyclic Antidepressants (TCAs) increase availability of serotonin, norepinephrine and dopamine. They can be extremely effective in treating depression, when SSRIs, SRNIs or other more commonly prescribed agents fail. Of note, they can be lethal in overdose, and there may be additional required monitoring (EKGs for example). They’re contraindicated in patients with various medical conditions (such as closed angle glaucoma), or should be used w/ caution. I believe that these medications are often under-prescribed (as they can be very effective), but with that said, they should only be prescribed by an experienced clinician. Examples include Nortriptyline, Clomipramine and Amitriptyline.
• Monoamine Oxidase Inhibitors (MAOIs) also increase the availability of serotonin, norepinephrine and dopamine. Like TCAs, they can be extremely effective for treating depression, and may be underutilized in the present day, but with that said, should only be prescribed by an expert mental health clinician. MAOIs require that patients follow a specific diet (low tyramine), as foods high in tyramine could cause patients on MAOIs to develop hypertensive crisis (a potentially life-threatening condition). Patients generally require a “wash out” period, where they are off all anti-depressants for a prolonged period of time before starting an MAOI (or off an MAOI for a similar wash out period) before starting their next anti-depressant trial. This can make it challenging to start an MAOI. Examples include Parnate (tranylcypromine), Nardil (phenelzine), Emsam (selegiline) and others.

This information is not to be used as medical advice, and any decision making regarding anti-depressants or any psychiatric medications, should be a shared decision-making process with your psychiatrist or medical provider, while you are actively under their care.

Matching Antidepressants to Symptoms and Life Situations

A psychiatrist or other mental health provider, should also consider a patient’s real-life situations, when deciding on a specific medication for an anti-depressant trial.

• Pregnancy: Medications such as Prozac (fluoxetine) or Zoloft (sertraline), are considered safer for pregnancy by some, given research data and a longer history of their use for depression in pregnancy (compared to many newer agents).
• Peri-Menopause / Menopause: SRNI’s, such as Cymbalta (duloxetine) and Effexor (venlafaxine) are often utilized, as they may be more effective in treating depressive symptoms during this stage in a woman’s life.
• Chronic Pain: There’s evidence that SNRI’s, such as Cymbalta (duloxetine) and Effexor (venlafaxine) may be helpful in the treatment of certain forms of chronic pain. If a patient suffers from both depression and chronic pain, we’ll often discuss SNRIs as potential options.

Patients should discuss options, risks and benefits with their medical provider, and as mentioned, treatment must be individualized (there’s no one-size-fits-all).

How to Prepare for an Appointment About Antidepressants

An initial appointment with a psychiatrist or other mental health professional, to discuss anti-depressants or any psychiatric medications, should be thorough (typically 60-90 minutes) and extensive. The provider should be screening for not only depression, but bipolar disorder, anxiety disorders, substance use difficulties and medical conditions (that can affect psychiatric symptoms). They should also take into consideration a patient’s behavioral patterns, life situations, personality, and any history of trauma, as the best treatment plan may be affected by all of the above; an anti-depressant trial may be reasonable after going through this type of evaluation, but it’s also possible, that it won’t be indicated at all!

There are several recommended steps for patients to take, to help them be prepared for their psychiatric evaluation, and discussion of anti-depressants. These include:

• Patients tracking their mood changes, sleep, and functioning over several weeks.
• Patients making a complete list of medications, supplements and medical conditions.
• Preparing a list of previous medication trials, including dosages, effects and side effects.
• If unknown, patients asking family about family history of mental illness (including a history of bipolar disorder) and medication trials among family members.
• Preparing questions for the provider, including questions about common side effects, and putting some thoughts into which side effects they may be most concerned about.
• Finally, if previous evaluations have been completed, or if there have been any recent labs, having PDFs available for your provider can be very helpful.

What to Expect When Starting or Changing an Antidepressant

Benefits from antidepressants such as SSRIs and SNRIs, are typically at full effect after about 6-8 weeks (once on the right dose for the patient). This means, that it’s not uncommon for someone to start an anti-depressant, and feel no benefit for weeks (or longer), or until it’s titrated once or twice. Not responding to the initial dose of an anti-depressant does NOT necessarily mean, that it’s not the right medication for the patient. This is why it’s so important to have regular follow-up with your provider to discuss effect (and need for titration), and to also not stop a medication prematurely.

Side effects are often transient, and can fade with time. It’s not uncommon for patients to have some upset stomach, “activation” (increased anxious energy), headache, lower libido (or delayed orgasm), or feel a little tired when starting these medications (or after a dose increase) and it’s not uncommon for these side effects to be transient. These side effects can often be mitigated with timing, or other strategies, that the experienced mental health professional can help a patient with. This is why giving a medication a full trial (and working closely with your psychiatrist or other specialist) is so important.

If an SSRI or SNRI isn’t tolerated (for example, let’s say Zoloft (sertraline) causes someone to have significant GI upset, changing to a medication (even within the same class) can often be an easy solution. Just because a side effect occurs with one medication, doesn’t mean (at all), that it’s going to happen with another, even in the same class. I tell my patients that if we’re starting an SSRI or SNRI, and they have severe side effects, to reach out right away, and I’ll likely just send in a different medication within the same class – this way, we don’t waste another month or two before their next visit, before treating their depression.

I always tell patients, that if they’re feeling worse (emotionally), and it’s moderate, severe, worsening (or if there are any suicidal thoughts), that they should reach out right away, so that we can discuss options and assess their reaction (if they’re in danger, then they’re to call 988, 911 or go to an ER). As an example, sometimes you’ll realize that someone is actually on the bipolar spectrum, by their reaction to an SSRI or SNRI (even without any history of manias or mixed episodes)- and as mentioned, being on an anti-depressant can be dangerous for many individuals with bipolar disorder.

Safety, Side Effects, and When to Get Urgent Help

Anti-depressant medications, such as SSRIs and SNRIs are generally well tolerated. Side effects are often minimal and transient, and can often be mitigated by using the lowest effective dose, or by employing strategies (even just regarding the timing of when to take the medication), that can often make them a non-issue. With that said, they are not always indicated, and not always tolerated. Working with a psychiatrist or other mental health provider who is experienced in psychopharmacology, can improve the chances that a patient will find the right medication for their depression, at the lowest effective dose, with the fewest number of side effects.

Common side effects include:

• Fatigue
• Upset stomach
• Changes in libido (or delayed orgasm).
• Dry mouth
• Constipation (or other gastrointestinal side effects)
• Headache
• “Activation” – increased anxious energy, particularly when starting.

*If someone experiences a significant worsening of symptoms, increased impulsivity, decreased need to sleep, or suicidal thoughts, they should seek immediate medical attention.

It’s extremely important that patients disclose to their psychiatrist or medical professional the use of any alcohol, recreational drugs, and their current medication/ supplement list. Interactions between medications and other substances can be severe, and a thorough discussion about interactions and risks, should take place whenever a patient is taking an anti-depressant or other psychiatric medication.

Frequently Asked Questions About Choosing an Antidepressant

What is the best medication for depression?

There is no “best” medication for depression. Patients should meet with an experienced psychiatrist or medical professional, who can discuss pros and cons of various options, and take into consideration a patient’s unique illness, genetics, side effect tolerability profile, co-occurring psychiatric conditions, and medical conditions.

How long does it take for anti-depressants to work?

Anti-depressants generally take about 4-6 weeks for full effect, and patients may not feel any effect, until they are on the right dose, for that period of time. For example, it’s not uncommon for someone to have no response at all at a starting dose of an SSRI, and then have complete remission of depression 4-6 weeks after their dose is increased at a follow-up visit.

Do genetics play a role in choosing an anti-depressant?

If an anti-depressant worked well for a family member, who has similar symptoms, it may be more likely to work for your depression. However, this is not always the case, and a full evaluation, diagnosis and discussion of options with a mental health professional is still very important. Additionally, genetic testing may be helpful when a patient has failed many trials without tolerating a medication, or without improvement in symptoms.

Do I need to stay on an anti-depressant forever?

Generally, no. Providers will make recommendations based on various factors including frequency of depressions and severity. For example, if someone has had one or two mild to moderate depressions, over the course of 5-10 years, it would not be uncommon for a provider to recommend 6-12 months of treatment and then tapering w/ monitoring. However, if someone has frequent depressions, or severe depressions with suicidal thoughts, remaining on an anti-depressant may be the recommendation.