Other Antidepressants

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Harvard Medical School
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Other Antidepressants

Depression
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What Kind Of Treatment Is Available?
Other Antidepressants
Other Antidepressants
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Because these "other" antidepressants differ from more widely prescribed antidepressants, they are good choices when other antidepressants have not worked.
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InteliHealth
2011-04-25
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InteliHealth/Harvard Medical Content
2014-04-25

Reviewed by the Faculty of Harvard Medical School

Other Antidepressants
These "other" antidepressants all have an effect on chemical messengers in the brain, but each has a somewhat different effect. They act differently from selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), making them good options if SSRIs have not worked. Depending on your needs and your doctor's preference, these antidepressants sometimes are prescribed as first, before the better known SSRIs.
 
Like all antidepressants, these drugs usually take a few weeks to start working fully. All are equally effective, as long as the dosing is correct. Their side effects are different from SSRIs, but they tend to be as well tolerated.
 
Warnings
 
Suicide Risk. All antidepressants carry warnings about suicide. In October 2004, the Food and Drug Administration began requiring that manufacturers include a warning on package inserts for all antidepressants. The warning mentions the risk of suicidal thoughts, hostility and agitation in both children and adults.
 
After you start taking any antidepressant, there is a risk that you may feel worse rather than better. The danger is greatest in the first few weeks of treatment, so make sure you follow-up with your doctor. There is also a small risk for an increase in suicidal thinking and behavior. Fortunately, some research shows that the overall suicide rate decreases in people taking antidepressants. However, a small number of people using antidepressants do encounter a lower mood, and feel more anxious, irritable, self-destructive or impulsive.

 

Bupropion
 
Bupropion (Wellbutrin) works on the neurotransmitters norepinephrine and dopamine. Because bupropion does not cause sexual side effects, it is a popular alternative for people who give up on selective serotonin reuptake inhibitors (SSRIs), which can cause sexual side effects. Because bupropion has a different mechanism from SSRIs, though, so it may not be as effective for people who have already had a good response to an SSRI. Of course, this also means that bupropion may very well work when SSRIs do not.
Dosing
 
Bupropion is marketed under two names. Under the name Wellbutrin, it is marketed as an antidepressant, while as Zyban it is marketed as an aid to quit smoking — but these drugs are chemically identical. Be careful therefore NOT to get prescriptions for both drugs at the same time.
 
Bupropion is usually taken two or three times per day, at least four hours apart. The reason for dividing the doses is that bupropion leaves the body quickly, and if the blood level climbs too high, there is a risk of seizure. Many physicians now prescribe slow-release forms of the drug, which may reduce that risk. Slow-release bupropion pills must be swallowed whole — don't crush or chew them.
 
Although some people get a good response with doses of 150 to 200 milligrams per day, many people require doses of 300 to 450 milligrams. (Older adults generally take lower doses.) The maximum dose is 450 milligrams per day (three 150-milligram doses). No single dose should be more than 150 milligrams (unless it is a sustained or extended release form). Above that dose, the incidence of seizures goes up significantly.
Bupropion may be taken with food to reduce stomach distress.
 
Side Effects
 
Common side effects are not dangerous, but can be uncomfortable:
  • Agitation or anxiety, tremors
  • Trouble sleeping or drowsiness
  • Stomach distress, nausea, constipation, changes in appetite, weight loss
  • Dry mouth
  • Increased sweating
  • Headache
  • Skin rash
  • Ringing in the ears
If you notice these or any other changes, talk to your doctor.
Some severe effects may occur with bupropion. They are rare, except in people who already have a vulnerability to them:
  • Seizures (convulsions), especially at high doses
  • Psychosis (unrealistic thinking)
If you miss a dose, do not double up on your dose.
Bupropion carries the same warnings about suicide risk as other antidepressants. (See above.)

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Mirtazapine
 
Mirtazapine (Remeron) increases the release of the chemical messengers norepinephrine and serotonin. It can be used as an antidepressant, as well as an antianxiety drug.
Dosing
 
Mirtazapine can be taken in a single daily dose. It is usually used at bedtime, because of its sedative effects.
Some people find relief taking 15 milligrams per day, but others require 30 or 45 milligrams. (Older adults generally take lower doses.) Mirtazapine is available as a disintegrating tablet, which can be taken without water. Handle the pill carefully so it doesn't start dissolving before you put it on your tongue. It dissolves in your mouth within seconds.
Mirtazapine can be taken with or without food.
 
Side Effects
 
Common side effects are not dangerous, but can be uncomfortable:
  • Dry mouth
  • Feeling like you are tranquilized (sedation)
  • Increased appetite and weight gain
  • Dizziness
Less-common side effects include stomach upset, abnormal dreams and tremulousness. Rarely, this drug can cause seizures.
Mirtazapine carries the same warnings about suicide risk as other antidepressants. (See above.)
If you notice these or any other changes, talk to your doctor.

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Trazodone
 
Trazodone (Desyrel) effects both serotonin and norepinephrine. This drug has been available for 30 years. It was initially popular as an alternative to tricyclic antidepressants.
Dosing
 
The starting dose of trazodone is 100 or 150 milligrams two or three times through the day, but most people require doses approaching 600 milligrams per day to feel a positive effect. (Older adults generally take lower doses.) Many people cannot tolerate high doses because of the side effects, particularly sedation. For this reason, trazodone is more often prescribed as a sleep aid rather than as an antidepressant. It is often prescribed to counteract sleep disturbances caused by selective serotonin reuptake inhibitors (SSRIs).
To reduce the chances of stomach distress or dizziness, take this drug with food or a light snack at bedtime.
 
Side Effects
 
Common side effects are not dangerous, but can be uncomfortable:
  • Dizziness
  • Sedation, drowsiness
  • Mouth dryness
  • Headache
  • Nausea, constipation or diarrhea
  • Unpleasant taste
A rare but troubling side effect in men is a persistent and painful erection (called priapism). This may need medical attention.
Trazodone carries the same warnings about suicide risk as other antidepressants. (See above.)
If you notice these or any other changes, talk to your doctor.

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Venlafaxine
 
Similar to tricyclic antidepressants, venlafaxine (Effexor) boosts concentrations of serotonin and norepinephrine. Your doctor may prescribe venlafaxine as a first choice or after a selective serotonin reuptake inhibitor (SSRI) has failed to help you. Venlafaxine is sometimes used to treat anxiety.
Dosing
 
Venlafaxine is taken two or three times per day. It comes in a slow-release form that can be taken once per day. Slow-release pills need to be swallowed whole — don't crush or chew them.
Although some people get a good response with doses of 75 to 150 milligrams per day, many people require doses of 300 to 375 milligrams per day. (Older adults generally take lower doses.)
Venlafaxine may be taken with food to reduce stomach distress.
 
Side Effects
 
Common side effects are not dangerous, but they can be uncomfortable:
  • Nausea
  • Sedation or trouble sleeping
  • Dizziness
  • Sexual problems
  • Blurred vision, constipation, dry mouth
  • Headache
  • Anxiety or nervousness, tremulousness
  • Increased sweating
If you notice these or any other changes, talk to your doctor.
 
Venlafaxine can cause blood pressure to rise. The higher the dose you take, the more likely it is that your blood pressure will go up. This occurs in 10 percent to 15 percent of people taking more than 300 milligrams per day of venlafaxine. (It occurs in fewer than 5 percent taking less than 200 milligrams per day.) Your doctor should monitor your blood pressure while you take this drug. Blood-pressure monitoring is particularly important if you have a history of liver or kidney problems.
 
Discontinuation of venlafaxine. Venlafaxine is eliminated quickly from the body, so it is common to experience symptoms when you stop taking the drug. Symptoms are similar to those that occur when people stop taking tricyclic antidepressants and SSRIs.
 
Venlafaxine carries the same warnings about suicide risk as other antidepressants. (See above.)
If you miss a dose of venlafaxine, do not double up on your dose.

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Duloxetine
 
Duloxetine (Cymbalta) is similar to venlafaxine, mirtazapine and tricyclic antidepressants in that it boosts concentrations of serotonin and norepinephrine. Duloxetine may be prescribed if other, more time-tested antidepressants have not worked.
Types And Doses
 
Duloxetine (Cymbalta) is similar to venlafaxine, mirtazapine and tricyclic antidepressants in that it boosts concentrations of serotonin and norepinephrine. Duloxetine may be prescribed if other, more time-tested antidepressants have not worked.
 
The starting dose of duloxetine is 20 milligrams twice per day. Doses up to 60 milligrams per day are approved, though research has shown that some patients need higher doses (up to 120 milligrams per day) for a good effect. The capsule can be taken with or without meals, and must be swallowed whole — do not crush it or remove the contents to sprinkle on food or in liquid.
 
Side Effects
 
The most common side effects are not dangerous, but can be uncomfortable:
  • Nausea
  • Dry mouth
  • Constipation
  • Poor appetite
  • Headache
  • Insomnia
  • Drowsiness
  • Sweating
If you notice these or any other changes, talk to your doctor.
 
Discontinuation of duloxetine. Duloxetine is eliminated quickly from the body, so it is common to experience symptoms when you stop taking the drug. Symptoms may include dizziness, nausea, headache, tingling, vomiting, irritability and nightmares. The drug should be tapered, not stopped abruptly.
Duloxetine carries the same warnings about suicide risk as other antidepressants. (See above.)

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Last updated April 25, 2011


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