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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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 judgment, one of these antidepressants may be prescribed before a better known SSRI.
 
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.
  
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.

Discontinuation of antidepressants.
When stopping any antidepressant, it’s possible to develop uncomfortable symptoms as your body readjusts to being without the medication. There is a wide range of symptoms, but most common are flu-like symptoms, trouble sleeping, nausea, feeling unsteady or off balance, sensory disturbances, and feeling overstimulated. These symptoms usually are mild. In most cases, they last a week or two. They tend to go away if you start the same or similar antidepressant.

Symptoms are more pronounced after longer periods of treatment, especially when stopping an antidepressant that leaves the body quickly.

Because symptoms can be associated with any antidepressant, it is important not to stop an antidepressant abruptly. Rather, work with your doctor to taper the dose. 

 
Bupropion
 
Bupropion (Wellbutrin) works on the neurotransmitters norepinephrine and dopamine. It does not cause sexual side effects, so it is a popular alternative for people who can't tolerate the sexual side effects of selective serotonin reuptake inhibitors (SSRIs). 
 
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 quiting smoking — but these drugs are chemically identical. Be careful therefore NOT to get prescriptions for both drugs at the same time.
 
Dosing. 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. Also, 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.
 
Side effects include agitations, sleep troubles, stomach distress, dry mouth, increased sweating and headache.
 
Rarely, bupropion can cause seizures.

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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.) In addition to pills, 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.
 
Side effects include dry mouth, sedation, dizziness, stomach upset, increased appetite and weight gain.
 
Rarely, this drug can cause seizures.
 

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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). 
 
Side effects include dizziness, sedation, drowsiness, mouth dryness, headache, stomach distress or an unpleasant taste.
 
A rare but troubling side effect in men is a persistent and painful erection (called priapism). This may need medical attention. 

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Venlafaxine
 
Venlafaxine (Effexor) works on the chemical messengers serotonin and norepinephrine. It is a serotonin and norepinephrine reuptake inhibitor (SNRI). 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. 
 
Side effects include nausea, sedation or trouble sleeping, dizziness, sexual problems, blurred vision, constipation, dry mouth, headache, anxiety and increased sweating.
 
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. Your doctor should monitor your blood pressure while you take this drug. 

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Desvenlafaxine

Desvenlafaxine (Pristiq) is chemically related to venlafaxine and similarly is a serotonin and norepinephrine reuptake inhibitor (SNRI).

Dosing. The starting dose is 50 milligrams. That dose is therapeutic for most people, but doses can range as high as 400 milligrams per day.

Side effects include headache, nausea, diarrhea, dry mouth, increased sweating, nervousness, sleepiness or trouble sleeping. Sexual problems can also occur. A rise in blood pressure is also possible, so your doctor should monitor your blood pressure.

 
Duloxetine
 

Duloxetine (Cymbalta) is a serotonin and norepinephrine reuptake inhibitor (SNRI). Duloxetine may be prescribed if other, more time-tested antidepressants have not worked.

Dosing. The starting dose of duloxetine is 20 milligrams, twice per day, with doses ranging up to 120 milligrams daily.

Side effects include nausea, dry mouth, constipation, poor appetite, headache, insomnia, drowsiness and sweating.

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Vilazodone

Vilazodone (Viibryd) works in two ways. Like an SSRI, it blocks the reuptake of serotonin. It also binds to one of the serotonin receptors. It is a relatively new drug, so your doctor is likely to prescribe it after other medications have failed to help you.

Dosing. Vilazodone doses start at 10 milligrams a day and can go up to 40 milligrams daily. It is given once a day.

Side effects include diarrhea, nausea, vomiting, dry mouth, dizziness, and sleeplessness. Less commonly it can cause night sweats, poor appetite, sedation, tremor, blurry vision, increased urination, and sexual problems. 

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Levomilnacipran

Levomilnacipran (Fetzima) is a serotonin and norepinephrine reuptake inhibitor (SNRI).

Dosing. The starting dose is 20 milligrams, usually with an increase to 40 milligrams/day. Doses can go up to 120 milligrams/day depending on response.

Side effects include nausea, vomiting, dizziness on standing, constipation, increased sweating, increased heart rate, and decreased appetite. Sexual side effects can also occur. 

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Vortioxetine

Vortioxetine (Brintellix) boosts serotonin, but it has novel properties that make it different from SSRIs. It binds to some serotonin receptors and blocks others, while it also blocks the reuptake of serotonin. It is a relatively new drug, so your doctor is likely to prescribe it after other medications have failed to help you.

Dosing. The dosage range is 5 to 20 milligrams/day.

Side effects include nausea, vomiting, constipation, sexual dysfunction, dizziness, and diarrhea.

Last updated October 07, 2014


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