Top 5 Antidepressants: Best Depression Medications for Treating Symptoms

Disclaimer: This information is for educational purposes only and does not replace professional medical advice. Always consult with a healthcare provider for personalized treatment options.

Understanding Depression

Depression is one of the most prevalent mental health conditions worldwide, affecting over 300 million people worldwide. It is more than just “sadness” or the occasional blues that one may experience.

Depression is a mood disorder that involves persistent feelings of sadness and low energy. It can affect your day-to-day activities, making even the smallest tasks seem tedious and leading to various problems emotionally and physically.

In India, the prevalence of depression among the general population is estimated at 15.1%. 

Symptoms of depression 

The severity and frequency of the symptoms of depression vary from person to person. If you have been experiencing the following symptoms for at least 2 weeks, you may want to consider seeking professional help.

Symptoms are classified into emotional, physical, and behavioural.

The emotional symptoms of depression include:

• Feelings of sadness and tearfulness
• Feeling hopeless; life may feel unworthy of living
• Low self-esteem, along with feelings of guilt
• Irritability, uncontrollable crying, or anger outbursts, even for small matters 

Physical symptoms of depression:

• Low energy and extreme tiredness
• Difficulty falling asleep or getting up in the morning; oversleeping
• Changes in appetite; may eat too little or too much
• Decreased sexual desire/libido
• Physical problems that don't go away with treatment or cannot be attributed to any other cause—digestive issues, muscle cramps, back pain, headaches 

Behavioural symptoms of depression:

• Persistent pessimistic thoughts, hopelessness, and negative outlooks on life.
• Loss of interest in activities and hobbies once enjoyed 
• Sluggish movements and speaking
• Difficulty in thinking, remembering, concentrating, and decision-making
• Social isolation 
• Poor personal hygiene 

In severe cases of depression, one may have recurrent thoughts of suicide and attempts to self-harm.

Types of depression

Listed below are the types of depression:

• Major Depressive Disorder (MDD)
• Persistent Depressive Disorder/ Dysthymia 
• Bipolar Disorder
• Seasonal Affective Disorder (SAD)
• Postpartum Depression.

Importance of Treatment

What will you do when you break an arm? Visit a doctor and put a cast on. Why? Because the cast gives you sufficient time for your bones to heal. Then why should it change when it comes to mental health? Seeking treatment for depression is like putting a cast over your brain to help it heal and navigate through life.

If left untreated, depression can significantly affect an individual's emotional and physical well-being.

Depending on the severity, the necessary interventions can be done—psychotherapy, medications, a combination of both, or therapy alone. 

In this article, we'll be focusing on the role and types of depression medications (antidepressants) in the treatment of depression.

Overview of Antidepressant Medications

Antidepressants are a group of medications prescribed by a healthcare professional to treat moderate-to-severe depression. 

Each antidepressant works differently for everyone. Please do not be disheartened if the antidepressant first prescribed to you by your doctor doesn't work out as expected. Some amount of trial and error might be required to find out what's best for you.

At the beginning of the course of treatment, the doctor usually starts you on a lower dose and may alter it subsequently depending on your progress.  

How Do Antidepressants Work to Treat Depression?

Although the exact principle is not known, it's largely thought to work by increasing the levels of neurotransmitters (chemical messengers) such as serotonin, norepinephrine, and dopamine in your brain. These neurotransmitters play a major role in mood regulation. 

It has also been observed that antidepressants might induce neuroplasticity, a process that involves the alteration of the structure of the brain by strengthening or weakening the connections between neurons (brain cells).

Other Conditions Treated By Antidepressants 

Apart from depression, antidepressants are also used in the treatment of other medical psychological conditions, such as -

• Obsessive-Compulsive Disorder (OCD)
• Post-traumatic Stress Disorder (PTSD)
• Generalized Anxiety disorders 
• Panic Disorder 
• Social Anxiety Disorder/ Social phobia
• Bulimia nervosa  

A few other conditions for which antidepressants may sometimes be prescribed include:

• Migraine 
• Insomnia 
• Chronic pain

Limitations of Antidepressants

Even though antidepressants help significantly reduce the symptoms of depression, they don't treat the root cause. Hence, they cannot be used to cure depression.

Like any other medications out there, antidepressants also come with their own set of side effects, which will be discussed later in this article.

Remember to not stop taking the medications abruptly without consulting your doctor, as it carries the risk of withdrawal symptoms, and in some cases, the person might go into a relapse.

Some individuals might not tolerate them well or will have to switch from one category of antidepressant to another. In some cases, an individual might be advised to take more than one type of antidepressant. 

Best 5 Antidepressants types used to treat Depression

Here are 5 top categories of  antidepressants in treating depression:

1.Selective Serotonin Reuptake Inhibitors (SSRIs). 

SSRI - 1. Selective Serotonin Reuptake Inhibitors are the most commonly prescribed classes of antidepressants, mainly due to their high efficacy and fewer side effects.

Some examples of SSRIs are:

• Fluoxetine 
• Citalopram 
• Escitalopram
• Sertraline 
• Paroxetine 

Usually, once serotonin carries out its function, it'll be absorbed from the brain by nerve cells (known as reuptake) into the bloodstream.

In an individual who's clinically depressed, the serotonin levels in the brain will already be low. SSRIs exert their action by preventing the absorption of serotonin into the blood so that more serotonin is available in the brain. Remember that SSRIs don't increase the synthesis of serotonin in the body; instead, they help make use of the already available serotonin.

Common side effects seen with use of SSRIs :

• Headache
• Disturbed sleep
• Dryness of mouth (xerostomia)
• Gastrointestinal issues (upset stomach, diarrhoea)
• Nausea and vomiting 
• Decreased sexual desire 

A few risk factors seen with SSRIs:

• The Risk of suicide is seen in some cases among teenagers and young adults (less than 25 years old), especially in the first 1-2 weeks after starting the treatment, if someone's taking it for the first time, or at a higher dose. If you or your loved one experiences suicidal thoughts while taking antidepressants, get in touch immediately with your doctor.
• Antidepressant Discontinuation Syndrome (ADS)- Antidepressants, especially if taken continuously for 6 weeks or more, shouldn't be abruptly stopped. Instead, the dose should be gradually tapered under the supervision of your healthcare provider. 
• Serotonin syndrome: It happens when there's too much serotonin in your body. It is caused by higher doses of medications or supplements that boost serotonin levels in your body. Symptoms can vary from mild (diarrhoea, nausea) to severe (seizure, fever). It is a medical emergency and needs intervention as soon as possible.

Benefits of SSRIs:

SSRIs are considered relatively safe and can reduce the symptoms of moderate to severe depression. Compared to other classes of antidepressants, the side effects are lower and tend to go away with long-term usage.

2. Serotonin and norepinephrine reuptake inhibitors (SNRIs).

SNRIs are also known as dual-acting antidepressants. They are usually prescribed to people for whom SSRIs do not work as effectively.

Common examples of SNRIs include:

• Venlafaxine
• Desvenlafaxine 
• Duloxetine
• Milnacipran

Unlike SSRIs, where the target is a single neurotransmitter, SNRIs work by increasing the availability of two neurotransmitters in the brain: serotonin and epinephrine (noradrenaline).

Initially, it was thought that SNRIs were more effective than SSRIs, but there's no conclusive evidence that SNRIs are more effective in treating depression. For some people, SSRIs may work better. 

Commonly known side effects of SNRIs:

• Nausea and vomiting (usually in the first 2 weeks)
• Dry mouth 
• Agitation
• Reduced appetite 
• Weight loss
• Profuse sweating 
• Dizziness
• Sleepiness
• Constipation 
• Sexual dysfunction 

The risks and complications of SNRIs are mostly the same as those of SSRIs.

Benefits of SNRIs:

Duloxetine, one of the common SNRIs, is also used to treat conditions such as fibromyalgia and chronic musculoskeletal pain.

3. Serotonin Modulators.

For some people, healthcare providers may prescribe this group of antidepressants as the first-line treatment. They are as safe and effective as the SSRIs and SNRIs.

Common examples of serotonin modulators:

• Nefazodone
• Vilazodone
• Vortioxetine

They work by modifying one or more serotonin receptors and preventing their reuptake. This leads to improved serotonin levels in your brain.

Common side effects include:

• Dry mouth 
• Nausea
• Dizziness
• Bleeding (common- gastrointestinal, less common- nose, gums, vagina, joints)
• Blurred vision 
• Sexual dysfunction 
• Constipation 

Risk factors of specific serotonin modulators:

• Nefazodone is not recommended for people with liver disease, as it carries the risk of liver failure.
• Vilazodone is associated with a high incidence of gastrointestinal distress such as nausea, vomiting, and diarrhoea.

Benefits of serotonin modulators: 

Additionally, it is used in the treatment of conditions such as severe migraine, obesity, and GERD (gastroesophageal reflux disease).

4. Cyclic Antidepressants.

This category of antidepressants is further divided into tricyclic and tetracyclic based on their structure. They are not used as a first-line treatment as they pose more side effects. They're recommended by your doctor if your symptoms don't improve after taking SSRIs, SNRIs and serotonin modulators, or sometimes in case of treatment-resistant depression.

Few examples:

 Tricyclic antidepressants-

• Amitriptyline
• Doxepin
• Desipramine

Tetracyclic antidepressants -

• Mirtazapine
• Maprotiline

Cyclic antidepressants work by inhibiting the reuptake of serotonin and norepinephrine by nerve cells, thereby increasing their availability in the brain. But they also tend to affect other chemicals present in the brain, which explains their higher risk of side effects.

Side effects of cyclic antidepressants 

• Dry mouth and dry eyes
• Disorientation
• Seizure (more in maprotiline)
• Constipation 
• Low blood pressure 
• Increased cholesterol levels
• Weight gain ( usually seen with amitriptyline, imipramine, and doxepin)

Risk factors of cyclic antidepressants 

Cyclic antidepressants may not be suitable for individuals with the following health conditions:

• Thyroid problems
• Glaucoma 
• Prostate enlargement 
• Heart problems

Benefits of cyclic antidepressants:

Apart from treating treatment-resistant depression, it can also be used for conditions such as obsessive-compulsive disorder (OCD) and chronic bedwetting.

5. Atypical antidepressants

Atypical antidepressants, like the term itself, are a class of medicines that don't fall into the group of typical antidepressants due to different mechanisms of action. 

Examples of atypical antidepressants include:

• Bupropion
• Dextromethorphan
• Esketamine

There's no single working principle for atypical antidepressants, as each one of them may work by increasing one or more neurotransmitters— serotonin, norepinephrine, and dopamine. The end result involves increased levels of neurotransmitters in the brain.

Side effects of atypical antidepressants:

• Nausea
• Headache 
• Dry mouth 
• Diarrhoea
• Dizziness 
• Fatigue

Risk factors 

It's better for people with the following health conditions to avoid these medications:

• Seizure disorders
• Liver problems 
• Heart disease 

Benefits

It can be used in treatment-resistant depression and for smoking cessation (especially bupropion) in some.

Apart from these 5, there are other antidepressants too-

• Selegiline
• Phenelzine
• Trazodone
• Tranylcypromine

Factors to Consider When Choosing an Antidepressant

There are several factors involved when deciding on an antidepressant. It's more like a trial-and-error method, as there is no single best antidepressant for all. 

1.Symptoms specific to the patient 

The symptoms of depression can vary from person to person. So it's important to clearly communicate all the symptoms you're experiencing to the doctor so that they can prescribe the antidepressant accordingly. 

For example, if you're finding it too difficult to sleep, the physician may prescribe a medicine that helps you fall asleep at night. 

So keep in mind that treatment that's tailored to your concerns is always the best.

2. If it worked for someone in your family

Check if a particular medication has worked out well for a parent or any other blood relative. If yes, chances are high that the same medicine will work out for you. 

3. Possible Side Effects 

Side effects depend on the type of medicine as well as the person. Some side effects, like weight gain and sexual dysfunction, can make it difficult to stay consistent with the medications. If you experience such bothersome side effects, discuss it with your doctor.

4. Pregnancy and breastfeeding 

Usually, the benefits of these medicines outweigh their side effects. The risk of birth defects and growth retardation is less. Still, it's better to discuss all the possible risk factors with your doctor so that they can suggest a more suitable medication if you're expecting or planning on becoming pregnant.

5. Other health conditions 

Some antidepressants may have bad effects on other health conditions you may have. On the other hand, these medications may help treat the symptoms of other mental or physical health conditions.

E.g., SNRIs are useful in treating depression as well as chronic pain and fibromyalgia.

6. Cost of medicines

Some antidepressants may be expensive, so it's better to ask for a generic version (if available). Also, make sure that the medicines prescribed are covered by your health insurance.

Managing Side Effects of Antidepressants

There are a few side effects that are common to most of the antidepressants, such as:

1. Nausea
2. Dry mouth 
3. Increase in appetite 
4. Weight gain
5. Fatigue and drowsiness 
6. Gastrointestinal disturbances such as diarrhoea, vomiting, constipation
7. Low sex drive
8. Suicidal thoughts (at the beginning of treatment)

Most of the symptoms usually go away with long-term use. But serious symptoms such as suicidal ideations shouldn't be ignored. 

Contact your healthcare provider or emergency help immediately if you experience such bothersome symptoms or they are becoming worse.

Antidepressant Augmentation and Boosters

In some cases of depression, especially major depressive disorder (MDD) and treatment-resistant depression, the prescribed antidepressants might not effectively improve the symptoms of depression. 

So, your doctor might add another medication to the existing antidepressant or may replace it with another class of antidepressant. This is known as antidepressant augmentation. 

A few examples of augmentation strategies are:

• Lithium is highly effective, but there are more chances of adverse effects.
• Thyroid hormone pills are almost as effective as lithium and are better tolerated.
• Bupropion carries fewer sexual  side effects
• Mood stabilizers showed overall improvement in depression in some
• Antipsychotics- some showed significant improvement and remission rates.
• Supplements- omega 3 fatty supplementation has been shown to boost the efficacy of antidepressants and significantly improve the symptoms of depression.
• Creatine- A study conducted in women with MDD using creatine and SSRI showed higher rates of remission of depression.

Can Depression Go Into Remission?

Remission can be defined as a phase in which the symptoms of depression have been partially or fully reduced. You may feel more relieved from the symptoms that used to exhaust and numb you. 

According to the DSM-5, a person is said to have attained remission if they don't show significant symptoms of depression for at least a period of 2 months. Even then, it's important to understand that there's no uniform time frame for remission, as it largely depends on each individual and the effectiveness of the treatments they are receiving.

Remember that remission is not equivalent to recovery. If not sustained properly, remission can go into relapse. Take care to keep a watch on yourself or your loved ones if they're going through the same.

Remission can be achieved by medications alone or in combination with psychotherapy such as Cognitive Behavioural Therapy (CBT) or interpersonal therapy. CBT can also help prevent relapse. 

A few tips to maintain the state of remission include:

1. Continuing medications after consulting with your doctor 
2. Cognitive Behavioural Therapy 
3. Group therapy - sharing experiences can help one progress and realize that they're not alone
4. Practicing mindfulness

Seeking Help and Getting Diagnosed with Depression

Antidepressants are usually prescribed as the first-line treatment in adults who have moderate to severe clinical depression (more severe form) or MDD.

Before prescribing antidepressants, your healthcare provider may take the following factors into consideration:

• Symptoms experienced by the patient; their severity and frequency
• If they had experienced similar symptoms before, 
• Family history: people with a positive family history of depression are more susceptible. 
• Other health conditions, such as untreated hormonal problems and vitamin deficiencies, can also manifest as depression. 

Be open and honest with your doctor. Remember, they're here to help you, and maintaining a good patient-doctor relationship is essential to figuring out the best possible antidepressant.

Importance of Adherence to Treatment

Getting through depression is a combined effort of you and your doctor. Of course, depression can make it difficult for you to put in active efforts, but trust your doctor and take the leap of faith.

Here are a few tips that may help you stick to your treatment:

1. Take medicine at the prescribed dose at the same time every day: tag it along with other routine activities, such as after dinner or after brushing your teeth, so that it becomes a habit. 
2. Know what you eat: As much as medicines, the food we eat is also important. Focus on eating more fruits and vegetables, and less sugary and fried foods. Also, take care to avoid alcohol and illegal drugs, as they may negatively interfere with the medications and lower their effects.
3. Lower stress at work and home: Try and open up to your family, friends, and coworkers about your condition so that they can take care of a few things for you.
4. Trust the process: antidepressants take anywhere from 4-6 weeks, and therapies take even longer to show complete effects. Do not feel disheartened if you don't see results immediately; instil faith that it's all going to work out.

Non-adherence to the devised plan of treatment can lead to:

• A relapse into depression
• Further progression of depression, in some cases, even hospitalization
• Poor quality of life
• Disruption in daily life activities
• Neglecting self-care

Healthy Lifestyle Practices to Complement Medication

Here are a few lifestyle modifications that may help you, along with medications:

1. Exercise: Studies have shown that exercise such as walking, jogging, and yoga can help combat features of depression
2. Healthy Diet: Remember that our gut is the second brain, so what we eat also affects our mood. Following a  healthy diet (as mentioned above earlier) may help reduce stress and symptoms of depression
3. Sleep Hygiene: ensure sleep hygiene techniques like putting away gadgets and limiting heavy work to at least 1-2 hours close to bedtime; setting a comfortable sleeping environment; going to bed and waking up at the same time every day; and avoiding caffeinated drinks. 6–8 hours before bed, etc.
4. Mindfulness and relaxation: negative thoughts and depression often go hand in hand. Approach your thoughts with compassion and acknowledge your condition with an empathetic heart. 
5. Social Connection: Engaging in meaningful conversations with your loved ones can help you feel better and strengthen your bond with them.

Frequently Asked Questions (FAQs)

How long does it take for antidepressants to work?

You might see an improvement in a few symptoms within 1-2 weeks. For the medicines to be fully effective, it may take around 4-8 weeks.

Can antidepressants cause dependency?

While dependence on antidepressants is not generally seen, they do possess the potential for withdrawal symptoms on an abrupt stoppage or tapered dose.

What should I do if I miss a dose?

In case you remember a day's missed dose in a few hours, have it. If you remember it a few hours before the next day's dose, skip it. Never take two doses on the same day, as it could lead to dangerous side effects.

Can I drink alcohol while taking antidepressants?

No. It's best to avoid drinking, as it can hinder the effects of your antidepressants and make it more difficult to treat the symptoms.

What are the long-term effects of taking antidepressants?

Common adverse long term effects include feeling emotionally numb ( not like oneself), sexual problems, weight gain, and withdrawal symptoms.

Should I disclose all medications and supplements to my healthcare provider?

Yes, always discuss with your doctor any other medicines or supplements you're taking, as some drugs may react negatively with the antidepressants. 

By doing so, your doctor can prescribe the best possible antidepressant and avoid further complications.

If you or your loved one experiences any of the above-mentioned signs and symptoms, please do not hesitate to reach out to any of the helpline numbers below:

•  VISHRAM: A 24x7 helpline by Snehi, providing emotional support and suicide prevention.  

   - Helpline Number: 022-27717070 / 022-27717080

• VANDREVALA FOUNDATION: Offers emotional support and suicide prevention services.

   - Helpline Number: 1860-266-2345

• iCALL: Initiative by Tata Institute of Social Sciences (TISS) providing counseling via telephone and email.

   - Helpline Number: 022-25521111 (Monday to Saturday, 8 am to 10 pm)

   - Email: icall@tiss.edu

• LIFELINE FOUNDATION: Provides emotional support and crisis intervention.

   - Helpline Number: 033-24637401 / 033-24637432

• SAHAI: Provides emotional support, befriending, and suicide prevention services.

   - Helpline Number: 080-25497777 / 080-65659222

• NIMHANS: National Institute of Mental Health and Neuro Sciences, Bangalore, offers tele-consultation services.

  - Helpline Number: 080-46110007 (Monday to Saturday, 9.30 am to 1.30 pm)

Glossary of terms

1.Neurotransmitters

Chemicals in the brain that transmit signals between nerve cells, acting as messengers.

2. Serotonin 

A neurotransmitter that plays a role in mood regulation, imparts a “feel-good” state of mind and well-being. Also improves appetite, memory and sleep.

3. Norepinephrine/ Adrenaline 

A neurotransmitter that influences stress reaction; responsible for the “fight-or-flight” response, increases alertness and attention.

4. Dopamine 

A neurotransmitter that plays a pivotal role in motivation, decision-making, movement, arousal, learning and memory.

Conclusion and Call to Action

Depression remains a common mental health issue globally, affecting millions with its debilitating symptoms of persistent sadness, loss of interest, and hopelessness. Antidepressants are usually the first line of treatment for moderate-to-severe depression. They are categorized into many types based on their mechanisms of action. Here we saw the most commonly prescribed classes of antidepressants and their crucial role in treating depression by balancing neurotransmitter levels in the brain. Pairing antidepressants with non-medical strategies such as psychotherapy, exercise, mindfulness practices, and social support networks can enhance the outcomes of remission and recovery. Identifying the signs and symptoms, seeking professional help, and adopting a holistic approach to treatment are essential steps towards managing and overcoming depression, promoting mental well-being, and living a fruitful life. 

References 

-Higuera, V. (2020). Depression: Types, Causes, Treatment, and More. Healthline. https://www.healthline.com/health/depression

-Herndon, J. (2021, November 30). Understanding the Pros and Cons of Antidepressants. Healthline. https://www.healthline.com/health/depression/antidepressants-pros-and-cons#disadvantages

-Cleveland Clinic. (2023, March 1). Antidepressants. Cleveland Clinic. https://my.clevelandclinic.org/health/treatments/9301-antidepressants-depression-medication

-Aungst, C. (2021, September 24). A Guide to the Most Common Types of Antidepressants. GoodRx; GoodRx. https://www.goodrx.com/conditions/depression/best-antidepressant-medication

-Pharm, J. (2022, February 8). What Are the Top 5 Antidepressants? MedicineNet; MedicineNet. https://www.medicinenet.com/what_are_the_top_5_antidepressants/article.htm‌

-Mayo Clinic. (2019). Selective Serotonin Reuptake Inhibitors (SSRIs). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/depression/in-depth/ssris/art-20044825

-Cleveland Clinic. (2023, May 3). SSRIs. Cleveland Clinic. https://my.clevelandclinic.org/health/treatments/24795-ssri

-Elsevier Drug Class Overview | Serotonin Modulator Antidepressants. (n.d.). Elsevier.health. https://elsevier.health/en-US/preview/serotonin-modulator-antidepressants

-‌What are some common side effects of antidepressants? (n.d.). Drugs.com. https://www.drugs.com/medical-answers/common-side-effects-antidepressants-3440087/

-What’s Remission in Depression? (2022, April 7). Psych Central. https://psychcentral.com/depression/severity-and-remission-in-major-depressive-episode

-How to Know Which Antidepressant Is Right for You. (n.d.). Verywell Mind. Retrieved July 19, 2024, from https://www.verywellmind.com/how-doctors-choose-the-best-antidepressant-for-you-1065501

-Jessica Warner, M. D., & Noah S. Philip, M. D. (2013). Augmentation Strategies in MDD Therapy. Www.psychiatrictimes.com, 30. https://www.psychiatrictimes.com/view/augmentation-strategies-mdd-therapy

-Image Designed By Freepik