Antidepressant medication

Advice for adults

FACT SHEET 11

There is a great deal of misinformation about antidepressant medication and there is no simple explanation of how antidepressants work. Medication can be important in the treatment of moderate to severe depression and in some anxiety and related disorders. This fact sheet looks at what antidepressants do, how they work and where to get more information and help. HOW DO ANTIDEPRESSANTS WORK?
Research shows that more severe forms of depression are associated with specic changes in the brain, including changes to some hormones and chemical message systems. In these forms of depression, there are alterations in the activity of the brain in areas under the inuence of neurotransmitters serotonin and noradrenaline which may cause a major depressive episode. This is associated with the symptoms and disability seen with depression. Antidepressant medication is thought to increase the levels of serotonin and noradrenaline in some areas of the brain. However, depression is not simply a deciency of these chemicals. Different types of antidepressants work in slightly different ways, but they all have an inuence on parts of the brain related to emotions and motivation.

The Therapeutic Goods Administration (Australias regulatory agency for medical drugs) and manufacturers of antidepressants do not recommend antidepressant use for depression in young people under the age of 18. There are, however, no government (i.e. Pharmaceutical Benets Scheme) restrictions placed on the prescription of antidepressants and doctors are not prevented from prescribing them if they feel they are needed. There is concern that a small percentage of young people up to the age of 24 years taking SSRIs for the treatment of depression may experience an increase in suicidal thoughts and behaviour. Research shows the risk to be roughly 4percent compared to 2percent for those taking a placebo (dummy pill). No deaths from suicide have been reported in any clinical trials. However, a young person will require close medical supervision and monitoring in the early stages of treatment if an antidepressant isprescribed. For more information see Youthbeyondblue Fact Sheet 5 Antidepressants For The Treatment of Depression in Adolescents and Young Adults.

Chronic illness
Like any medication, antidepressants can produce side-effects. Insome cases, taking antidepressants can affect existing symptoms or treatments for other illnesses. It is important for people to let doctors know about any illness they may have and any medication they are taking.

WHEN IS ANTIDEPRESSANT MEDICATION USED?

Antidepressant medication is often prescribed, alongside psychological treatments, when a person experiences a moderate to severe episode of depression and/or anxiety. Sometimes they are also prescribed when other treatments have not been helpful.

Pregnancy and breastfeeding

The decision to take medication while pregnant or breastfeeding isan individual one. It should be made in consultation with a doctor after considering the risks and benets to both the mother and baby. If a woman is breastfeeding, generally specic types of medications are preferred. While a number of factors will inuence the choice of antidepressant, a group of antidepressants called tricyclics, as well as sertraline, citalopram and uvoxamine are mostcommonly prescribed for breastfeeding women. Studies show that paroxetine is generally not recommended at thistime.1

WHICH ANTIDEPRESSANTS ARE THE MOST USEFUL?

Making a decision about which antidepressant is best for a person can be complex. This decision should be made in consultation with a doctor after careful assessment and consideration. People can help the doctors assessment by providing as much information as possible about themselves and their medical history. The following should be considered and discussed with the doctor before starting antidepressants.

Symptoms
When deciding on the most appropriate antidepressant medication, its important to consider what symptoms they treat. Some classes of antidepressant medication are more effective in treating specic depression-related symptoms, while other types can be helpful in managing anxiety disorders.

Age
Depression is common and can affect people of all ages, however, generally medication is not recommended as the rst choice for the treatment of depression in children and young people.

 Buist, A. Guidelines for the Use of SSRIs in Pregnant Women, Obstetrics and Gynecology, Vol. 7, No. 4, Summer 2005, pp.18-20.

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Antidepressant medication
Advice for adults
FACT SHEET 11

People who have bipolar disorder and experience an episode of depression will often be given a mood stabiliser alone. It can take time for mood stabilisers to work. Sometimes antidepressants are used along with mood stabilisers to help ease the symptoms. Antidepressant medication is generally not recommended for use by itself in people with bipolar disorder as it can trigger mania.

Reversible Inhibitors of Monoamine Oxidase A (RIMAs)

RIMAs have few side-effects and are non-sedating. They may be less effective for more severe forms of depression than some other antidepressants, but are helpful for people who are experiencing problems with anxiety or are having difculty sleeping. This class includes: moclobemide.

TypES oF AnTidEprESSAnTS
There are many different types of antidepressant medication. Your doctor may need to nd the medication and dose which is most effective for you. Keep in mind antidepressants take time before they start to help (at least two weeks). Below is a description of the different classes of antidepressants. Please note, this list only includes the generic medication names and not the pharmaceutical brand names. Please look on your medication packaging to nd the name of the medication you are taking (this is usually written in lowercase). There are differences in effects and side-effects of the antidepressants listed below, which can be discussed with your prescribing health professional.

Monoamine Oxidase Inhibitors (MAO-Is)

MAO-Is are seldom prescribed in Australia as people are required to keep to a special diet, otherwise serious side-effects can be experienced. This class includes: tranylcipramine phenlzine.

TriCyclic Antidepressants (TCAs)

TCAs are effective, but have more harmful side-effects than newer drugs such as SSRIs. They are more likely to cause low blood pressure so this should be monitored by a doctor. They are more risky if a person were to overdose. This class includes: nortriptyline clomipramine dothiepin doxepin imipramine amitriptyline.

Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs are the most commonly prescribed antidepressants in Australia and are often a doctors rst choice for most types of depression. Generally, SSRIs are well-tolerated by most people and generally, are non-sedating. This class includes: sertraline citalopram escitalopram paroxetine fluoxetine fluvoxamine.

Noradrenaline-Serotonin Specic Antidepressants (NaSSAs)

NaSSAs may be helpful when there is difculty sleeping and poor appetite. Generally, they are low in sexual side-effects, but may cause weight-gain. This class includes: mirtazapine.

Serotonin and Noradrenaline Reuptake Inhibitors (SNRIs)

SNRIs have fewer side-effects compared to the older antidepressants (such as TriCyclic Antidepressants), are often prescribed for severe depression and are safer if a person were to overdose. This class includes: venlafaxine desvenlaxafine duloxetine.

Noradrenaline Reuptake Inhibitors (NARIs)

NARIs are designed to act selectively on one type of neurotransmitter (noradrenaline). They are less likely to cause sleepiness or drowsiness than some other antidepressants, but are more likely to make it difcult for people to sleep. This class includes: reboxetine.

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Please note: When the symptoms are directly due to depression, they are likely to begin to improve following four to six weeks of effective therapy. For example, although SSRIs commonly make sleep disturbance/insomnia worse initially, they are associated with improved sleep four to six weeks later. TCAs are commonly prescribed for their wide range of general benets, but are also the most toxic antidepressants if taken in large quantities. SSRIs or clomipramine (a TCA) would be the first choice if obsessive compulsive symptoms are prominent. All of these drugs have been shown to be effective antidepressants, but their effectiveness differs from person toperson.

HOW LONG DO PEOPLE NEED TO TAKE ANTIDEPRESSANTS?

Like any medication, the length of time a person takes antidepressants depends on the severity of the illness and how the person responds to treatment. For some people, antidepressants are needed only for a short time (generally six to 12months) with psychological treatments and self-help techniques being sufcient. For others, antidepressants are needed on an ongoing basis in the same way that someone with asthma would use respiratory medication. People often want to stop taking antidepressants quickly because they are concerned they are addictive. This may be because they confuse them with sedatives, a group of medications that are used to help a person feel relaxed and, insome cases, fall/stay asleep. Stopping some antidepressants quickly (e.g. some SSRIs and SNRIs) can lead to a discontinuation syndrome, which consists of u-like symptoms. Generally this lasts for several days and can be avoided if the medications likely to do this are stopped gradually, on a doctors recommendation and under supervision. Sometimes discontinuation symptoms are severe, including irritability, agitation, dizziness and confusion. Unlike antidepressants, sedatives are designed to be used only for a short time. If used for long periods of time, sedatives may be craved and needed in higher doses in order for them to have the same effect. This is not the case with antidepressants. Stopping medication should only be done gradually, on a doctors recommendation and under supervision.

WHAT SIDE-EFFECTS DO ANTIDEPRESSANTS HAVE ON THE PERSON TAKING THEM?

Antidepressants can make people feel better, but antidepressants will not change their personality or make them feel happy all the time. Like any other medication, some people who take antidepressants also experience some side-effects. Common side-effects include: nausea sweating weight gain headaches dizziness dry mouth anxiety agitation

sexual difficulties (e.g. difficulty becoming/staying aroused). Some of these symptoms are short-lived. However, people taking antidepressants who experience any of these symptoms should tell their doctor, as there are ways of minimising these or other sideeffects. The likelihood of a particular side-effect happening varies between people and medication. Adverse side-effects may occur in a minority of people when taking very low doses of antidepressants. This is because their bodies break down the medication more slowly than the majority of people. There is a blood test doctors can order to predict if youre likely to react this way and if necessary, they can adjust the dose of medication accordingly. It is not uncommon for people with depression to have suicidal thoughts. Treating the depression effectively will reduce the likelihood of a person hurting him/herself. In the period of time between the person starting antidepressant medication and responding to treatment which can be more than two weeks the person should still be monitored by the doctor and his/her progress reviewed, as the risk of suicidal behaviour may even be slightly increased.

WHERE TO GET HELP

A General Practitioner (GP) is a good person with whom to discuss your concerns in the rst instance. Your GP will be able to conduct or arrange any necessary medical tests, provide treatment or refer you to a mental health professional. It is recommended that you go to your regular GP or another GP in the same clinic as they will have access to your medical le. If you dont have a regular GPor clinic, a list of GPs with expertise in treating common mental health problems is available at www.beyondblue.org.au click Finda Doctor or other Mental Health Practitioner or contact the beyondblue info line on 1300 22 4636 (local call cost from a landline) or infoline@beyondblue.org.au. Psychologists can assist people who are having difculty controlling their emotions, thinking and behaviour. Clinical psychologists are specialists in the assessment, diagnosis and treatment of mental illness such as depression, anxiety and related disorders. Psychiatrists are doctors who have undergone specialist training to treat all mental disorders. They can make medical and psychological assessments, conduct medical tests and prescribe medication. Depending on their expertise and type of practice, they can also provide psychological treatments such as Cognitive Behaviour Therapy (CBT) and Interpersonal Therapy(IPT).

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Antidepressant medication
Advice for adults
FACT SHEET 11

Somehave particular areas of speciality. If you would like a consultation with a psychiatrist, you will need a referral from your GP. Mental health nurses are specially trained to care for people with mental health problems such a depression, anxiety and related disorders. They work with psychiatrists and General Practitioners to review a persons mental health, monitor medication and provide information about mental health problems and treatment. Some have training in psychological therapies. If you would like a referral to a mental health nurse who works in a general practice, ask your GP. Social workers in mental health are specially trained to work with people who are experiencing difculties in life. Social workers can support people with depression, anxiety and related disorders by helping them nd ways to manage more effectively some of the situations that trigger these disorders such as family issues, nancial problems, work stress and living arrangements. Mental health social workers can also provide focused psychological self-help strategies. Occupational therapists in mental health help people who have difculties functioning because of a mental health problem (such as anxiety or depression) to participate in normal, everyday activities. Mental health occupational therapists can also provide focused psychological self-help strategies. For a list of psychologists, psychiatrists, social workers and occupational therapists with expertise in treating mental health problems, visit www.beyondblue.org.au and click Find a Doctor or other Mental Health Practitioner or contact the beyondblue info line on 1300 22 4636 (local call cost from alandline) or infoline@beyondblue.org.au.

Lifeline
13 11 14 24-hour counselling, information and referral (local call)

Black Dog Institute

www.blackdoginstitute.org.au Information on depression and bipolar disorder including causes, treatments, symptoms, getting help and current research ndings

MensLine Australia
1300 78 99 78 www.menslineaus.org.au Counselling for men with family and relationship problems especially around family breakdown or separation this service provides anonymous telephone support, information and referral (local call)

Suicide Call Back Service

1300 659 467 Telephone support for those at risk of suicide, their carers and those bereaved by suicide

CRUfAD
www.crufad.org Information and internet-based education and treatment programs for people with depression or anxiety

Multicultural Mental Health Australia

www.mmha.org.au 02 9840 3333 Provides mental health support for people from culturally and linguistically diverse backgrounds

MORE INFORMATION
beyondblue
www.beyondblue.org.au Info line 1300 22 4636 or infoline@beyondblue.org.au Information on depression, anxiety and related disorders, available treatments and where to get help

Therapeutic Goods Administration

www.tga.gov.au Information relating to all registered therapeutic goods, including prescription medicines, available in Australia

THINGS TO REMEMBER
Medication can be important in the treatment of moderate tosevere depression and in some anxiety-related disorders. Stopping medication should only be done gradually, on a doctors recommendation and under supervision.

Youthbeyondblue
www.youthbeyondblue.com beyondblues website for young people information on depression, anxiety and how to help a friend Learn more about self-help techniques beyondblue online Fact sheet 6 Reducing stress beyondblue online Fact sheet 7 Sleeping well beyondblue online Fact sheet 8 Keeping active beyondblue Fact sheet 9 Reducing alcohol and other drugs beyondblue online Fact sheet 10 Changing your thinking beyondblue A Guide to What Works for Depression acomprehensive review of all known treatments for depression, including medical, psychological, complementary and lifestyle interventions.

beyondblue has developed Clinical Practice Guidelines for: Depression in adolescents and young adults Depression and related disorders in the perinatal period. The guidelines were approved by NHMRC in February 2011 visit www.beyondblue.org.au/guidelines for more information.

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