Medication

If you are diagnosed with depression, bipolar disorder or a related illness, your healthcare provider may suggest medication as an initial course of treatment, possibly in combination with psychotherapy. The medication that is best for you depends on issues such as your symptoms and other health conditions you may have. Most people find that medications for mood disorders improve their mood and provide relief from symptoms. Over the course of treatment, patients with bipolar disorder commonly require adjustments or substitutions to their medication plan.

Antidepressants

Antidepressants help relieve depression or anxiety by promoting changes in brain chemistry and communication between brain cells known to regulate mood. Their benefits typically outweigh the possible side effects. They are called antidepressants because research showed first that they help treat depression. Later research showed that they work in many other conditions, particularly anxiety disorders. There is a wide range of antidepressant medication available, including:

  • Selective serotonin reuptake inhibitors (SSRIs)
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs)
  • Trycyclic antidepressants (TCAs)
  • Monoamine oxidase inhibitors (MAOIs)
Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs:

  • Are the most commonly prescribed antidepressant in the U.S.
  • Are easier to tolerate and safer than older antidepressants like TCAs and MAOIs

SSRIs are also effective in treating anxiety, panic, obsessive-compulsive disorder and the co-occurrence of these conditions. People who respond to antidepressants (1/3 get full relief, 1/3 get partial relief, and 1/3 get no response) usually notice some benefit after one month of an effective dose, but the full effect often takes 2 months or more once a therapeutic dose has been reached. Examples include Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil, Pexeva), Sertraline (Zoloft).

Serotonin and Noradrenalin Reuptake Inhibitors (SNRIs)

SNRIs:

  • Are often prescribed for severe depression and/or co-occurring conditions, as they are often slightly stronger than most SSRIs.
  • May be helpful if you have chronic pain in addition to depression

Examples include, Desvenlafaxine (Pristiq, Khedezla), Duloxetine (Cymbalta), Levomilnacipran (Fetzima), Venlafaxine (Effexor XR)

Tricyclic Antidepressants (TCAs)

TCAs:

  • Are effective, but have more harmful side effects than other antidepressants
  • Lead to more cardiac side effects, and may be toxic in overdose
  • Are sometimes used in patients with treatment-resistant depression when other treatments have failed

Examples include Desipramine (Norpramin), Imipramine (Tofranil), Nortriptyline (Pamelor), Protriptyline (Vivactil), Trimipramine (Surmontil)

Monoamine Oxidase Inhibitors (MAOIs)

MAOIs:

  • Were the first type of antidepressant developed
  • Are effective, but have more side effects than other antidepressants
  • Typically require diet restrictions because they can cause dangerously high blood pressure when taken with certain foods or medications
  • Are sometimes used in patients when other treatments have failed

MAOIs work by inhibiting the activity of enzymes called monoamine oxidase, which keep key neurotransmitters from being broken down or metabolized. MAOIs can also be used to treat panic disorder, social anxiety or agoraphobia. Examples include Isocarboxazid (Marplan), Phenelzine (Nardil), Selegiline (Emsam), Tranylcypromine (Parnate)

Note: In some cases, people taking antidepressants may experience an increase in suicidal thoughts or behavior, especially in the first few weeks after starting or when the dose is changed.

Mood stabilizers

Mood stabilizers are a class of medications that have been shown to be effective in preventing both the manic and depressive episodes of bipolar disorder, and/or reducing their symptoms. Two types of medications are commonly used as mood stabilizers: lithium and atypical mood stabilizers.

Lithium

The element lithium has been used as a mood stabilizer for more than 50 years. Lithium has been shown to be particularly effective in patients whose manic episodes consist mostly of elevated mood or euphoria. Lithium is also useful in treating the depressive episodes in bipolar disorder either alone or when combined with other medications.

Side effects associated with lithium:

  • If dose increases are done too quickly or the dose is too high, nausea, vomiting or diarrhea
  • In regular use, may cause dry mouth and excessive thirst which then leads to more frequent urination
  • Slight hand tremors are common
  • When used in high doses and for many years, may cause renal (kidney) damage (seen in a small percentage of patients)

To maximize the benefits of lithium and minimize these side effects, and to protect the thyroid and kidneys (both of which can be impacted by lithium in the bloodstream), regular blood tests are required when lithium is prescribed.

Anticonvulsants

Many in this class of medications were originally used to treat seizures and so are called anticonvulsants. Some anticonvulsants turned out to be useful particularly for bipolar disorder and in some cases for depression. The main medications considered mood stabilizers include lithium, carbamazepine (Tegretol), valproic acid (Depakote), and lamotrigine (Lamictal). Side effects vary substantially depending on the medication. Most require regular blood tests to monitor the blood levels, since there is an ideal blood level for effectiveness.

Antipsychotics

Antipsychotic medications were first-developed to treat psychosis, but later were found to work with mood disorders without any psychotic symptoms, but the name stayed as “antipsychotics”. In lower doses, some of them can improve mood (such as quetiapine (Seroquel) or aripiprazole (Abilify). In higher doses, they work more for psychotic symptoms like delusions or hallucinations. They may be used alone or in combination with mood stabilizers or antidepressants. Side effects vary greatly between antipsychotics, but most can cause weight gain and other metabolic problems, while some can cause serious tremors, so dosing and monitoring are essential.

Ketamine

Clinics across the U.S. have begun offering ketamine infusions to treat severe depression. Ketamine has not been approved by the FDA to treat depression. However, there is growing evidence that low doses of ketamine may be life-changing for patients with treatment-resistant depression. According to the National Institutes of Health (NIH), up to a third of people with depression do not respond to antidepressants; ketamine may be an effective medication for these patients.

What to discuss with your healthcare provider about your new medications:

  • Let your mental health care provider know all of the prescriptions and over-the-counter drugs, herbal or dietary supplements, and vitamins you are taking in order to avoid any dangerous drug interactions.
  • Ask your doctor how the medication will help? What side effects might occur? Should I avoid any particular foods or drinks?
  • Ask your doctor or pharmacist how to properly take a new medication
  • Find out how long it will take for the medication to begin working—and do not stop taking it because you feel better! Discuss with your doctor when and how to taper and stop medications.
  • Ask for your doctor’s after-hours phone number in case you experience serious side effects or need to speak with them for any reason.

References

Cuijpers, P., Sijbrandij, M., Koole, S. L., Andersson, G., Beekman, A. T., & Reynolds, C. F. (2013). The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: A meta‐analysis of direct comparisons. World Psychiatry, 12(2), 137-148.

Kennedy, S. H., Lam, R. W., McIntyre, R. S., Tourjman, S. V., Bhat, V., Blier, P., ... & McInerney, S. J. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 3. pharmacological treatments. The Canadian Journal of Psychiatry, 61(9), 540-560.

MacQueen, G. M., Frey, B. N., Ismail, Z., Jaworska, N., Steiner, M., Lieshout, R. J. V., ... & Ravindran, A. V. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 6. special populations: youth, women, and the elderly. The Canadian Journal of Psychiatry, 61(9), 588-603.

Yatham, L. N., Kennedy, S. H., Parikh, S. V., Schaffer, A., Beaulieu, S., Alda, M., ... & Ravindran, A. (2013). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013. Bipolar disorders, 15(1), 1-44.