Depression; FDA-Approved Medications That are Helpful.

Depression
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Depression is a state of low mood and aversion to activity that can affect a person’s thoughts, behavior, tendencies, feelings, and sense of well-being. A depressed mood is a normal temporary reaction to life events such as loss of a loved one. It is also a symptom of some physical diseases and a side effect of some drugs and medical treatments. Depressed mood is also a symptom of some mood disorders such as major depressive disorder or dysthymia.

Depression is a serious medical illness. Also called “major depressive disorder,” or “unipolar depression,” it affects about 350 million people worldwide and is a leading cause of disability, according to the World Health Organization.

If you have depression, you may not recognize the symptoms or may think symptoms are due to a lack of sleep or a poor diet. Or you may realize you’re depressed but feel too tired or ashamed to seek help.

Not all depression requires treatment with medication. But medications approved for the treatment of depression by the U.S. Food and Drug Administration (referred to here as “antidepressants”) can help improve symptoms in some people.

Diagnosing Depression

Diagnosis—which should be from a health care professional—depends on the number, severity, and duration of depressive symptoms, which can include:

  • depressed mood
  • loss of interest or pleasure in almost all activities
  • changes in appetite or weight
  • disturbed sleep or sleeping too much
  • slowed or restless movements
  • fatigue or loss of energy
  • feelings of worthlessness or excessive guilt
  • trouble in thinking, concentrating, or making decisions
  • thoughts of death or suicide

Doctors typically consider your history and review your behavior and mental status when evaluating a possible diagnosis of depression. Then, a doctor can evaluate symptoms, rule out physical causes of depression (such as thyroid disease or Parkinson’s disease), and decide if depression is an appropriate diagnosis.

Doctors should also screen you for bipolar disorder, a brain disorder that causes unusual shifts in mood, energy, and activity levels, as well as changes in your ability to do everyday tasks. If certain medications approved for treatment of depression are wrongly prescribed to a person with bipolar disorder, they can cause mania, a type of unusually elevated or excited mood. If mania is severe, a person can become psychotic. (Read this Consumer Update for more on bipolar disorder.)

Treatment with Medication

Antidepressants are medications that are thought to work by changing brain chemicals called neurotransmitters—primarily serotonin, norepinephrine, and dopamine—which are involved in regulating mood.

Some antidepressants have classifications

  • selective serotonin reuptake inhibitors (SSRIs); examples are Prozac (fluoxetine), Celexa (citalopram), and Paxil (paroxetine)
  • serotonin norepinephrine reuptake inhibitors (SNRIs); examples are Effexor (venlafaxine) and Cymbalta (duloxetine)
  • tricyclic antidepressants (TCAs); examples are Elavil (amitriptyline), Tofranil (imipramine), and Pamelor (nortriptyline)
  • monoamine oxidase inhibitors (MAOIs); examples are Nardil (phenelzine) and Parnate (tranylcypromine)

Other antidepressants include:

  • Remeron (mirtazapine)
  • Wellbutrin (bupropion)

Medications approved for treatment of depression affect different neurotransmitters in a variety of ways. For example, SSRIs increase the signaling of serotonin in the brain. And MAOIs block monoamine oxidase, an enzyme that breaks down neurotransmitters.

“Some evidence shows that the most effective way to treat many patients with depression is through both talk therapy and prescribed antidepressant medication,” adds Mitchell Mathis, M.D., director of the Division of Psychiatry Products at the FDA. Talk to your doctor about the best treatment for you.

Antidepressant Effectiveness

In general, you must take regular doses of a prescribed antidepressant for several weeks before you’re likely to have the medication’s full effect.

You shouldn’t stop taking medication without talking with your doctor—even if you feel better. Stopping can result in withdrawal symptoms like anxiety and irritability. Or depression could return.

Note: A significant percentage of people may not respond to a prescribed antidepressant. In these cases, switching to a different medication or adding another medication can sometimes help treat symptoms. Some people may not respond to medication at all, Mathis notes. If you have concerns about antidepressants you are taking, talk with your doctor.

Common Side Effects

Common side effects of antidepressants can include:

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It may take some time for your doctor to determine the medication that works best for you.

Serious Risks

Some antidepressants can have serious risks. Discuss these risks with your doctor. Some of the relevant risks are listed below.

Suicidal thinking: In 2004, the FDA asked manufacturers to add a boxed warning to the labeling of all antidepressant medications. This labeling warns about the increased risk of suicidal thinking or suicidal behavior in children and adolescents taking antidepressants during initial treatment and with dose increases. In 2007, FDA requested that the warning be extended to include young adults through age 24.

If you or someone you know is having thoughts of suicide, you can immediately call your doctor; go to a hospital emergency room; or call the confidential and toll-free National Suicide Prevention.

Birth defects: Some antidepressant medications might harm a fetus if taken during pregnancy. If you are considering an antidepressant medication and are pregnant, plan to become pregnant, or breastfeeding, talk to your doctor about benefits and risks.

High blood pressure: Those taking monoamine oxidase inhibitors must avoid certain foods that contain high levels of the chemical tyramine. This chemical is in many cheeses, wines and pickles, and some medications including decongestants. If you take MAOIs and consume this chemical, they may interact and cause a sharp increase in blood pressure, which could lead to a stroke or other complications. Talk to your doctor about the best diet for you.

Ways to Prevent a Deadly Drug Interaction

You should not be afraid to take your medications because of the possibility of drug interactions. Drug interactions can be intimidating for anyone who regularly takes prescription medications, but you can learn how to manage and prevent them.

Drugs with a narrow therapeutic index (that is, having little difference between toxic and therapeutic doses), and certain disease states like epilepsy or depression are especially prone to serious drug interactions. In addition, multiple interactions may occur when someone is taking several drugs, as is often the case with older patients.

While most interactions are usually not life-threatening, some mixtures of medications can lead to serious — and even fatal — consequences. Pharmacists and doctors are well-trained to review and predict drug interactions. You can also use online drug interactions tools to help gauge the risk prior to discussing with your doctor or pharmacist.

Education and communication is key. You should consult with your health care providers, research reliable drug information, and empower yourself to lower the risk of interactions and maximize your medical treatments. Here are nine tips to achieve that goal.

Communicate Frequently

Tell your pharmacist each time you start or stop a medication, including any over-the-counter (OTC) drug, herbal supplement, or vitamin. Keep an updated list of meds, including nonprescription drugs — and share with your health care providers, including your dentist, anytime you start or stop a medication.

  • Prescription drugs are not the only medicines that can interact. Non-prescription drugs can have serious consequences, too. For example, the herbal St. John’s Wort is commonly used as an OTC supplement for depression. If combined with other antidepressants such as the SSRIs like fluoxetine (Prozac) or sertraline (Zoloft), the risk of a rare but serious and potentially fatal condition called serotonin syndrome can occur, with symptoms such as confusion, hallucination, seizure, extreme changes in blood pressure, and even death.
  • Read your Medication Guide each time you get a new prescription or refill. The FDA updates prescription drug labels frequently, and there could be changes in your Medication Guide. Review your possible interactions and ask questions if you are concerned or don’t quite understand the medical jargon.
  • If you discover that you are at risk for an interaction, call your doctor. It may be that the interaction is minor, and no action is needed. On the other hand, you may need to avoid the drug or have an alternative medicine prescribed. NEVER stop a medication without first speaking to your doctor.

Research Your Meds Yourself

  • Use a reliable online drug interaction tool like  to become engaged in your health and learn about your medications. If you need help understanding the information, be sure to call your pharmacist. Always check for drug interactions even when you purchase OTC medications, herbal supplements or vitamins.
  • The Drug Interaction Checker explains the mechanism of each drug interaction, the level of significance of the interaction (major, moderate or minor), and in certain cases, can provide the recommended course of action to manage the interaction. The Drug Interaction Checker will also display any interactions between your chosen drug(s), food or beverages, and even other diseases.
  • To see all possible drug interactions, just enter one drug name and select “check for interactions.” Information is provided for all interactions at both the consumer and professional level.
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Keep All of Your Prescriptions at One Pharmacy

  • By keeping all of your prescriptions at one pharmacy, a regular drug review and drug interaction screen can be done electronically that incorporates all of your medicines. Talk with your pharmacist and doctor and communicate new and discontinued medications with all of your health care providers. Communication is key to preventing drug interactions.
  • When you buy OTCs or herbal supplements, ask your pharmacist to double check for interactions and ask if they can add the agent to your regular drug profile for future drug interaction checks. If your pharmacist does not know that you are taking OTC products, they can’t check for drug interactions with prescription medication. Be sure to read the Drug Facts Label on each OTC product you use, too.

Take Any Food and Beverage Drug Interactions Seriously

  • Your pharmacist or doctor may ask about specific foods or drinks you consume depending upon which drugs you take. Common food items involved in drug interactions include foods rich in vitamin K, which can interact with certain blood thinners like warfarin and make them less effective, possibly leading to a clot. Certain citrus juices like grapefruit juice are notorious for changing blood levels of some drugs, too. Calcium can bind with some drugs and prevent absorption.
  • For example, if you take the blood thinner warfarin, increasing vitamin K levels in the body can increase clotting and reduce the effectiveness of warfarin, which could result in a stroke. Foods rich in vitamin K include beef liver, broccoli, brussels sprouts, cabbage, collard greens, endive, kale, lettuce, mustard greens, parsley, soy beans, spinach, Swiss chard, turnip greens, watercress, and several other foods. While there is no need to avoid products that contain vitamin K, you should maintain a consistent level of consumption of these products.
  • Grapefruit or grapefruit juice consumption can also result in drug interactions that may increase the level of the medicine in your blood, possibly causing drug toxicity. For example, blood levels of some cholesterol drugs known as statins —  atorvastatin, lovastatin, or simvastatin —  can be affected by drinking grapefruit juice, and lead to severe muscle injury known as rhabdomyolysis. Not all medicines contained in a class of drugs like the statins may lead to the interaction, so your doctor will be able to prescribe another drug. Cranberry juice, orange juice, pomegranate juice, and even garlic can lead to interactions with drugs, too.

 

Tell Your Doc About Caffeine Use, Alcohol Use, and Illegal Drug Use

  • Socially-used drugs can have an especially harsh effect with other drugs. For example, some asthma drugs like the beta-2 agonist albuterol (Proventil HFA, Ventolin HFA) can have a stimulant effect, and if combined with caffeine, can interfere with sleep or lead to a rapid heart rate, which can be dangerous in people woth heart disease. The stimulant effect from caffeine can be additive to stimulation from decongestants, too.
  • Alcohol can worsen drowsiness, especially when mixed with other drugs that cause sedation, which may put you at a higher risk for a fall or a car accident. Alcohol should never be combined with opioid painkillers or anxiety medications like benzodiazepines. Life-threatening respiratory depression can occur.
  • A particularly concerning, yet often unknown interaction between alcohol and cocaine has been reported. The National Institute on Drug Abuse (NIDA) has found that the human liver combines cocaine and alcohol and manufactures a third substance, cocaethylene, that intensifies cocaine’s euphoric effects but may increase the risk of sudden death. According to the NIDA, this drug-drug interaction, between cocaine and alcohol, is the most common two-drug combination that results in drug-related deaths.
  • Illicit drugs combined with other illicit drugs can be particularly dangerous. Combining heroin and cocaine into one syringe, often called a “speedball”, is a mixture that is used by some injecting drug users, often with fatal results.

Don’t Take a Medication Prescribed for Someone Else

  • Medications are prescribed specifically for an individual person, often based on their age, weight, and specific type of medical condition. In addition, when you take medications that are not prescribed for you, there is no health care provider involved to review for potential interactions or safety based on your medical conditions.
  • For example, taking someone else’s antibiotic for a sore throat might not only lead to a possible drug interaction, it might worsen your infection. The antibiotic might not be the appropriate drug to treat the bacterial strain, and you probably won’t have a full course of antibiotic which can result in antibiotic resistance and failed treatment. Plus, if your sore throat is viral, instead of bacterial, you may not need an antibiotic at all. Your doctor can test you for this.
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Follow All Dosing Recommendations on Your Prescription Bottle

  • Your prescription bottle will have specific directions for taking your medicine. For example, you may need to space the timing of when you take your medications. Some drug interactions involve binding of one drug to the other in the stomach. Antacids are commonly linked to this type of interaction. Your pharmacist will put a sticker on the your bottle to warn you of this interaction. To avoid the interaction you may space the timing of your doses, taking each drug 2 hours before or 4 hours after the other drug.
  • Antacids can also raise the pH in your stomach, and may result in an early dissolution of enteric coatings — for example, enteric-coated aspirin or ibuprofen — which should normally dissolve in the intestine. This could lead to severe stomach bleeding or lowered absorption of the drug. Your pharmacist will provide specific instructions.
  • DO NOT change the dose of your medication unless approved by your doctor. If your warning sticker suggests that you avoid a drug, or a certain class of drugs altogether, be sure to follow these instructions. Many patients that take blood thinners like warfarin need to avoid over-the-counter and prescription drugs that may increase the risk of bleeding; for example, NSAIDs (ibuprofen, naproxen) or aspirin.

Tell Your Health Care Provider About Your Medical Conditions

  • In people who have high blood pressure, OTC oral decongestants like pseudoephedrine (Sudafed) or phenylephrine (Sudafed PE) may increase blood pressure, even if their blood pressure is controlled with a medication. People with uncontrolled or severe high blood pressure need to avoid these medications.
  • Another common example of a disease-drug interaction is the use of the antihistamine diphenhydramine (Benadryl) in patients with certain types of glaucoma known as acute angle-closure (narrow-angle) glaucoma. For example, diphenhydramine can exhibit anticholinergic effects which can dilate the pupil and provoke angle closure in people with narrow angles. Antihistamines should be avoided in people with angle-closure glaucoma or only used under the supervision of a physician.

Do NOT Buy Drugs From Risky Online Pharmacies

  • While it may be a tempting way to save money on medications, buying medications — prescription or OTC — from foreign countries or from unreliable websites on the Internet can be costly to your health. According to the U.S. Food and Drug Administration “the safety and effectiveness of imported drugs have not been reviewed by the FDA, and their identity and potency can’t be assured.” You could receive the wrong drug, the wrong strength, or even outdated, expired medications. If you are not sure what’s in your medication, you can’t run a reliable drug interaction check to look for any serious problems.

References

  1.  Mata, D. A.; Ramos, M. A.; Bansal, N; Khan, R; Guille, C; Di Angelantonio, E; Sen, S (2015). “Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis”JAMA314 (22): 2373–2383. doi:10.1001/jama.2015.15845PMC 4866499PMID 26647259.
  2. Davey, C. G.; Yücel, M; Allen, N. B. (2008). “The emergence of depression in adolescence: Development of the prefrontal cortex and the representation of reward”. Neuroscience & Biobehavioral Reviews32 (1): 1–19. doi:10.1016/j.neubiorev.2007.04.016PMID 17570526.
  3. Jeronimus; et al. (2016). “Neuroticism’s prospective association with mental disorders: A meta-analysis on 59 longitudinal/prospective studies with 443 313 participants”Psychological Medicine46 (14): 2883–2906. doi:10.1017/S0033291716001653PMID 27523506.
  4. Kotov; et al. (2010). “Linking “big” personality traits to anxiety, depressive, and substance use disorders: a meta-analysis”. Psychological Bulletin136(5): 768–821. doi:10.1037/a0020327PMID 20804236.
  5.  “Signs and Symptoms of Mild, Moderate, and Severe Depression”.
  6. Plöderl, M; Tremblay, P (2015). “Mental health of sexual minorities. A systematic review”. International review of psychiatry (Abingdon, England)27(5): 367–85. doi:10.3109/09540261.2015.1083949PMID 26552495.
  7.  Rogers, Donald; Pies, Ronald (9 January 2017). “General Medical Drugs Associated with Depression”Psychiatry (Edgmont)5 (12): 28–41. ISSN 1550-5952PMC 2729620PMID 19724774.
  8. Botts, S; Ryan, M. Drug-Induced Diseases Section IV: Drug-Induced Psychiatric Diseases Chapter 18: Depression. pp. 1–23.

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