Posted: Apr 28, 2014 10:00 AM
 
Antidepressants get a bad rap, but for those who need them, they're heaven-sent. Experts chime in on which meds are best, and why.
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Xanax. Prozac. Ativan. Cymbalta. Trying to determine what each medication does and which one might work best for you can be seriously overwhelming.

The word "antidepressants" is quite misunderstood. The much-prescribed medication is used not just for depression but also to treat anxiety. The symptoms of these two conditions are overlapping, which is why getting the appropriate medication can be so confusing.

Is it depression or anxiety (or both)?

"This is a good question that has occupied some of the best minds of the field," says Dr. Henry Abraham, a psychiatrist with more than 40 years of experience. "Unfortunately, the answers still are not clear. What is certain, however, is that depression can occur without anxiety, and anxiety can occur without depression. What confuses people is often times they occur together."

Depression

SIGECAPSSS

Symptoms of Depression

Sadness
Inability to enjoy things
Guilt that is exaggerated
Energy that is reduced
Concentration that is poor
Appetite that is altered
Psychomotor agitation or retardation
Sleep disturbance
Sexual difficulties
Suicidal ideas

"Depression is characterized by persistent low mood and other symptoms that interfere with functioning, such as difficulty concentrating and trouble with sleep and appetite," says Los Angeles M.D. Anandhi Narasimhan. These feelings of sadness last for weeks or months and are typically accompanied by hopelessness and diminished energy — you find yourself taking no pleasure in the things that you normally enjoy.

Dr. Abraham suggests using the acronym SIGECAPSSS to describe the symptoms of depression. "Does the patient have symptoms of Sadness, Inability to enjoy things, Guilt that is exaggerated, Energy that is reduced, Concentration that is poor, Appetite that is altered, Psychomotor agitation or retardation, Sleep disturbance, Sexual difficulties and Suicidal ideas? The more a person answers yes to these, the greater the likelihood the patient is suffering from a significant depression."

Anxiety

Anxiety tends to have opposite symptoms, such as fear, confusion, constant worrying, inability to relax, shortness of breath and upset stomach.

"Anxiety tends to have opposite symptoms, such as fear, confusion, constant worrying, inability to relax, shortness of breath and upset stomach," explains pharmacist John Fazio, owner of New London Pharmacy. "It is not uncommon for patients with depression to also experience anxiety, which can lead to the confusion about a definitive diagnosis."

Dr. Abraham defines anxiety as "a disorder presenting with needless worry, phobias, panic attacks and/or obsessions and compulsions."

It's important for your doctor to be aware of all of your symptoms to make a proper diagnosis and prescribe medication. Fazio cites a study that suggests that as many as 85 percent of patients with depression were also diagnosed with anxiety," says Fazio.

NYC psychiatrist Prakash Masand, president of Global Medical Education, puts that number even higher. "90 percent of patients with clinical depression have anxiety symptoms but not necessarily an anxiety disorder."

"Most patients will be taking medications to treat both depression and anxiety;" says Fazio, "however, your doctor may prescribe an antidepressant alone to start before adding an anti-anxiety agent." Oftentimes, the symptoms of anxiety diminish once the depression is relieved.

"If both depression and anxiety are present, it becomes a matter of clinical judgment whether one or both should be treated with medication," adds Dr. Abraham.

Medication may or may not be interchangeable

To treat depression and/or anxiety, your prescribing doctor chooses a medication based not only on your symptoms but on other factors as well, such as your body's chemistry, your age and other medical conditions you may have. "Dosing usually starts low and is increased gradually until the desired effect is reached without having intolerable side effects," says Fazio.

To treat depression and/or anxiety, your prescribing doctor chooses a medication based not only on your symptoms but on other factors as well, such as your body's chemistry, your age and other medical conditions you may have.

"Many antidepressant drugs also have anti-anxiety effects and some are effective for anxiety disorders like panic disorder, OCD, social anxiety disorder, PTSD and generalized anxiety disorder," says Dr. Masand. On the flip side, however, "most anti-anxiety medications are not very good antidepressants, even though they are commonly prescribed to depressed patients for accompanying anxiety."

SSRIs and SSNIs: Long-term treatment for depression and anxiety

The medication prescribed for depression helps regulate norepinephrine and/or serotonin, which are neurotransmitters in the brain. "Antidepressants work by blocking reuptake in the body," explains Fazio. "This prevents their metabolism and allows a higher concentration to be available in the brain."

"Selective serotonin reuptake inhibitors [SSRIs] and serotonin norepinephrine reuptake inhibitors [SNRIs] are the major types of medication used to treat depression," says Dr. Narasimhan. "They work by increasing the release of the chemicals which help regulate mood and anxiety."

SSRIs work on one neurotransmitter: serotonin. Medications include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa) and escitalopram (Lexapro). Side effects are varied and range from agitation, nausea, diarrhea to low sex drive and long-term weight gain.

SSNIs work on two neurotransmitters: serotonin and norepinephrine. SSNIs include venlafaxine (Effexor), duloxetine (Cymbalta) and mitrazapine (Remeron). Side effects are similar to those of SSRIs and also may include heart disease, liver disease and severe withdrawal symptoms.

Benzodiazepines: Short-term treatment for anxiety

"Benzodiazepine has anti-anxiety, anticonvulsant, muscle relaxant, sedative and hypnotic effects and works primarily by enhancing the effect of the neurotransmitter GABA in the body's nervous system," says Fazio.

Powerful benzodiazepines are prescribed for immediate treatment (to address a panic attack, for example) and are not recommended for extended use. "They can be habit-forming, addictive and may result in withdrawal symptoms as well as causing a person to develop a tolerance to their effect," warns Dr. Narahimhan. "Given these risks, benzodiazepines should be used sparingly and preferably for the short term."

Benzodiazepines include alprazolam (Xanax), clonazepam (Klonopin) and lorazepam (Ativan). In addition to their addictive properties, "they can cause impaired judgment and drowsiness and can increase the risk of falls, especially in the elderly," says Dr. Narahimhan.

Brand-name and generic considerations

"All brand-name medications that are FDA approved are appropriate for use in the treatment of depression and anxiety," says Fazio. Whether some brands perform better than others depends on your tolerance to a medication and its side effects. "This can vary widely from individual to individual, so it is best to have a conversation with your physician regarding which medication is the best option," cautions Dr. Narasimhan.

Generics often can work well for many individuals and are often well-tolerated.

"Because of cost and co-pays, generic antidepressants are more prescribed in terms of volume," says Dr. Masand. While they offer an affordable alternative to pricier meds, they "can have some variability in things like side effects and effectiveness given that they may be manufactured in different places," says Dr. Narasimhan. That being stated, "generics often can work well for many individuals and are often well-tolerated."

For the most part, "patients would get the same effect from a brand name medication and its generic counterpart," says Fazio. "You can consult your doctor or pharmacist if you think a certain brand or generic is not working for you."

editor's note^

Please do not make any medical decisions without first consulting with your physician.

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