by Sergio Silva, M.D.

Created on: August 30, 2009

The most commonly prescribed class of antidepressants today are the selective serotonin reuptake inhibitors (SSRIs), the so-called "Prozac family" of medications, of which Prozac was the prototype, but which also includes Zoloft, Paxil, Luvox, Celexa, and Lexapro. They are widely prescribed because they are very safe and generally well-tolerated, and they are highly effective at improving a person's mood and reducing symptoms of tearfulness, hopelessness, irritability and also anxiety, including panic attacks, obsessions, and compulsions.

Because they all share the same mechanism of action-increasing the bioavailability of the neurotransmitter serotonin-they are all remarkably similar with respect to how they help, as well as in regard to their side effect profiles. This is because, by and large, it is the increase in serotonin itself that is responsible for both the beneficial effects on the brain as well as the bothersome physical effects that occur elsewhere in the body, such as the GI tract. Various types of serotonin receptors are widespread throughout the body and wherever serotonin acts upon one of these receptors, you get an effect, sometimes a desired effect, but also more often than not, a side effect. In this respect the SSRIs are remarkably similar; differences are usually a matter of degree. Where these medications tend to differ more so is in relation to their effect at other, non-serotonergic, receptor sites, such as acetylcholine or histamine receptors, which is what accounts for the differences in their side effect profiles and hence, their tolerability for a given patient.

Practitioners are fond of saying that the choice of SSRI is an empiric one: starting an SSRI for the first time, making dosage adjustments, resuming therapy and/or switching to a new and different medication in this class is essentially a trial-and-error process, they explain, but that doesn't mean that it is completely arbitrary or haphazard (although some prescribers tend to want to approach it that way). Educated guesses can be made before a medication trial is undertaken, if not regarding how useful a medication's effect on an individual's mood will be, then at least with regard to how well or how poorly it will be tolerated. This mindfulness on the part of the prescriber, as well as the person agreeing to subject himself to a trial of this type of medication, can avoid wasted time and an unpleasant experience.

So, how best to choose among this family of medications?

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