by Nicole Evans M.D.

Created on: December 22, 2009   Last Updated: December 15, 2010

There are numerous antidepressants on the market now.  The huge selection makes it difficult to know which antidepressant is the best one for individuals suffering from depression.  Antidepressant categories include SSRI’s, SNRI’s, SDRI’s, mood stabilizers, atypical antipsychotics, tricyclics antidepressants and more. 

Fortunately, there are clues in each person’s history, in the specific characteristics of their depression, in their coexisting medical conditions and in their concerns regarding side effects.  These clues can help guide you and your physician to the antidepressant that is likely to be most effective for you. 

Selecting a first-line antidepressant using patient history:

Age:

-Children and adolescents should be started on Fluoxetine, the only antidepressant FDA approved for this age group.

-Adults older than 65 years of age should be started on a serotonin reuptake inhibitor.  Citalopram (Celexa) is known to have fewer drug interactions, an important consideration in elderly people who are at greater risk for polypharmacy.

Family history of a response:

A person often knows of an antidepressant that worked well in their mother, brother, or child.  There is a higher rate of successful treatment of depression and/or anxiety if the same medication that was effective in a first-degree relative is tried.

Past response:

Occasionally, an individual may have been treated successfully for depression in the past.  If this is the case, the same antidepressant medication is as likely to be successful the second time around.

Selecting a first-line antidepressant using depression characteristics:

-Bipolar depression: Treat with a mood stabilizer such as lithium or lamotrigine, plus an antidepressant.

-Psychotic depression: Treat with an antidepressant plus an atypical antipsychotic.

-Depression with obsessive compulsive (OCD) features: Treat with an SSRI.

-Panic attacks: Treat with an SSRI.

-Agitated depression: Treat with a sedating antidepressant such as Amitryptiline (Elavil) or Mirtazipine (Remeron).

-Depression with psychomotor retardation: Treat with a non-sedating antidepressant such as an NRI or SSRI.

-Medication-resistant depression: Treat with electroconvulsive therapy or a combination of medications.

Selecting a first-line antidepressant for coexisting medical conditions:

-Heart disease: Avoid tricyclic antidepressants.

-Stroke: Use caution with SNRI’s and NRI’s that may cause low blood pressure.

-Pain: Duloxetine (Cymbalta), Venlafaxine (Effexor) and Amitryptiline (Elavil) are good choices.

Selecting a first-line antidepressant with concern of side effects:

-Gastrointestinal side effects: Use nontricyclic antidepressants.

-Anticholinergic symptoms: Use nontricyclic antidepressants.

-Sexual dysfunction side effects: Avoid SSRI antidepressants.

-Weight gain: Avoid atypical antipsychotics.

-Postural hypotension (low blood pressure with standing): Use an NRI.

-Diabetes: Avoid atypical antipsychotics.

Selecting an antidepressant from the myriad of choices on the market doesn’t have to be a guessing game.  Share your history and your concerns with your physician in order to select the antidepressant that works best for you.

Reference:

Mann JJ. The medical management of depression. N Engl J Med. 2005;353:1819-34.

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