Updated: Dec 6, 2020
Antidepressants are not one-size-fits-all. The choice of an antidepressant should be tailored to the character of the depression. Is your depression characterized by insomnia? The agent chosen should be less activating and induce sleep, such as one to be taken at night. Is your depression characterized by an increase in appetite? Perhaps the agent chosen should suppress the appetite, and they do exist! Some with depression also experience neuropathic pain, some antidepressants work for pain! These are generally the tricyclics.The choice of an antidepressant is an art and those are skills possessed by Psychiatric Advanced Nurse Practitioners. When the wrong agent is chosen; perhaps an activating antidepressant is given to someone experiencing insomnia, the provider is fighting against the symptoms and the agent is likely to fail. Did you know that half of clients prescribed antidepressants fail to fill their first dose? This rising lack of trust in the effectiveness of antidepressants could eventually cost us an important tool in preventing suicide. The key is education and judicious prescribing. People need to be aware of what to expect with their therapy, and how the medications work to be successful. Communication is the key.
Antidepressants have to be given time to work. Some antidepressants, such as Zoloft, can take 8 weeks to reach the therapeutic threshold. They can take 3 months to work if you are over 65. Many selective serotonin reuptake inhibitors, such as Zoloft, Prozac and Celexa, are activating and often patients complain of feeling WORSE in the first month of therapy. This is called "activation" and occurs as the level of medication becomes therapeutic, it's actually a sign that the medication is becoming effective. This causes confusion in patients, because activation often produces anxiety, when the medication is often taken to remediate symptoms of anxiety. If the antidepressant is the right choice, it eventually will when activation is over and the medication reaches the therapeutic level, but in the meantime often providers will prescribe an anxiolytic to combat the anxiety of activation.
Cytochrome P450 enzymes also play a factor in a clients response to medications, and can determine if the client is a rapid- or slow-metabolizer of the medications. If you're a rapid metabolizer, the medications will be metabolized so rapidly they will never have a chance to reach a therapeutic level. It is the opposite with slow metabolizers. This can be detected through laboratory testing. I offer this alternative to my clients, and it may be an option if you have never been able to respond to certain medications.
Antidepressants are notorious for sexual side effects. These side effects can be mitigated through determining if the client is a candidate for an antidepressant that doesn't cause these effects, or the use of an adjuvant medication that will counter this side effect.
Contact me for expert care of your depression symptoms.
Bethany Heath ARNP PMHNP BC