Antidepressant Medications
This week we’ll jump in to the topic of antidepressants, and try to clarify the different types. Depression is very common in general, and specifically about 1 in 5 older adults will experience symptoms of depression in a calendar year. As a person ages, there are many reasons they may experience these symptoms ranging from personal health changes to health changes of friends and family. Sometimes the symptoms are so severe that a person may appear to have the cognitive changes that occur with dementia! Because of the complexity of aging and the side effects of medications, patients and providers must work together to choose the right antidepressant.
The most commonly prescribed antidepressants are the Selective Serotonin Reuptake Inhibitors (SSRIs). This long term describes what these medications do in the brain; they prevent serotonin, which is a “feel good” neurotransmitter from being inactive and cause it to spend more time operating within the brain. A commonly known SSRI is Prozac (also known as fluoxetine), which has been FDA approved for treatment of depression for nearly 40 years! Because of the side effects of some SSRIs, in older adults I tend to prescribe escitalopram and citalopram more often as these are generally tolerated better.
Another common class of antidepressants are the Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs). These, similar to SSRIs, keep serotonin and norepinephrine in an active state. Norepinephrine in the brain helps with alertness, and in the rest of the body helps with the “fight or flight” response. SNRIs are particularly helpful for older adults with depression who are also experiencing other symptoms such as painful neuropathy (nerve pain), fibromyalgia, and even hot flashes after menopause. Duloxetine and venlafaxine are tolerated well by older adults, and are the two of this class that I will prescribe often.
Atypical antidepressants, such as bupropion and mirtazapine, I use less often as sole treatment for depression. Bupropion can have many unwanted side effects in older adults, and mirtazapine can cause sleepiness and weight gain. Another class of antidepressants, the serotonin modulators, are also less commonly prescribed for older adults for the sole treatment of depression. One of these medications, trazodone, is used as a sleep aid, as is the atypical antidepressant mirtazapine.
There are two other classes of antidepressant medications, tricyclic antidepressants (TCAs) and MonoAmine Oxidase Inhibitors (MAOIs). These are older antidepressants and because of the side effect profile, they are rarely prescribed for older adults. I frequently taper patients off these types of medications and switch to an SSRI or SNRI because of the safety concerns as we age.
Overall there are many types of antidepressant medication and no “one size fits all” recommendation. Sometimes the best thing is to use what has worked in the past, and sometimes it is to try something new. It is very important to discuss all your concerns with your provider to make sure the right medication is selected! I want to be sure to highlight the importance of counseling as well, even though this is a Medication week topic. The combination of medication and counseling together is highly effective for treatment of depression, much more than medication alone!
Key Points:
Depression is very common in general, and about 1 in 5 older adults will experience symptoms of depression in a year’s time
Antidepressants come in many types, and partnering with your provider will help achieve the desired goals of treatment
Antidepressants plus counseling gives the best chance of treating depression effectively!
