The many myths surrounding antidepressant medications can turn some people off taking them. If you’re suffering from depression, don’t be misled by myths. Find out more about the different types of antidepressants and how they work, and make an informed decision.

What are antidepressants?

Antidepressants are medicines used to help people who are experiencing a major depressive illness; this includes postpartum depression (PPD). Antidepressants are also used to treat other conditions, such as obsessive-compulsive disorder, premenstrual syndrome, chronic pain and eating disorders. 

In the treatment of depression, antidepressants lead to an improvement in the symptoms in 85% of people who take them. With the help of antidepressant medications and/or counseling or psychotherapy most people can achieve significant recovery from depression much sooner than if their depression remained untreated.

Are antidepressants necessary?

Whether antidepressant medication is the best treatment for you depends on how severe your depression is, your medical history and your personal preferences. Most women with postpartum depression do well with a combination of antidepressant medications and psychotherapy.

In cases of severe depression, there is strong evidence that antidepressants are more effective than any other treatment. If depression is mild or moderate, psychotherapy alone may be sufficient. However, the use of antidepressant medications or herbal remedies may prove helpful in assisting you to engage more actively in psychotherapy. Your health care professional will help you to decide if medications may benefit you. 

How do antidepressants help?

Antidepressant medications help reduce feelings of extreme sadness, hopelessness and lack of interest in life that are typical in people with depression. Specifically antidepressants... 

  • Improve energy levels and concentration.
  • Normalize sleep and appetite.
  • Reduce feelings of hopelessness and thoughts of death.
  • Restore motivation and the capacity for pleasure.
  • Decrease unwanted feelings of guilt.
  • Minimize depressed mood.

How do antidepressants work? 

Our brain functions by sending electrical impulses via nerve pathways. These electrical impulses are carried by chemicals called neurotransmitters. Neurotransmitters are needed for normal brain function and are involved in the control of mood and in other responses and functions, such as eating, sleep, pain and thinking. 

In individuals with depression the levels of neurotransmitters, i.e. serotonin, norepinephrine and dopamine, in the brain are lower than in non-depressed individuals. All antidepressant medications work by slowing the removal of neurotransmitters from the brain. By restoring the brain's chemical balance, antidepressants help to relieve the symptoms of depression.

Different types of antidepressants

Antidepressants are not all the same. There are a numerous different types of antidepressant medications available. These are categorized into different 'chemical classes'. Each grouping of antidepressant medication differ in the way they work, their side effects, and to some extent in their level of effectiveness. Antidepressants are classified into the following groups...

  • Selective Serotonin Reuptake Inhibitors (SSRIs)
  • Norepinephrine Reuptake Inhibitors (NRIs)
  • Tricyclic antidepressants
  • Tetracyclic antidepressants
  • Monoamine Oxidase Inhibitors (MAOs)
  • Herbal therapies

One type of antidepressant is not stronger than another, it simply works in a different way. Different women may have a better response to one antidepressant compared to another. Unfortunately, there is no way of knowing at the time of diagnosis which antidepressant will be most beneficial to an individual woman. 

Below are listed examples of different antidepressants. Please note that not every antidepressant currently available on the market is included.

1. Selective Serotonin Reuptake Inhibitors (SSRIs)

When choosing an antidepressant for you, your doctor will generally choose one of the newer SSRIs as they are very effective and have fewer side effects than other antidepressant medications. Although SSRIs are structurally different from each other they all act by increasing the levels of the neurotransmitter, serotonin. SSRIs include...

  • Prozac ™ (Fluoxetine)
  • Paxil ™ or  Aropax ™ (Paroxetine)
  • Zoloft ™ (Sertraline)
  • Celexa ™ or Cipramil ™ (Citalopram)

2. Norepinephrine Reuptake Inhibitors (NRIs)

Two antidepressants that affect two neurotransmitters, serotonin and norepinephrine, are... 

  • Effexor ™ (Venlafaxine)
  • Serzone ™ (Nefazodone)

Another chemically unrelated antidepressant, which has more affect on norepinephrine and dopamine than on serotonin is...

  • Bupropion ™ (Wellbutrin) 

3. Tricyclic antidepressants

In the past Tricyclics were the most commonly used medications for the treatment of depression. Today Tricyclic antidepressants are not generally used as a first option due to the availability of newer SSRIs, which have fewer side effects.

Tricyclic antidepressants also act by increasing the levels of both serotonin and norepinephrine in the brain.

  • Anafranil ™ (Clomipramine)
  • Elavil ™ (Amitriptyline)
  • Aventyl ™ or Pamelor ™ (Nortriptyline)
  • Norpramin ™ or Pramin ™ (Desipramine)
  • Tofranil ™ (Imipramine)
  • Sinequan ™ or Adapin ™ (Doxepin)

4. Tetracyclic antidepressants

Tetracyclic antidepressants are uniquely different to other antidepressants in the way it enhances the effect of serotonin and norepinephrine.

  • Remeron ™ or Avanza ™ (Mirtazapine) 

An older tetracyclic antidepressant is..

  • Ludiomil ™ (Maprotiline)

5. Monoamine Oxidase Inhibitors (MAOs)

MAOs are rarely used in the treatment of postpartum depression. They are not generally prescribed unless one or more other antidepressants have failed. MAOs work by inhibiting the enzyme monoamine oxidase, which breaks down neurotransmitters. Although the mechanism is different, the result of MAOs in the treatment of depression is the same as other forms of antidepressants.

  • Nardil ™ (Phenelzine)
  • Marplan ™ (Isocarboxizid)
  • Parnate ™ (Tranylcypromine)

6. Herbal therapies

Herbal remedies to treat depression include: St. John's Wort, SAMe, ginkgo biloba, and caffeine. With the exception of St. Johns Wort there is insufficient clinical data to support the use of these treatments. 

St. John's Wort is a herb that has been used for centuries for medicinal purposes, including treatment of depression. There is much debate about exactly how the active ingredients (hypericum/ hyperforin) in St. John's Wort actually works. One theory is that it inhibits the breakdown of neurotransmitters. 

St. John's Wort is not a proven therapy for depression. Although there is some scientific evidence that it is useful for treating mild to moderate depression, studies suggest that St. John's Wort is of no benefit in treating moderate or severe depression.

Common myths about antidepressants

Antidepressants are possibly the most poorly understood of all medications.  There are many myths surrounding their use; these include...

1. Antidepressants are addictive

FALSE: This is a commonly held belief due to confusing antidepressants with anti-anxiety medications, some of which can be addictive. Antidepressants are not addictive. However, when it's time to cease antidepressants it is important that you discontinue their use by gradually reducing doses. This is done to allow your body time to adjust.

2. Antidepressants are 'happy pills'

FALSE: Although antidepressants relieve symptoms of depression they do not artificially induce a feeling of bliss or unrealistic feelings of well-being. They are not 'uppers' or stimulants. Antidepressants relieve the symptoms of depression and help the depressed person feel the way he/she did before becoming depressed.

3. Antidepressant dull your senses

FALSE: Some people believe antidepressants will turn you into a zombie-like creature. This is not true. Nor do antidepressants insulate you from life, make you not care about important things, or become insensitive to pain or loss.

Some antidepressants can make you feel a little sleepy. These are usually taken in the evening before bed so that you can take advantage of the sleepy effect and gain a good night's sleep.

4. Taking antidepressants is a sign of weakness

FALSE: Some women feel ashamed or embarrassed to take medications believing it proves they have failed as a mother. Some men also discourage their partners from taking antidepressants believing it proves they have failed to support their wife/partner as well as they believe they should. Depression is an illness. Just as medications may be used to treat asthma, allergies, infections or diabetes, medications may be used to treat depression.

5. You become immune to the effects of antidepressants and need to continually increase your dose

FALSE:  Sometimes the dose may need to be increased but this is to gain maximum benefits from the antidepressant. Different people respond to different doses. Once you have stabilized on a dose for you, you will generally remain on that dose until it's time to cease taking the medication.

6. You can't take antidepressants while you're breastfeeding

FALSE: Although some medications are not safe to be taken while breastfeeding, there are a number of antidepressants that can be safely taken while breastfeeding.

7. Your depression needs to be "really bad" before you need to use antidepressants

FALSE: Antidepressant medication can be helpful even when depression is mild.

8. Herbal remedies are safer than medications

FALSE: Simply because a herbal remedy comes from plants does not mean they are completely safe. Many so-called "natural" substances can have harmful effects, especially if they are taken in large quantities or if they interact with something else the person is taking.

A major concern when using herbal remedies is that the strength and quality of products are often unpredictable. Herbal remedies differ in content not only from brand to brand, but also from batch to batch. Information on labels may be misleading or inaccurate.

What you need to know about antidepressants

1. Antidepressants take time to work

Once you have started taking antidepressant medications you need to take them regularly (as instructed) to gain maximum benefit.  It will take from 1 to 3 weeks before you will begin to recognize benefits, and it will take as many as 8 weeks before the full therapeutic effect occurs.

2. Finding the right antidepressant

Some people respond better to one antidepressant compared to another. If there is little or no change in your symptoms after 5 or 6 weeks of regular use, a different antidepressant may be necessary. You should discuss this with your healthcare professional.

3. It takes time to recover from depression

Antidepressants will not cure your depression, the simply treat the symptoms.  It's generally recommended that if an antidepressant is effective, it should be taken for a minimum of 6 months because there is a high likelihood that depression will recur if it's stopped sooner.

4. Cease antidepressants gradually

When you feel you have recovered from depression, discuss ceasing antidepressants with your healthcare professional. Antidepressants should be stopped gradually to allow your body time to adjust. (For individuals with bipolar disorder or chronic major depression, antidepressants may be maintained indefinitely).

5. Use caution when using other medications

It's important to be aware that antidepressants can affect other medications you may be taking. When taken together, some medicines can cause serious problems. When taking antidepressants (including St. John's Wort) it's important to tell your doctor, pharmacist and dentist.

6. Restrict alcohol

It's recommended to minimize your alcohol intake when taking antidepressants because alcohol is a depressant, and because antidepressants may increase the intoxicating effects of alcohol.

7. When using MAOs

For the small number of people whom MAOs are the best treatment, it is necessary to avoid certain foods that contain high levels of tyramine, such as many cheeses, wines and pickles, as well as foods containing monosodium glutamate, and medications such as decongestants, amphetamines, insulin, some narcotics, anti-Parkinsonian medications and local anesthetics. (Your healthcare professional will provide you with a full list and provide specific information).

These food restrictions are for only necessary if you are using MAOs and are not necessary when using other antidepressants.

Side effects of antidepressants 

Like other medications, along with the many benefits of taking antidepressants there is also a possibility of unwanted side effects.

1. SSRIs and NRIs

The SSRIs and other newer antidepressant medications generally have fewer side effects than tricyclics. Most side effects, if they present at all, will generally pass with time. 

  • Gastrointestinal problems
  • Headaches
  • Insomnia
  • Anxiety
  • Agitation

2. Tricyclic antidepressants

Not all tricyclic medications produce all side effects, and not everybody gets them. Some side effects will disappear quickly, while others may remain for the length of treatment. Side effects vary depending on which medication is used. The most common side effects of tricyclic antidepressants and ways to deal with them are...

  • Blurred vision - this passes.
  • Drowsiness as a day time problem* - this usually passes soon.
  • Dry mouth - drink lots of water, chew sugarless gum, clean teeth regularly.
  • Constipation - maintain a high fiber diet of bran, prunes, fruit and vegetables.
  • Weight gain - increase exercise.
  • Dizziness when changing position - rise from a bed or chair slowly.
  • Increased sweating - regular showers.
  • Changes in sexual desire - if worrisome this should be discussed with your doctor.
  • Muscles twitches - usually passes.

*Avoid driving or operating heavy equipment if you are feeling drowsy.

3. Tetracyclic antidepressants

  • Drowsiness
  • Dizziness
  • Anxiousness
  • Confusion
  • Increased weight and appetite
  • Dry mouth
  • Constipation
  • Upset stomach
  • Vomiting

4. MAOs

  • Dizziness when changing position.
  • Rapid heartbeat.
  • Loss of sexual interest
  • The interaction of tyramine in certain foods and/or medications can bring about a sharp increase in blood pressure.

5. St. John's Wort

No serious side effect has been reported. Minor side effects include...

  • Gastrointestinal discomfort
  • Fatigue
  • Dry mouth
  • Dizziness
  • Skin rash
  • Hypersensitivity to sunlight

Why it's important to see a doctor for antidepressants

Antidepressants are prescription-only drugs, so you won't be able to purchase them without first seeing your doctor.

As you can see, there are many different types of antidepressants and there are also many things that need to be taken into consideration when choosing the 'right' antidepressant for you; e.g. your health, other medications you may be taking, or whether you are breastfeeding, etc. 

Your doctor will take a thorough medical history, and physically examine you before prescribing antidepressants. A medical assessment is very important, as there are a number of medical and emotional conditions that can mimic symptoms of depression. These need to be assessed in order to choose the most effective treatment.

Breastfeeding and antidepressants 

Nursing mothers often worry about the effects of taking antidepressants on their baby. The amount of medication that passes into breast milk can vary depending on the type of antidepressant used. Many tricyclic antidepressants and the newer SSRIs have minimal transfer into breast milk.

Breastfeeding should be continued where possible as breastfeeding offers many health benefits to the baby and mother, not least is the enhanced quality of mother-baby interaction. A theoretical concern regarding the use of antidepressants while breastfeeding is that some babies may not gain weight well. Your baby's weight may need to be monitored more regularly if you are taking antidepressants while breastfeeding. If problematic then medications can be adjusted. But consider all other reasons for poor weight gain as well.

Dr. Thomas Hale author of Medications & Mothers' Milk highlights that "the long term effects of antidepressant medications on infants remain unknown". However, he suggests mothers should continue breastfeeding while receiving appropriate drug treatment necessary for their depression. It is often preferable to use antidepressants to treat postpartum depression than to not treat since the outcome for baby is generally better when the mother is coping better. 

The following antidepressant medications are commonly used for the treatment of postpartum depression while breastfeeding as there is evidence that any potential risks to babies are low. 

  • Zoloft (Sertraline) according to Dr Hale this is the "best drug choice so far".  It has a low transfer rate to breast milk.
  • Paxil (Paroxetine) has a low transfer rate to breast milk and is suitable for use when breastfeeding.
  • Tricyclic antidepressants have a low transfer rate to breast milk, except for Doxepin which has a high transfer rate.

The following antidepressants are recommended for use in breastfeeding only "if the potential benefit justifies the potential risk to the infant".

  • Effexor (Venlafaxine) is a popular drug in Australia for treating depression. It is less popular in the USA due to reported side effects.
  • Prozac (Fluoxetine) has been linked with reduced growth in babies.
  • Celexa (Citalopram) has a high transfer rate to breast milk. Use with caution and watch your baby for side effects (i.e. excessive sleepiness, decreased feeding and weight loss.)
  • Bupropion (Wellbutrin) has a high transfer rate to breast milk. It may reduce breast milk supply but this is undocumented.
  • St. John's Wort. There have been no studies on the transfer rate to breast milk, therefore caution is recommended when breastfeeding.

DISCLAIMER: Please always consult with your doctor. The above information is for educational purposes only.

Written by Rowena Bennett.

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