What are the most effective anti-depressants?

  • There is no best antidepressant. It depends on you and what works for you. No research studies have shown that any class of antidepressants works better than other.

    Here is my list of pro’s and con’s:

    Selective Serotonin Reuptake Inhibitors (SSRI’s): fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), citalopram (Celexa), paroxetine (Paxil) and fluvoxamine (Luvox).

    SSRI’s work pretty well with minimal side effects (i.e. overall GI upset’s, weight gain, headache, diarrhea, etc. are not big issues. Yes these side effects still occur but compared to, say, statin’s to treat cholesterol problems, SSRI’s overall are well tolerated). They can cause three different sexual side effects: decrease in sex drive, trouble achieving and maintaining erection, and issues with delayed orgasm or complete absence of orgasm.

    Out of all the SSRI’s, I like fluoxetine (Prozac), sertraline (Zoloft) and escitalopram (Lexapro) the best.

    Fluoxetine (Prozac) has been around since 1986. It is a plus that some patients have been taking it for 30 years and still doing well. The longer the data exists, the more I feel comfortable with the medication. It can be a bit activating (i.e. causes some increase in energy level) and some patients find that helpful while some find that anxiety-provoking. As a result, fluoxetine (Prozac) tends to be dosed in the morning. However, I have also seen fluoxetine (Prozac) causing sedation. If that’s the case it should be dosed at bedtime. The biggest two pro’s of fluoxetine (Prozac) are a) cost. It has been around since 1986. It is dirt cheap. Very affordable. and b) lack of serotonin discontinuation/withdrawal symptoms. Fluoxetine (Prozac) has one of the longest half-life out of all antidepressants, at about 3–5 days. So when you stop fluoxetine (Prozac), it acts as its own self taper. And let us be honest with each other, do all of our patients take their medications daily? No, they have the tendency to skip a dose or two here and there. If they do that on fluoxetine (Prozac), they don’t feel any side effects at least (obviously efficacy will wane because well, there is a reason it is still dosed once daily).

    Fun fact about fluoxetine (Prozac). Due to its long half-life, Eli Lilly came out with Prozac weekly. Initially you would think, that is a great idea! Why not? But as it turned out when you have to remember taking one dose per week (say on Saturday), then you tend to forget taking it. Taking a medication daily is better in terms of compliance.

    Sertraline (Zoloft). Another favorite SSRI of mine. Relatively neutral, middle-of-the-road in terms of side effects, meaning it is not usually activating or sedating. Very little drug-drug interactions, meaning it does not interact or interfere with the metabolism of other medications like blood pressure or cholesterol meds, etc. Flexible dosing. You can dose as low as 12.5mg (1/2 tab of 25m which is the smallest tab it comes in at) and all the way to 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, and 300mg. You can go 37.5mg, 125mg and 250mg if you need to but I am usually not that obsessive. Weight-neutral. When I say weight-neutral, it means that less than 10% of people gain weight on it. However, it does not mean you cannot be one of those 10% of people who do gain weight on it. Always be monitored by your doctor closely.

    Escitalopram (Lexapro). One of the newest SSRI’s. It used to be not my favorite due to cost. But it has by now been generic for quite a while so cost has gone down tremendously so it is now on my favorite list. Another middle-of-the-road antidepressant with minimal drug-drug interaction, just like sertraline (Zoloft). Dosing wise not as flexible as Zoloft so 5mg, 10mg, 15mg, 20mg and 30mg. Relatively weight neutral.

    Citalopram (Celexa). It used to be my favorite. However, it is very similar to escitalopram (Lexapro) so if patients fail escitalopram (Lexapro) then I don’t tend to switch to citalopram (Celexa) next so it has fallen out of my favorite list.

    Paroxetine (Paxil). It is not my favorite but I trained at UCLA Women’s life clinic where we deal with post-partum depression a lot. And my mentors there including Dr. Vivian Burt, do like paroxetine (Paxil) quite a bit. Paroxetine (Paxil) tends to be more sedating so dosing at bedtime is common (however I have also seen it disturbing people’s sleep and if that’s the case, you need to move it to the morning). Some psychiatrists really like paroxetine (Paxil) because many patients are anxiously depressed and have trouble with sleep. Then the side effects of paroxetine (Paxil) can help counter anxiety and insomnia. Killing two birds with one stone so to speak. Paroxetine (Paxil) is not on my favorite list because it tends to cause a) weight-gain, b) anticholingeric side effects (dry eyes, dry mouth, bladder retention, etc. but that’s why it is good for sleep. Think about diphenhydramine (Benadryl), then you know about the side effects in paroxetine (Paxil)., c) it can have some drug-drug interaction with other medications, and d) it tends to be hard to come off. Meaning it has more issues with serotonin discontinuation/withdrawal symptoms compared to fluoxetine (Prozac).

    Fluvoxamine (Luvox). My least favorite SSRI. It has to be dosed twice a day due to short half life. And you know the more times you have to dose an antidepressant a day, the less compliant your patients will be taking that medication. It is FDA-approved for treating anxiety disorder but it can be used to treat depression too, of course.

    Anyway, I have seen people whose lives are changed by fluoxetine (Prozac) and escitalopram (Lexapro) but only partially responded to paroxetine (Paxil) while having intolerable side effects on sertraline (Zoloft). I have also seen people who respond very well to paroxetine (Paxil) and sertraline (Zoloft) but are very disappointed by escitalopram (Lexapro) and fluoxetine (Prozac).

    Therefore it is important for you to work closely with your physician to find the best antidepressant for you. Only your physician can render you medical advice and guide you properly. My list of “favorite” or “best” antidepressant should be thrown out of the window because only you and your experience count in your trials to find the best antidepressant for you.

    Ok, I am tired of typing. Maybe I will add my opinions on other classes of antidepressants later when I have more time.

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