Depression Symptoms Treatment

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Newer antidepressants are gradually replacing old tricyclic antidepressants because of comparable efficacy with fewer side effects and a much lower risk of death from overdose. Newer-generation antidepressants include trazodone hydrochloride, bupropion hydrochloride, and the selective serotonin reuptake inhibitors fluoxetine hydrochloride, sertraline hydrochloride, and paroxetine.

Trazodone and bupropion, unlike tricyclic antidepressants, are ineffective for panic. Anticholinergic effects-dry mouth, blurred vision, constipation, and urinary retention — and cardiovascular effects are less with the newer drugs than with tricyclic antidepressants. Weight loss can occur with bupropion and fluoxetine. Overdose lethality is rare with these newer drugs.

Newer antidepressants, like tricyclic antidepressants, show efficacy at two to six weeks, and about 50% to 70% of depressed patients obtain benefit. Patients who partially respond or do not respond may benefit from lithium or triiodothyronine augmentation or by changing to a different class of drug, such as from trazodone to serotonin reuptake inhibitors and serotonin reuptake inhibitors to bupropion.

Trazodone is highly sedating, and dose titration to the maximum tolerated dose is required in the 100-mg to 600-mg at bedtime range based on daytime sedation. Trazodone, 50 mg to 100 mg, is widely used as a hypnotic in lieu of potentially addicting medications. It may worsen preexisting ventricular arrhythmias. It causes priapism in about 1 in 7,000 men.

Bupropion is highly activating, may benefit adults with attention deficit disorder, and has the advantage among antidepressants of causing no sexual dysfunction. It has the disadvantage, however, of a higher seizure risk than tricyclic antidepressants. Patients with eating disorders, head trauma, seizure history, or who are taking other drugs that lower the seizure threshold (such as theophylline) should not receive this drug. The dosage is 300 to 450 mg daily and must be divided.

Fluoxetine, the first marketed serotonin reuptake inhibitor, has now been shown to be beneficial in many conditions including depression, mixed anxiety-depression, anorexia, bulimia, panic, and obsessive-compulsive disorder. The other serotonin reuptake inhibitors, sertraline and paroxetine, will probably show a similar spectrum of action and have the advantage of a shorter half-life to allow for more rapid dose adjustment and washout in case of intolerance. Selective serotonin reuptake inhibitor antidepressants may be lethal in combination with monoamine oxidase-inhibitor antidepressants.

Both bupropion and paroxetine carry less risk of precipitating mania in patients with bipolar depression than do tricyclic antidepressants.

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