antidepressants

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Introduction

Antidepressants are medications used in the treatment of depression, but many can also be used in conditions such as anxiety disorders and obsessive compulsive disorder. Most antidepressants are taken orally.

What we already know

Antidepressants can be divided into six groups, based on their mechanism of action:

  1. Selective Serotonin Reuptake Inhibitors (SSRIs)“ e.g. Citalopram, Sertraline
  2. Serotonin-Noradrenaline Reuptake Inhibitors (SNRIs)“ e.g. Venlafaxine, Duloxetine
  3. Noradrenergic and Specific Serotonergic Antidepressants (NaSSAs) e.g. Mirtazapine
  4. Tricyclic Antidepressants (TCAs)“ e.g. Amitriptyline, Imipramine
  5. Monoamine Oxidase Inhibitors (MAO-Is) e.g. Phenelzine, Moclobemide
  6. Miscellaneous“ e.g. Bupropion, Trazodone, Reboxetine

Side effects depend on the mechanism of action and can vary from person to person.

NICE guidelines suggest use of antidepressants in moderate or severe cases of depression only. The risks of antidepressant medication use in mild depression outweigh the benefits, so other forms of therapy (e.g. CBT) are recommended in these cases.

Areas of uncertainty

  • The exact mechanisms of action – we are yet to find out exactly why and how many of the antidepressants work (there are inconsistencies in the monoamine theory of depression)
  • How to limit side effects associated with antidepressant use
  • How many people experience withdrawal effects and how best to withdraw from antidepressants
  • Using antidepressants in special groups – limited data exists for which antidepressants (if any) are best to use in pregnant women, children and the elderly

What’s in the pipeline

  • Ketamine has been shown to have promising antidepressant effects, although further randomised placebo-controlled trials are needed (Coyle and Laws, 2015)
  • Research is ongoing into the biological causes of depression and it is hoped that when this is better understood, therapy can be targeted towards the exact cause
  • Further research is also being conducted into the long term effects of antidepressants
  • Research aimed at developing more personalised treatment for depression is also underway

References

NICE guidelines CG90 (2009) ‘Depression in adults: The treatment and management of depression in adults’ [PDF]

Semple, D. and Smyth, R. (eds.) (2013) Oxford Handbook of Psychiatry. 3rd ed. Oxford: Oxford University Press. (Publisher)

Coyle, C. M. and Laws, K. R. (2015), ‘The use of ketamine as an antidepressant: a systematic review and meta-analysis.’ Hum. Psychopharmacol Clin Exp, doi: 10.1002/hup.2475 [Abstract]

Acknowledgement

Written by: Josephine Neale
Reviewed by: Helge Hasselmann
Last updated: Jun 2019
Review due: Jun 2020

Our antidepressants Blogs

Antidepressant withdrawal: recommendations for support from people with lived experience

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Hannah Bowers summarises a study exploring the need for antidepressant withdrawal support, from 708 survey respondents with lived experience.

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The experience of treatment-resistant depression: we need to rethink treatment for people who do not respond to antidepressants

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Amelia Talbot summarises a qualitative meta-synthesis exploring people’s experiences of living with ‘treatment-resistant’ depression.

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Serotonin hypothesis of depression: balance (and imbalance) is in the eye of the beholder

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The 2022 review by Moncrieff et al on the serotonin theory of depression received a great deal of media coverage. In this blog, Rebecca Wilkinson and Sameer Jauhar shed fresh light on this research and what it means for mental health science and practice.

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Antidepressants, cognition, and emotional blunting: what’s the evidence?

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Angharad de Cates reviews a recent Danish trial, which finds that escitalopram reduced participants’ reinforcement sensitivity compared to those on placebo. This lower reinforcement sensitivity may be similar to the emotional blunting effect often reported by patients during SSRI treatment.

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Antidepressant withdrawal or depression relapse? International guidelines on antidepressant discontinuation are unclear

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Adele Framer summarises a systematic review which finds that major guidelines on antidepressant discontinuation only give clinicians vague guidance on distinguishing withdrawal from relapse.

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Youth mental health interventions: umbrella review presents efficacy and acceptability data

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In his debut blog, Nick Meader tackles a huge umbrella review of youth mental health interventions, which presents the efficacy and acceptability of 72 different approaches to help children and young people.

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No evidence that medication can prevent PTSD in people exposed to trauma, according to new Cochrane review

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In his debut blog, Richard Meiser-Stedman explores a recent Cochrane systematic review which finds no evidence for the use of medication to prevent the onset of PTSD in people who have been exposed to a traumatic event.

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Maintenance or discontinuation of antidepressants for depression? Findings from the ANTLER trial

For every 6 people stopping their medication there was one additional relapse compared to those who maintained their antidepressant treatment, suggesting that stopping medication has an increased risk of relapse.

Raphael Rifkin-Zybutz and Sameer Jauhar summarise the recently published ANTLER trial, which explores whether antidepressant maintenance can reduce the risk of relapse in depression.

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Psychotherapy and antidepressant tapering can help people at risk of depression relapse, but more evidence needed before we can provide personalised treatment

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Jessica Scaife reviews a individual patient data meta-analysis exploring the continuation of antidepressants versus sequential psychological interventions to prevent relapse in depression.

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The benefits and harms of antidepressants for youth depression and anxiety #ActiveIngredientsMH

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Mark Horowitz and Joanna Moncrieff consider a new #ActiveIngredientsMH review published today in The Lancet Psychiatry, which looks at the knowns and unknowns of antidepressant treatment in young people with depression and anxiety: efficacy, predictors, and mechanisms of action.

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