Synopsis: Many people are not told what to expect when prescribed an antidepressant medication. Basic information, such as the dosing range, the goal of treatment, how side effects can be overcome and how long to stay on the medication, is frequently left out of a clinical encounter. This article outlines a methodical approach to antidepressant treatment for depression.

BY LEN LANTZ, MD / 10.31.20; No. 39 / 7 min read

Disclaimer: Yes, I am a physician, but I’m not your doctor, and this article does not create a doctor-patient relationship. This article is for educational purposes and should not be seen as medical advice. You should consult with your physician before you rely on this information. This post might also contain affiliate links. Please click this LINK for the full disclaimer.

Diagnosis: the place to start in treating depression

Good treatment is dependent on an accurate diagnosis. Ask yourself, “How was my diagnosis of depression made?” It is just as important to know what conditions you don’t have as the ones you do have. An accurate diagnosis requires you and your doctor to be thorough. Having depressive symptoms alone does not mean that you immediately qualify for an antidepressant or that one would help you. For more information, please check out my very first article, “Does a Psychiatric Diagnosis Even Matter?” to learn more.

What other options have you tried?

There are many strategies for targeting depression. If you are relying on an antidepressant alone, you might be missing out on some interventions that could help your depression now and prevent it from coming back in the future. If you haven’t looked into or tried additional treatments, consider reading some of my other articles:

• “Cognitive Behavioral Therapy (CBT) – the Most Effective Therapy?”

• “The Surprising Results of Exercise for Depression”

• “Behavioral Activation for Depression”

• “A Plan for Stubborn Depression”

What symptoms are you trying to target?

Knowing what you are going after is important. For example, if you have anxiety, you might not start with Wellbutrin (bupropion), as the medication can increase anxiety in a substantial portion of people. You might try to leverage the side effects of a medication to your advantage. In the case of depression and insomnia, you might consider Zoloft (sertraline) at bedtime, as the medication can be sedating, or Prozac (fluoxetine) in the morning, as the medication perks up some people during the day.

It is also important to determine how you will measure the severity of your illness and your treatment progress. The goal of treatment for depression must always be full remission. Anything else will leave the door open for depression to return. Rating scales can help both with tracking symptom improvement and helping determine remission. For more information on rating scales, please check out my article, “Depression Rating Scales – Getting Unstuck.”

Strategies for antidepressant medication changes

Many people don’t know how often their antidepressants should be changed when they have not achieved remission. The best teachers I had in medical school and residency routinely reminded me of 2 basic rules to guide me in the treatment of my patients:

1. If it ain’t broke, don’t fix it.

2. If it’s broke, fix it.

I realize that does not sound very scientific, however, sometimes doctors violate these basic, common-sense rules. There is a 3rd rule that I always try to follow as well, which is:

3. Only change one thing at a time.

If you changed 2 or more medications at the same time and experienced side effects, you might not know what caused the side effects. If you changed more than one medication and experienced symptom improvement, you might not know what caused the improvement. If your doctor routinely changes more than one medication at once, you might want to read my article, “Finding a Good Psychiatrist.” Also, if possible, I try not to change a medication when someone is in the middle of a life circumstance that could improve or worsen target symptoms. Otherwise, we could end up confused about the cause of improvement or worsening. Some other general strategies that I use for my patients when I’m prescribing an antidepressant medication are:

• No dosage change is made if one of the following is present for a person

  • Is in full remission of depression

  • Has ongoing incremental improvement in target symptoms that are not yet in remission

• Increase dosage if one of the following is present for a person

  • Is tolerating the medication well but improvement in target symptoms has plateaued after a sufficient time interval based on age (see below)

  • Is not yet on the maximum FDA dose and has residual symptoms of depression

• Switch antidepressants if one of the following is present for a person

  • Has intolerable side effects

  • Is on the maximum dose of an antidepressant after a sufficient time interval with minimal-to-no improvement in target symptoms

• Add to an antidepressant (augmentation) if one of the following is present for a person

  • Has seen substantial benefit from a medication but has residual symptoms of depression

  • Has specific target symptoms (ex: anxiety, insomnia, fatigue) that remain after other symptoms of depression have improved

• Decrease dosage and/or stop an antidepressant if one of the following is present for a person

  • Is in full remission of depression for a sufficient time interval

  • Feels overmedicated and requests a dosage reduction

  • Felt better on a lower dose

  • Desires to stop the medication

Age can affect medication selection and the speed of medication changes

The older a person is, the longer it might take to see the full effects of a medication. Age can determine the FDA-approved dosing range and/or the speed at which medications should be changed. If you or your doctor want to change medications faster or slower than is recommended, make sure that you have a good reason why. It is also critical that you take your medications daily and not skip doses. Skipping doses will confuse your treatment picture and can lead to more severe depression.

Children: In general, kids should have a response to a medication change by the 4-week mark. Antidepressants can substantially help childhood depression, but keep in mind that there is an increased risk of suicidal ideation in 1 out of about 140 kids who are prescribed antidepressant medication. There are 2 antidepressant medications approved by the FDA for the treatment of childhood depression: Prozac (fluoxetine) and Lexapro (escitalopram). If you think the FDA should take action to find more medication treatments for childhood depression, you might be interested in reading my article, “The FDA’s Duty to Children’s Mental Health.” Other medications are effective in pediatric depression but may be considered off-label, which means that they have been approved by the FDA to treat a different condition, such as anxiety, or were only approved to treat depression in adults but not children.

Adults: Every antidepressant that is approved by the FDA is approved for use for adults. In general, adults should have a response to an antidepressant change by the 8-week mark.

Pregnancy/Breastfeeding Individuals: There is a low risk that your antidepressant will harm your child and a high risk that you will relapse into depression if you stop your medication. In general, newer research indicates that women should strongly consider staying on an antidepressant that works. For more information on psychiatric medication use during pregnancy and breastfeeding, visit Mass General’s MGH Center for Women’s Mental Health.

Older adults: The general strategy for treating depression in elderly people is to start at a low dose and increase the medication slowly to reduce the risk of side effects and to give the medication time to work. In general, older adults should have a response to an antidepressant change by the 12-week mark.

How long to stay on an antidepressant medication

The recommendations vary for how long to stay on an antidepressant after you have reached full remission of depression. For most people with a single episode of depression, it is recommended that they stay on an antidepressant for 12-18 months after full remission and then to taper off the medication under the supervision of their doctor. It is not recommended to abruptly stop an antidepressant, as this can lead to chemically-induced depressive symptoms and serotonin withdrawal symptoms (vertigo and flu-like symptoms) that can last weeks to months. Sometimes the 12-18 month timeframe is shortened if the person is feeling emotionally blunted or overmedicated. If someone has had more than one episode of depression, they might choose to remain on an antidepressant medication to prevent or delay a future relapse into depression. A final thing to consider is that many antidepressants also treat anxiety. Some individuals achieve remission of depression but remain on the medication to continue treating their anxiety, as their anxiety returns when they taper off the antidepressant.

Not all antidepressants are the same

I’ve been surprised over time to see how many depressed patients have never had full antidepressant medication trials of more than one medication. Not all psychiatric medications treat depression and mood-stabilizing medications can be of limited benefit in the treatment of major depression. While augmenting strategies, such as adding lithium, thyroid hormone, an anticonvulsant or a new generation antipsychotic to a person’s current antidepressant medication can help treatment-resistant depression, such medications are unlikely to be effective for major depression in the absence of an antidepressant.

While it can be helpful to take 2 antidepressant medications from different categories, it does not make sense to simultaneously take 2 antidepressants from the same category. For a list of antidepressant medication categories, please read my article, “How Record Keeping Can Help Treatment-Resistant Depression.”

When trying an antidepressant for the first time, it usually makes the most sense to try a generic antidepressant that has robust research showing efficacy before trying a newer, brand-name medication. Your insurance may require a previous trial of one or more generic medications before approving more expensive brand-name medications or treatments, such as ketamine, transcranial magnetic stimulation (TMS) therapy or electroconvulsive therapy (ECT). There are also unique treatment strategies that can be used to treat specific depression patterns such as atypical depression, premenstrual dysphoric disorder (PMDD) and seasonal affective disorder.

Managing sexual side effects

Something to keep in mind about sexual side effects and antidepressants is that only about 25% of people on an antidepressant notice sexual side effects, such as low libido or delay/inability to reach orgasm. The remaining 75% of people see no impact on sexual functioning. Of the people who experience sexual side effects, most see improvement after remaining on the antidepressant for 6 months. If you are interested in learning about natural ways to improve libido, you can read my article, “Sexual Desire – 15 Natural Ways to Increase Libido.”

There are several prescribed medications that can improve libido. Two medications that - when added to another antidepressant - can improve antidepressant-related sexual dysfunction are the antidepressant Wellbutrin (bupropion) and the antianxiety medication Buspar (buspirone).

Imagine freedom from depression

Antidepressants and other psychiatric medications can be very effective at treating depression. You can talk with your doctor about your desire for a methodical approach to medications and medication changes so that you can achieve remission from depression. Think about having the certainty that you have achieved the best possible outcome from any medication because of following a stepwise strategy. You can achieve remission from depression and your active involvement in your antidepressant prescription changes will help you get there.

For further reading, check out:

• Len’s article, “Finding a Good Psychiatrist”

• Len’s article, “Medical Causes of Depression”

• Len’s article, “The Most Important New Findings in Depression”

• Straight Talk about Psychiatric Medications for Kids by Drs. Wilens and Hammerness

• Prescribers’ Digital Reference (PDR)

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