Pfenninger: Cautions when using antidepressants by Midland Daily News | Posted: Sunday, February 14, 2010 12:00 am
Does it seem to you that half the world is on antidepressants? Many people use them. One of the most
common class of drugs used to treat depression is the SSRIs, or selective serotonin re-uptake inhibitors.
There are six of them, and most people know their brand names. They include paroxetine (Paxil),
sertraline (Zoloft), fluoxetine (Prozac), citalopram (Celexa), escitalopram (Lexapro) and fluvoxamine
(Luvox). These six drugs account for a significant percentage of pharmaceutical sales in the United States
You have to wonder what our forefathers did when they became depressed. There wasn't much help
out there for them. These modern day antidepressants are miracle drugs. They can turn a life around in a
matter of weeks. Although psychotherapy is helpful in some situations, study after study has shown that
for major depression medications are best.
The SSRIs do have significant side effects. Each one is a little different. The question always comes
up, then, which is the best one to use to begin treatment. A large study reviewing 117 studies tried to
answer this very question. If there are no other considerations to be taken into account, Zoloft and
Lexapro appear to come out on top. However, the authors of this study point out that the research was not
that good. Most studies only included the first eight weeks of use for their data. There are so many other
things to take into consideration that the authors could not make a single recommendation as to which
drug should be chosen first. Individual differences such as age, other illnesses, medication history, and
long-term side effects were important considerations.
Although as a class SSRIs are tolerated quite well, there are some side effects which they all have.
Gastrointestinal problems, such as diarrhea which is very common, are among them. Zoloft probably has
the highest risk for this. Sexual dysfunction and sleep disturbances are also very common with all of the
SSRIs. Paxil is more likely to cause weight gain than Zoloft or Prozac. It is also more sedating which
may be disturbing to some patients but helpful to those who have insomnia. If sedation from the drug is a
problem, Lexapro or Celexa may be better tolerated. If switching medications doesn't seem to help with
insomnia, sedatives can be added, but more caution is needed when combining drugs.
The SSRIs do interact with many medications, and the lists are long. In some instances, the SSRI may
increase the activity of the other drug. Or, the other drug may decrease the activity of the antidepressant.
Seizure thresholds are reduced especially in people taking Prozac. Codeine may have less effect when
combined with an SSRI. It is important for women with breast cancer to understand that Prozac reduces
the protective effect of Tamoxifen. Proton-pump inhibitors (Aciphex, Nexium, Prevacid, Prilosec and
Protonix) are used for stomach upset, GERD, and ulcers. Prozac and Luvox can decrease their efficacy.
Another really important point to note is that combining any SSRI with a non-steroidal anti-
inflammatory drug, such as ibuprofen or aspirin, markedly increases the risk of bleeding from the
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Caution should be taken when starting antidepressants. Some people, such as the elderly, should start
with a small dose and work up gradually to the optimum. Patients with kidney or liver problems also
should be dosed slowly. When antidepressants are stopped quickly, patients may experience the
"discontinuation syndrome". They can experience flu-like symptoms, insomnia, loss of balance, and
agitation. Although the syndrome is self-limiting, it can be minimized by tapering the drugs very slowly.
Pregnancy produces a real dilemma for the patient and the doctor. Untreated depression in pregnancy
leads to pre-term labor, low birth weight, decreased fetal growth, and preeclampsia. If a woman has a
diagnosis of depression before getting pregnant, without medication she has a 50% chance of becoming
depressed again. This is three times higher than women who take antidepressants during pregnancy. The
only drug that we know for certain should not be taken during pregnancy is Paxil since it has been linked
to heart defects in babies. With all the SSRIs there is an increased risk for fetal lung problems and babies
do experience the discontinuation syndrome when they are no longer receiving the drug from their
mother. These babies have decreased muscle tone, jitteriness, feeding problems, irritability, sleep
disturbances, and even some respiratory problems. It truly is a difficult decision to make, as to whether or
not antidepressants should be taken during pregnancy, and there are no studies to clarify the decision.
There has been a lot of controversy about adolescents taking SSRIs. After all is said and done, it
should be known that Lexapro, Prozac, Luvox, and Zoloft have all been approved for use in adolescents.
It does appear that youth have more suicidal thoughts, especially while starting these antidepressants, but
they actually have far fewer completed suicides than without the drugs to treat their depression. They
must be monitored closely while on antidepressants.
SSRIs can also cause a myriad of other problems. The point of this article is not to scare people about
taking them but, rather, to make them aware that there are very effective, potent medications that restore
well-being to many people. At the same time, they carry significant risk and should be selected very
carefully depending on individual circumstances. If one of the drugs in the group does not work
effectively, it is likely that another one will.
Dr. John L. Pfenninger's column appears on Sundays. His office, Medical Procedures Center, is
4800 N Saginaw Rd Midland MI 48640 (989) 631-4545
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