Depression, part 3

By Alan Koenigsberg, M.D.

Tricyclic antidepressants were the medications used to treat depressive disorders when I did my internship and residency. They were and still are very effective, but can have bothersome side effects. Elavil, Pamelor and Sinequan are a few of those. I do have a few patients for whom I prescribe them, and they work well.

In the 1980s, the selective serotonin reuptake inhibitors (SSRIs) came out, such as Prozac, Paxil and Zoloft. Later ones were Celexa and Lexapro. These days, I tend to prescribe Zoloft or Lexapro if I choose an SSRI. 

The majority of the serotonin receptors in the body are located in the small intestine. I believe this is why I have found that Lexapro has been beneficial to many patients for their irritable bowel syndrome, along with treating their anxiety disorders.

Two of these medications, Prozac and Zoloft, have been shown to be safe to take during pregnancy. Clearly, this is extremely important to women of childbearing age.

After those, serotonin norepinephrine reuptake inhibitors (SNRIs) came out, such as Effexor, Pristiq, Fetzima and Cymbalta. Pristiq and Cymbalta are my go-to SNRIs.

Wellbutrin has been available for quite some time, and is also used to help people quit smoking cigarettes, as Zyban. It is very helpful to alleviate sexual side effects of the SSRIs.

More recently, Trintellix became available and is also an excellent antidepressant.

A substantial number of patients get fully better when taking a full therapeutic dose of these medications.

However, there are many people who only partially respond, and additional care and treatment is warranted. Those additional treatments are considered adjunct treatments and are common in general medicine as well as in psychiatry.

Adjunct treatments can include adding on thyroid hormone, such as Synthroid, or antipsychotics, even when there is no evidence of psychosis; these are FDA-approved medications to add on to an antidepressant. I tend to use Abilify or Seroquel most often. Lithium may be helpful as well as anticonvulsants, which are also known as mood stabilizers, such as Lamictal. There is a medical form of a vitamin, known as Deplin, which is L-methyl folate; it has been shown to be helpful.

Lastly, optimal treatment may require treating all residual symptoms of depressive disorders and may benefit from several medications.

While we do our best to avoid poly-pharmacy, sometimes it is appropriate and warranted.

For example, if a person has noticed clear improvement in symptoms of depression but still has persistent insomnia, a sleeping pill may be appropriate.

I have noticed that some patients in their 70s and 80s experience significant benefit from the antidepressant medicine, but are still cognitively fuzzy, have trouble concentrating and still have residual apathy. Low doses of Adderall, which is most often used to treat ADHD, have been shown to be effective.

Sometimes, treating depressive disorders can be simple and clear-cut. For those people, it is gratifying that their treatment is simple. For many, however, they may have other general medical conditions, or other medications that complicate the clinical picture, and the detailed kind of treatment outlined above may be appropriate.

The last part of this four-part series will focus on the other types of treatments available for depressive disorders.

Alan Koenigsberg, M.D., is a practicing psychiatrist and clinical professor of psychiatry at UTSW Medical School in Dallas.Depression, part 3

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