The Newer Antidepressant Medications

Compared to other forms of antidepressant medication treatment, the SSRI s and other newer compounds identified to treat depression such as venlafaxine, miitazapine, nefazodone and reboxetine are newcomers in 

Some professionals fear that the trend of prescribing an antidepressant immediately before any other type of intervention will discourage alternate and equally effective forms of treatment. Many fear that these newer antidepressants will become as familiar as Kleenex and as socially acceptable as spring water (Cowley, 1994, p. 41). 

There are several different types of medications that fall into the classification of selective serotonin reuptake inhibitors (SSRIs), which are commonly referred to as the second generation antidepressants. In the literature, they are almost always referred to by the acronym SSRIs. The SSRIs— fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine 

Introduced in 1988, Prozac is the oldest in the SSRI class and is still the most commonly prescribed (Morris, 1999). Prozac is a highly successful antidepressant that has revolutionized the treatment of depression because of its ability to raise serotonin levels in the brain. Increased availability of this neurochemical has been directly related to addressing effectively the symptoms prevalent in depression, and Prozac was recently approved to treat obsessive-compulsive disorder and the eating disorder bulimia. Prozac and the other SSRIs are also considered the medication of choice for working with depressed older individuals because of fewer side effects than the tricyclic medications (Haider Miller, 1993). In 1999 Prozac was endorsed by the FDA as being especially effective for geriatric depression (Hussar, 2000). 

Although the SSRIs are said to have revolutionized the treatment of depression, there are several new medications that have gained in popular- 

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Most of the newer antidepressant medications such as fluoxetine (Prozac), fluvoxamine (Luvox ), paroxetine (Paxil),... 

Studies clearly support that the neurochemical-based treatments for depression such as antidepressant medications and ECT are effective in lifting depressed moods. Controlled studies using neurochemically based treatments specifically for the treatment of major depression indicated that 78% of the depressed individuals improved with ECT, and 70% with the newer antidepressants medications (Maxmen Ward, 1995). In practice, it is estimated that 50% of individuals who take antidepressant medicines report feeling better or achieve complete remission. In addition, antidepressant medications can be used to treat related conditions such as obsessive compulsive disorder and overwhelming anxiety (Brophy, 1991). Antidepressants are often used to treat excessive anxiety since they can block the symptoms of panic including rapid heartbeat, terror, dizziness, chest pains, nausea, and breathing problems. 

Possible Side Effects of the Newer Antidepressant Medications... 

The fourth factor influencing medication choice is the safety of the medication. This is especially important given the snicide potential of depressed patients. The newer antidepressants, inclnding the SSRls and so-called atypical antidepressants, are mnch safer in overdose than the older TCAs and MAOIs. In the case of the TCAs, ingestion of a 1-2 week snpply is lethal 50% of the time. 

Finally, the expense of treatment can be a decisive factor in treatment selection. Depending on the dose, the cost of the newer antidepressants is 1 to 3 per day. The older TCAs and MAOIs are available in cheaper generic forms. However, these reqnire more stringent medical monitoring and periodic assessment of serum drug levels. 

TCAs derive their name from their chemical structure aU tricyclics have a three-ring nucleus. Currently, most clinicians are moving away from using TCAs as first-line drugs relative to the newer antidepressants, they tend to have more side effects, to require gradual titration to achieve an adequate antidepressant dose, and to be lethal in overdose. Some data suggest that TCAs may be more effective than SSRIs in the treatment of major depression with melancholic features (Danish University Antidepressant Group 1990 Perry 1996) however, many skilled clinicians and researchers continue to prefer the newer antidepressants, even for patients with melancholia, for the aforementioned reasons. Newer medications that affect both norepinephrine and serotonin (e.g., venlafaxine and mirtazapine) also may have superior efficacy in severely iU depressed patients or when remission is defined as the outcome (Thase et al. 2001). 

Because of the improved tolerability and safety of newer antidepressants, MAOIs are not currently used as first-line agents. However, MAOIs remain excellent medications for patients whose symptoms do not respond to the newer antidepressant drugs. Patients with atypical depression, characterized by oversleeping and overeating, show a preferential response to MAOI therapy compared with TCAs (Liebowitz et al. 1984 Quitkin et al. 1979 Ra-varis etal. 1980 Zisook 1985). 

In reality, most patients quickly stop taking the newer antidepressants because of their painful adverse effects, thereby protecting themselves from long-term adverse effects, including withdrawal reactions. Others stay on them mainly because of pressure from their doctors, including the lie that they have so-called biochemical imbalances. The more disturbed or distressed the individual before starting the medication, they more the individual is likely to deteriorate while taking it. 

Cardiovascular disease is not a contraindication to lithium, but the risks may be greater, in view of factors such as fluid and electrolyte imbalance and the use of concomitant medications. Close clinical and laboratory monitoring is necessary, and an alternative mood stabilizer may be preferred. While long-term tricyclic antidepressant therapy may be more cardiotoxic than lithium, the newer antidepressants (SSRIs and others) seem to be safe. 

Pharmaceuticals, Inc.) and isocarbazid (Marplan , Validus Pharmaceuticals). They also suppress tyramine uptake. In response to diet-related surges of tyramine, some patients experienced sudden increases in blood pressure that caused fatal brain hemorrhages [51]. Newer antidepressant medications are based upon the inhibition of serotonin reuptake. 

Owing to increased awareness of the illness and the advent of newer and safer antidepressant medications, the past two decades have seen improvements in the screening, diagnosis, and treatment of MDD. The willingness of generalist practitioners to involve themselves in the identification and treatment of MDD is noteworthy. To that end, antidepressants have become some of the most commonly prescribed drugs, and they account for 10 of the top 100 prescription drugs dispensed in the United States.1 Despite recent increases in the treatment of MDD, inadequate treatment remains a serious concern.2... 

Psychiatric medicines exert multiple effects for two principal reasons. First, they usually interact with more than one receptor type. There are two ways to look at this. You will often hear a medication with multiple receptor interactions called a dirty drug. This is because the more receptor interactions it has, the more effects, and hence side effects, it produces. As a result, great effort has been made to develop newer medications with fewer receptor interactions and, thus, fewer side effects. This effort has been quite successful with antidepressants, as we have moved from the effective but side effect-laden tricyclic antidepressants to newer antidepressants such as selective serotonin reuptake inhibitors. 

The key has been to avoid using treatments that worsen the disease. In this instance, this means avoiding anticholinergic (acetylcholine-blocking) medications that worsen dementia. As a result, when newer antidepressants such as the SSRIs became available, they quickly replaced the older tricyclic antidepressants because the latter are potent anticholinergics. For the same reason, the low potency anti-psychotics like chlorpromazine (Thorazine) were replaced by the higher potency antipsychotics like haloperidol (Flaldol) and more recently by the atypical antipsychotics. 

Moreover, experimental studies are often inconclusive. Rarely does the antidepressant medication far exceed the placebo in effectiveness, and sometimes subjects in the control group actually report greater symptom relief Equally important, the newer classes of antidepressant medications (the SSRIs), hyped as the latest wonder drugs, are actually no more effective than categories of medications (for example, tricyclic antidepressants) that were discovered in the late I950s. Finally, these studies have no way to assess whether medications work better than positive life changes. The sociologist Allan Horwitz asks ... 

Tricyclic antidepressant medications were developed in the 1950s and 1960s. Because they affect multiple neurotransmitters in the brain, they are thought to have more side effects than the newer class of SSRIs, which target the specific neurotransmitter serotonin. 

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