Antidepressants are medications that are prescribed mainly for depression, anxiety disorders (including panic attacks) and obsessive compulsive disorders. They are also used in pain syndromes, smoking cessation, premenstrual dysphoria and many other off-label disorders. They are BIG BUSINESS — 11 billion in sales in 2010 in the US alone. One in ten Americans are on an antidepressant!
Antidepressants were first discovered in the mid-fifties when researchers were trying to find a cure for schizophrenia. What they found was Tofranil, a tricyclic antidepressant. Sadly, it made schizophrenia worse, and happily, depression better. For the first time, psychiatrists had a tool other than psychotherapy, tranquilizers or electroconvulsive therapy (ECT) to treat the depressed patient. This discovery started the snowball effect, and quickly other drug companies followed suite with Elavil, Norpramin and Trazadone. The problem with this generation of antidepressants was the severity of the side effects.
In 1988, when Eli Lilly introduced Prozac, it was an absolute game-changer — less side effects and more effective. By 1990, annual sales of the “miracle drug” topped 1 billion. It wasn’t perfect, but compared to the competition it was fabulous.
Now there are over a dozen newer antidepressants: Zoloft, Paxil, Paxil CR, Celexa, Lexapro, Luvox, Luvox CR, Wellbutrin SR, Wellbutrin XL, Cymbalta, Pristiq, Viibryn…
So which one is the best? The answer is much less exciting than the question. NONE and ALL. It depends which one works for a particular person, and which has the least side effects for that person. Choosing a particular drug is often a litany of trial and error. There are no blood tests to help us choose the right one.The only real clue we have is if a family member did well or poorly on the chosen drug.
My feeling is that drugs alone are often not the best treatment for depression, anxiety or OCD. What seems to work best is often a combination of medication and psychotherapy. It’s a dual approach that addresses both the physiological and the underlying psychosocial issues. This is a great time to be depressed! Often it’s fixable.
Please feel free to ask any questions and I’ll do my best to answer them. Thanks!
Art Smukler, MD - Books & Thoughts 
Well my 1st thought is this medical literature or marketing for your blog and book ?
Your summary is excellent but shouldn’t all well trained psychiatrists know this ? Perhaps it is better directed to RNPs, PCPs.
Harry Stack Sullivan state” the purpose of a first appointment is to have a second appointment”. This requires a thorough evaluation, establishing rapport in a safe setting. All to often in my 40 yrs of OPT and consultative rx in C & P psychiatry I’ve been refereed both adult, children and teen pts after one visit with a therapist where the subject of suicidal ideation was observed /exposed to be immediately sent to me with out further investigation or office visits !
I believe the best antidepressant is a good empathetic knowledgable 1st office visit and hopefully psychotherapy depending on acuity the case
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Hi John; Thanks for your comments. You’re right on both counts. The purpose of this post was to both bring up an interesting medical issue (Over 200 people read the post and dozens commented) and to promote my blog and book. All in my opinion are interesting and hopefully will encourage discussion and feelings. Please, check out INSIDE THE MIND OF A PSYCHIATRIST. If you like it, follow along with me and share your observations. If you don’t, I still appreciate your interest. Thanks, Art
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It is disturbing to me that in reviews of treatment resistant depression there is rarely a rcommendation of psychotherapy. I could not agree more that psychotherapy is first, then augmented by medication, depending of course on severity.
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Have you seen patients experience bruxism, dyarthria, or disorders of cognition while on Cymbalta? And if so, is it dose-dependant and is there a cumulative effect after being on treatment for years?
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I’ve seen a lot of cognition problems and know how common bruxism is with SSRIs. Unfortunately, my experience with Cymbalta is limited and I’m not the best person to address your excellent question. Thanks, Art
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What’s the story on the suicides with some of these drugs?
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Hi Neal. Good question.
Even when the tricyclics were popular, back in the fifties, there was always a concern about suicide. The thinking is that if someone is in a deep depression, he doesn’t have the energy to act on his suicidal impulses. Then, as the depression lifts, and motivation increases, he has the energy to carry out the suicidal desire. This same thinking holds true with all the newer antidepressants (SSRIs, SNRIs, and duel action antidepressants).
The way to deal with this is to always discuss suicidal ideation with a patient and keep in close contact when medication is prescribed.
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