How to Choose an Antidepressant

Antidepressants are generally considered safe and effective for most people.

Before deciding which antidepressant to prescribe, a doctor may try to determine the severity of your symptoms and the condition you may have.

A recent literature review suggests that certain types of antidepressants may be better suited to treating certain types of depression (i.e., major or psychotic). Different antidepressants target or work on different symptoms.

Symptoms and preferred antidepressants

• anxiety: If you have depression and symptoms of anxiety, a selective serotonin reuptake inhibitor (SSRI) may be a good option for you.
• insomnia: If you’re having trouble sleeping, atypical antidepressants — such as mirtazapine or a tricyclic antidepressant — may be best.
• inability to feel pleasure: SSRIs and serotonin noradrenaline reuptake inhibitors (SNRIs) may work if you’ve lost interest in doing things you once enjoyed.
• melancholia or severe depression: An SNRI, tricyclic antidepressant, or an SSRI — such as vortioxetine (Trintellix, Brintellix) — may be better options for severe depression.
• pain: If you’re experiencing chronic pain due to a condition, such as fibromyalgia, an SNRI, such as duloxetine (Cymbalta), or a tricyclic antidepressant may help.

While soothing your symptoms is a goal of treatment, there’s more to consider. For example, if you’re having thoughts of suicide, this may be taken into consideration when deciding which antidepressant may work for you.

The U.S. Food and Drug Administration (FDA) warns that some children and teens may experience increased suicidal thoughts or behaviors while starting an antidepressant or changing doses or types of antidepressants.

When choosing an antidepressant, here are some questions to ask your doctor:

• Which medication will most likely help lower my symptoms?
• How long will it take before I see improvement?
• What are possible side effects, and will they be manageable?
• Will this medication interfere with other medications I’m taking, or worsen another condition I have?
• Is this medication safe to take during pregnancy and breastfeeding?
• This medication did not work for my parent or sibling. Will it work for me?
• Is this medication covered by my insurance? Is there a certain brand or type that is covered? If so, will that medication work the same way?
• How long will I be taking this medication? What’s the process if I want to stop taking it or switch to another one?

Coexisting conditions like anxiety disorders, eating disorders, and substance use disorders may occur together in part because their causes (biological, environmental) may be similar.

People may also develop depression after another medical diagnosis such as arthritis, diabetes, or cancer.

According to the National Alliance on Mental Illness, when anxiety and depression occur together, treatment may take more trial and error because symptoms tend to be more persistent and intense. Antidepressant treatment can still target your symptoms of depression, but additional medication may be necessary.

Some antidepressants can work to lower symptoms of both conditions. Sometimes when you treat one condition, like major depressive disorder, symptoms like restlessness, nervousness, irritability, and generalized anxiety may improve as well.

But the way a medication works for you will not be exactly the same as how it works for someone else. Some other antidepressant types may not be a good mix with your other medications (including natural supplements like St. John’s Wort) or coexisting health conditions.

Before your appointment to discuss medication, consider jotting these items down:

• your symptoms
• current or past conditions
• current or past medications, including supplements like vitamins and minerals
• allergies to medications or foods

Having this list with you when you talk with a doctor can help you both make the right choice in antidepressant.

What is helpful for one person may not be helpful for you. It may take trial and error to determine whether a certain antidepressant will work for you.

It can take several weeks to fully see the effects of an antidepressant. So, it can take time before you start seeing an improvement in your symptoms. It can also take time before side effects subside on their own or become manageable.

Remember that not everyone responds the same way to antidepressants or experiences the same side effects.

A 2018 systematic review found that most antidepressants were more effective than placebos, but some were still more effective than others.

Experts have, however, identified these antidepressants as highly effective:

• agomelatine (Valdoxan)
• citalopram (Celexa)
• escitalopram (Lexapro)
• fluoxetine (Prozac)
• sertraline (Zoloft)
• vortioxetine (Trintellix)

Only you and a doctor can determine the right antidepressant to start with. But it’s likely you’ll discuss starting with one of the antidepressants on the highly effective list.

A 2009 review of 117 high-quality randomized control trial (RCT) clinical studies found around 4 million people with depression over 18 had received new prescriptions for an antidepressant. Of these people, nearly 12% were prescribed sertraline and 14.5% were prescribed escitalopram.

Your first choice of antidepressant may work, but like many others considering antidepressants for the first time, you may need to try a few before finding the right fit. Changes to your dosage or medications may also be necessary in the future.

Starting with one antidepressant doesn’t mean you’ll stay with it. A doctor will be there to support you if you need to safely and slowly switch from one antidepressant to another.

A doctor’s direction and ongoing supervision is necessary to monitor for serotonin syndrome and symptom relapse and to monitor for suicidal thoughts or self-harming behaviors.

You can also prepare for your appointment by learning which questions to ask about antidepressant withdrawal.

Trying to find the right medication that works for you can be overwhelming. But working closely with a doctor or mental health professional can help you determine the right antidepressant or combination of medications that’s best for you.