All too often my House Of Cards binge session has been ruined by yet another Prozac or Pexeva commercial, almost leaving me teetering on the brink of anxiety, smart move on their part. Putting aside my endearment for commercials, it is important to highlight how anxiety and depression have become mainstream public health concerns in the United States as our men and women in uniform have returned home from serving their country in far flung corners of the earth, only to now fall victim to Post traumatic stress disorder (PTSD). In 2013, the United States Department of Veterans Affairs released a study that covered suicides from 1999 to 2010, which showed that roughly 22 veterans were committing suicide per day, or one every 65 minutes.
Without question, extensive reforms in the Veterans Administration are necessary to develop a robust support system to mitigate this rampant problem. However, you and I can raise awareness on this issue and reach out to veterans in our community to build a support network that serves to educate, give audience to their concerns, preemptively flag individuals who need professional/medical help, and link them with the resources that they need. In this vein, i’ll dedicate the rest of this post to informing our veterans about antidepressant medication.
There are several different categories of antidepressants, each of which bears a characteristic side effect profile and a mechanism of action. Given the association of depression with the levels and activity of neurotransmitters in the brain such as serotonin, norepinephrine, and dopamine, most antidepressants relieve depression by targeting the receptors of these neurotransmitters. Selective serotonin reuptake inhibitors (SSRIs) are one category of antidepressants, and they happen to the most commonly prescribed and effective subtype, with the least amount of side effects. While the exact mechanism is unknown, SSRIs are believed to alleviate symptoms by selectively blocking the reuptake of serotonin into presynaptic neurons, thereby increasing synaptic levels of the neurotransmitter available to bind to the postsynaptic receptor. Potential side effects of SSRIs may include nausea, vomiting, diarrhea, sexual dysfunction, and headache. Examples of SSRI’s include fluoxetine (Prozac, Selfemra), paroxetine (Paxil, Pexeva), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro).
Another class of drugs are serotonin and norepinephrine reuptake inhibitors (SNRIs). These block the reabsorption of the neurotransmitters serotonin and norepinephrine in the brain. Examples of SNRI medications include duloxetine (Cymbalta), venlafaxine (Effexor XR), desvenlafaxine (Pristiq, Khedezla) and levomilnacipran (Fetzima). Some side effects of SNRIs include nausea, dizziness, tiredness, constipation, and insomnia. Norepinephrine and dopamine reuptake inhibitors (NDRIs) are a class that block the reabsorption of norepinephrine and dopamine in the brain. They are one of the few antidepressants not frequently associated with sexual side effects. Bupropion (Wellbutrin, Aplenzin, Forfivo XL) falls into this category. Atypical antidepressants don’t fit neatly into any of the other antidepressant categories. Like other antidepressants, atypical antidepressants affect the levels of dopamine, serotonin, and norepinephrine in the brain. Atypical antidepressants include bupropion, mirtazapine, nefazodone and trazodone. Some common side effects include dry mouth, constipation, dizziness, and lightheadedness.
The last two classes of drugs include Tricyclic antidepressants (TCAs) and Monoamine oxidase inhibitors (MAOIs). TCAs block the reabsorption of serotonin and norepinephrine in the brain. Additionally, they block muscarinic M1, histamine H1, and alpha-adrenergic receptors. They were one of the first approved antidepressants but are generally no longer prescribed unless a patient has tried an SSRI first without improvement. TCAs affect several neurotransmitters in the brain and, as a result, cause numerous side effects. The most common side effects include dry mouth, constipation, blurred vision, dizziness, memory impairment, and delirium. Exmples of TCAs include amitriptyline, desipramine, doxepine , and Imipramine. MAOIs block the activity of monoamine oxidase, an enzyme that breaks down norepinephrine, serotonin, and dopamine in the brain and other parts of the body. These have many drug and food interactions and cause significant side effects in comparison to the new antidepressants, so have been replaced by the latter. Common side effects include postural hypotension, weight gain, and sexual side effects.
In precis, there exists a wide variety of antidepressant drug classes, each of which has drugs that target specific neurotransmitter receptors and have particular side effect profiles. The most effective class, which also fortunately has the least amount of side effects, are SSRIs and the least effective are MAOIs. PTSD, particularly among combat veterans, is a significant public health issue and it is imperative that we engage in a coordinated effort to inform our veterans and lend them the emotional and medical support they need to combat this condition. Lean in together with me in giving a shoulder to our service men and women, it is the least that we can do.
