The Right Antidepressant for You, According to a Clinical Pharmacist

Antidepressants are commonly prescribed to treat depression and anxiety—about 13 percent of Canadians take them, according to a small 2021 study. “They were designed to increase the release of specific neurotransmitters [like serotonin, norepinephrine and dopamine] in certain areas of the brain to help restore the imbalance and improve communication between neurons to treat symptoms of depression,” says Dr. Melanie McLeod, a board-certified psychiatric pharmacist. While physicians and researchers know this “correlates with improvement in depressive symptoms and brain functioning,” says McLeod, they still don’t fully understand how much of the improvements in mood are the result of the drugs,  and why some patients respond preferentially to certain antidepressants versus others. These unknowns are one of several reasons why doctors need to recommend various antidepressants to patients to find the one that works with them.

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In other words, antidepressants are not a one-size-fits-all treatment. A doctor or healthcare professional should examine a patient’s symptoms and medical history and tailor the treatment options to suit their specific needs, says McLeod. There are also many factors to consider when prescribing antidepressants, including tolerability, side effects, the patient’s symptoms (for example, choosing a medication with a sleep-promoting agent for someone experiencing insomnia), safety considerations related to other medical conditions, risk of drug interactions, patient preference, cost, and safety for specific individuals, age groups or illnesses. She says that, for women, there are additional considerations related to menstruation, pregnancy and lactation.

What’s more, there are different classes of antidepressants to consider. Many inhibit reuptake, which is the process where neurotransmitters are naturally reabsorbed back into nerve cells in the brain. A reuptake inhibitor prevents this from happening to increase neurotransmitter activity. Selective serotonin reuptake inhibitors (SSRIs) increase levels of serotonin in the brain while serotonin and norepinephrine reuptake inhibitors (SNRIs) increase both serotonin and norepinephrine. Norepinephrine and dopamine reuptake inhibitors (NDRIs) increase norepinephrine and dopamine. Tricyclics also impact serotonin and norepinephrine, but are less selective than SSRIs. They act on receptors throughout the body.

Here’s a rundown of the pros, cons and common side effects of some often-prescribed antidepressants. They’re sold under multiple trade names, but all are available in generic format, which tends to cost less.

(Note that discontinuation symptoms—such as nausea and difficulty sleeping—may occur with any of these medications when stopped abruptly.)

Escitalopram (Lexapro)

Pros: An SSRI often prescribedl for anxiety and depressive symptoms. Along with other SSRIs, it’s considered a top choice by some for use during pregnancy and lactation.
Cons: Potential for sexual dysfunction and weight gain.
Possible side effects: nausea, headache, dry mouth, dizziness, weakness, excessive sweating

Sertraline (Zoloft)

Pros: An SSRI that is used to treat depressive symptoms and other mental health conditions like obsessive-compulsive disorder (OCD) and panic disorder. Generally considered safe for use in pregnancy and lactation. Less expensive than other medications.
Cons: Potential for sexual dysfunction.
Possible common side effects: Nausea, sleep issues, headache, diarrhea, loss of appetite, dry mouth

Duloxetine (Cymbalta)

Pros: An SNRI used for anxiety and depression. It can also be used to treat pain from medical conditions like fibromyalgia and diabetic neuropathy.
Cons: Potential for severe drug interactions.
Possible common side effects: sleepiness, headache, insomnia, dizziness, blurred vision, diarrhea, lack of energy, constipation

Venlafaxine (Effexor)

Pros: An SNRI prescribed for anxiety and depression, and generally well tolerated. May help reduce menopause-related hot flashes.
Cons: Safety concerns to consider with pregnancy.
Possible common side effects: nausea, sweating, headache, drowsiness, dry mouth, dizziness

Bupropion (Wellbutrin, Aplenzin, Zyban)

Pros: An NDRI used for depression, seasonal affective disorder and smoking cessation. It may help improve focus, concentration and motivation, and help with coping with fatigue.
Cons: May be too stimulating for some; may aggravate anxiety symptoms and insomnia. Not always suitable for those with an eating disorder or who are prone to seizures.
Possible common side effects: agitation, drowsiness, difficulty falling asleep or staying asleep, dry mouth, dizziness

Mirtazapine (Remeron)

Pros: A tetracyclic drug used to treat symptoms of depression and anxiety. Promotes sleep and improves insomnia with low reports of sexual dysfunction. It can also increase appetite, which is beneficial for individuals who are underweight.
Cons: Its strong sedation effect causes excessive tiredness. Some experience unwanted weight gain. Can, on rare occasions, cause changes in menstrual cycle, which is considered to be a severe side effect.
Possible common side effects: dry mouth, headache, sleepiness, nausea, vomiting, diarrhea, constipation

Vortioxetine (Trintellix)

Pros: An SSRI that also modulates serotonin receptors. It’s used to treat major depressive disorder and has been shown to be helpful with improving cognitive impairment associated with depression. Low reports of sexual dysfunction and weight gain.
Cons: It can be expensive compared to other antidepressants. Nausea is quite prevalent in the first two weeks of treatment.
Possible common side effects: nausea, constipation, vomiting, dizziness, dry mouth, diarrhea, headache

Next: Frustrated Your Antidepressants Aren’t Working? Here’s What You Need To Know