My patient is a 25-year-old female with a first episode of depression. She presents with a depressed mood, unable to sleep at night, increased appetite with a 10-pound weight gain over the past two months, and she has no energy or interest in life anymore. She does not want to kill herself, but she wants to stop feeling so bad. How do I go about choosing an antidepressant for her?
SSRI’s are considered first line of treatment for most depressions. Generally, I choose an SSRI based on the side effects of each SSRI. Prozac is the only SSRI that is stimulating and decreases the need for sleep and can be associated with weight loss as it decreases appetite. Therefore it should be taken in the morning. It has the longest half-life of any SSRI and requires five weeks for complete elimination.
Zoloft and Celexa are considered sleep and weight neutral as they do not generally increase or decrease appetite or sleep. Though all SSRI’s can cause some initial gastrointestinal distress for the first 48 hours, Zoloft is probably the worst in this area. I therefore do not use it in someone with Irritable Bowel Syndrome, or other GI issues. Celexa is the most benign in terms of side effects, as long as the dose is 40mg or below. There is a black box warning against higher doses of Celexa due to QT prolongation risks at doses higher than 40mg. This is important in the event that my patient will need higher doses of SSRI’s. If their depression is severe, I would probably not start with Celexa for this reason.
Lexapro is the S-enantiomer of Celexa. It causes more sedation and weight gain than the other SSRI’s mentioned so far. It is helpful when my patients are having trouble sleeping or are losing weight due to a decrease in appetite from depression.
Luvox is an SSRI that is seldom used for depression, mainly due to its sedative properties. It is used more for OCD, though could be used for depression in patients with extreme difficulties with sleep.
Now, back to the patient… Given that she has symptoms of decreased sleep and increased appetite, we may not be able to target all her symptoms with one medication. Lexapro is sedating, which might make it a good choice with her decreased sleep, however it also increases appetite and since she has already gained 10 pounds we may not want to add to that weight gain. Celexa and Zoloft are both reasonable choices, and though they will not help her sleep immediately, as they begin to help her depression, her sleep should improve as well. Prozac is also a reasonable choice given her symptoms of increased appetite and decreased energy. However, her sleep may take more time to improve with Prozac. The way to get around this is to supplement the Prozac or Celexa or Zoloft with a sleep aid like Trazodone.