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Understanding antidepressant selection

Written by Joseph F. Wegmann, RPh, LCSW

A man holding an antidepressant pill in his hand.

With medication management playing an increasingly pivotal role in the treatment of mental health disorders, the challenges faced by clinicians are increasing. For one, nonmedical clinicians provide the majority of mental health services in the United States. For another, the majority of prescriptions and orders for psychotropic medications are written not by psychiatrists, but by family practice and primary care physicians. As a result, you may be working with patients whose drug use is not being monitored or whose medication is not being used in combination with psychotherapy.

But before you can begin collaborating effectively with prescribing practitioners, there are a few things you need to know.

Important factors for clinicians to consider

How the depression presents
There are several subtypes of major depressive disorder, but none of them are reliable predictors of antidepressant response. Nevertheless, there needs to be a starting point for the selection process. For example: Is the client’s depression accompanied by anxiety and insomnia? Or is it characterized by melancholia, hypersomnia, and a vegetative state? If it’s the former, any of the SSRIs—with the likely exception of Prozac (fluoxetine), because of its energizing properties—would be acceptable choices. The latter type of depression would be better served by Prozac (fluoxetine) or the SNRIs Effexor (venlafaxine), Cymbalta (duloxetine), Pristiq (desvenlafaxine), or Wellbutrin (bupropion).

Personal and family history
Has the client had any previous experience with an antidepressant? If yes, what were the results? If the medication was discontinued, why? If it worked, try it again, unless the client’s clinical condition has changed enough to no longer warrant its use. Does the client’s history include a family member who was prescribed an antidepressant drug and responded to it favorably? If so, use this possible DNA connection to the client’s advantage by trying the same medication.

Drug characteristics
Prozac (fluoxetine) and Wellbutrin (bupropion) are examples of “energizing” antidepressants, whereas Paxil (paroxetine) and Celexa (citalopram) tend to be more sedating. Initial choices, therefore, should be predicated on how the depression presents (as outlined above). The point here is that one size does not fit all, and selection should not be based on what samples are in abundant supply or which pharmaceutical representative just visited.

Reasonable expectations
When anyone is started on an antidepressant, the person should be informed as to what to expect from the drug. Let them know that antidepressants may take several weeks to generate any consistent, noticeable mood improvement. They should be counseled to take the medication as prescribed for a defined period of time—say six months—before a reassessment.

Initial response
This one’s important. After the first swallow, and with some waxing and waning for at least a few days, there will be side effects. Side effects tend to annoy patients, so when they’re in a vulnerable state, it’s easy for them to give up. If you believe your client may be at risk for noncompliance or for stopping the medication altogether, some cheerleading may be necessary. The most critical phase of antidepressant management is the first 7 to 10 days of treatment. Encourage patients to stay with the drug, because many side effects will abate within a week of initiation. (But not all side effects—physiologically adverse events such as sexual dysfunction may persist for some time.)

Let the client choose
Initial antidepressant selection is solely within the prescriber’s domain, right? Not so fast. No one antidepressant—or antidepressant class—consistently outperforms another. So let the client choose their antidepressant based on acceptable side effects. (By “acceptable side effects,” I mean those the client is willing to put up with or tolerate.) Prepare your client for an antidepressant trial by focusing on the drug’s side effects, not its therapeutic effects. Then have them share their selections with their prescriber; they’re not likely to get much pushback unless there are threatening contraindications. Proceeding in this manner helps the client put side effects in perspective, which in turn tends to mitigate the annoyance of having to endure them in the first place. Also, getting the client involved in the selection process helps them believe they have skin in the game when it comes to what they’ll be taking. The result: Exercisable choices fuel empowerment, and empowerment fuels compliance. That’s a win-win.

Finally, finding the right antidepressant fit can be tedious. Users should enlist the support of trusted family, friends, and even colleagues for encouragement as needed.

Help empower your clients


Part of your role as a patient advocate and protector is to address the medication-assisted treatments in your overall care plan. The “Psychopharmacology Intensive Online Course: Everything the Non-Prescriber Needs to Know” is designed to help you learn the newest advances in blending medication management with psychotherapy interventions for ADHD, depression, anxiety, psychotic disorders, substance abuse, and more.

Designed for counselors, nurses, psychotherapists, psychologists, and other mental health professionals, this comprehensive online course will walk you step by step through the science of psychopharmacology. Don’t wait to get the knowledge you need to answer your clients’ questions, manage side effects, understand medication reactions, and improve your treatment outcomes.

Register for this on-demand course today.

Joseph Wegmann, RPh, LCSW, is a licensed clinical pharmacist and a clinical social worker with more than 30 years of experience in the field of psychopharmacology. He has served as clinical director of pharmacy services at a major metropolitan area hospital and as regional director of hospital services for Premier Healthcare Corporation. He has also served as an adjunct professor of psychopharmacology in the School of Social Work at Southern University at New Orleans for 16 years, and he maintains an active psychotherapy practice specializing in the treatment of depression and anxiety.

Learn more about Joseph Wegmann’s educational products, including upcoming live seminars.

About the publisher

For more than 40 years, nonprofit organization PESI, Inc., has provided cutting-edge continuing education to professionals across the nation. Working alongside the world’s leading experts, PESI educates and instructs the general public, public organizations, private industry, students, and professionals in acquiring, developing, and enhancing their knowledge and skills.

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