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Treatments and drugs

By Mayo Clinic staff

Managing Depression

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Treatment for atypical depression is generally the same as for other types of depression. In some cases, a primary care doctor can prescribe medications to relieve symptoms. However, many people with atypical depression need to see a psychiatrist. Most people also benefit from seeing a psychologist or other mental health counselor. Usually the most effective treatment is a combination of medication and psychotherapy.

Atypical depression most often occurs as part of mild, long-lasting depression. However, it can cause more severe symptoms in some people, such as feeling suicidal or not being able to do basic day-to-day activities.

Here's a closer look at your treatment options.

Medications
Many types of medications are available to treat depression. They include:

  • Selective serotonin reuptake inhibitors (SSRIs). Doctors often start treatment by prescribing an SSRI. These medications are safer and generally cause fewer side effects than do other types of antidepressants. SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro). The most common side effects include decreased sexual desire and delayed orgasm. Other side effects may go away as your body adjusts to the medication. They can include digestive problems, jitteriness, restlessness, headache and insomnia.
  • Serotonin and norepinephrine reuptake inhibitors (SNRIs). These medications include duloxetine (Cymbalta), venlafaxine (Effexor XR) and desvenlafaxine (Pristiq). Side effects are similar to those caused by SSRIs. These medications can cause increased sweating, dry mouth, fast heart rate and constipation.
  • Norepinephrine and dopamine reuptake inhibitors (NDRIs). Bupropion (Wellbutrin) falls into this category. It's one of the few antidepressants that doesn't cause sexual side effects, and it usually doesn't cause weight gain. At high doses, bupropion may increase your risk of having seizures.
  • Atypical antidepressants. These medications don't fit neatly into another antidepressant category. They include trazodone and mirtazapine (Remeron). Both are sedating and usually taken in the evening. A newer medication called vilazodone (Viibryd) has a low risk of sexual side effects. The most common side effects of vilazodone are diarrhea, nausea, vomiting and insomnia.
  • Tricyclic antidepressants. Tricyclic antidepressants — such as imipramine (Tofranil) and nortriptyline (Pamelor) — tend to cause more severe side effects than newer antidepressants. So tricyclics generally aren't prescribed unless you've tried an SSRI first without improvement. Side effects may include low blood pressure, dry mouth, blurred vision, constipation, urinary retention, fast heartbeat, confusion or weight gain, among others.
  • Monoamine oxidase inhibitors (MAOIs). MAOIs — such as tranylcypromine (Parnate) and phenelzine (Nardil) — may be prescribed as a last resort, when other medications haven't worked, because they can have serious side effects. Use of MAOIs requires a strict diet because of dangerous (or even deadly) interactions with foods — such as certain cheeses, pickles and wines — and some medications including birth control pills, decongestants and certain herbal supplements. Selegiline (Emsam), a newer MAOI that you stick on your skin as a patch, may cause fewer side effects than other MAOIs. These medications can't be combined with SSRIs.
  • Other medications. Other medications may be added to an antidepressant to enhance antidepressant effects. Your doctor may recommend combining two antidepressants or medications, such as mood stabilizers or antipsychotics. Anti-anxiety and stimulant medications might also be added for short-term use. In addition, the FDA approved a medical food — a prescription that provides dietary management for a disease or condition — called Deplin, which contains L-methylfolate, a form of the vitamin folate. Studies have shown that adding Deplin to an antidepressant can be helpful, especially in women and those who can't process (metabolize) folate — a condition identified through a genetic test.

Finding the right medication
If a family member has responded well to an antidepressant, it may be one that could help you. You may need to try several medications before you find one that works. This requires patience, as some medications need eight weeks or longer to take full effect and for side effects to ease as your body adjusts.

If you're bothered by side effects, don't stop taking an antidepressant without talking to your doctor first. Some antidepressants can cause withdrawal symptoms unless you slowly taper off, and quitting abruptly may cause a sudden worsening of depression. Don't give up until you find a medication that's suitable for you.

If antidepressant treatment doesn't seem to be working, your doctor may recommend a blood test called the cytochrome P450 (CYP450) to check for specific genes that affect how your body processes antidepressants. This may help identify which antidepressant might be a good choice for you, although these genetic tests may not be widely available and they have limitations.

Antidepressants and pregnancy
If you're pregnant or breast-feeding, some antidepressants may pose an increased health risk to your unborn child or nursing child. Talk to your doctor if you become pregnant or are planning to become pregnant.

Antidepressants and increased suicide risk
Most antidepressants are generally safe, but the Food and Drug Administration (FDA) requires that all antidepressants carry "black box" warnings, the strictest warnings for prescriptions. In some cases, children, teenagers and young adults under 25 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed. So these age groups need close monitoring by loved ones, caregivers and health care providers. If you — or someone you know — have suicidal thoughts when taking an antidepressant, immediately contact your doctor or get emergency help.

Psychotherapy
Psychotherapy is a general term for treating depression by talking about your condition and related issues with a mental health provider. Psychotherapy is also known as talk therapy, counseling or psychosocial therapy.

Through these talk sessions, you can learn how to identify and make changes in unhealthy behavior or thoughts, explore relationships and experiences, find better ways to cope and solve problems, and set realistic goals for your life. Psychotherapy can help you regain a sense of satisfaction and control in your life and help ease depression symptoms such as hopelessness and anger.

Hospitalization and residential treatment programs
In some people, depression is so severe that a hospital stay is needed. Inpatient hospitalization may be necessary if you can't care for yourself properly or when you're in immediate danger of harming yourself or someone else. Psychiatric treatment at a hospital can help keep you calm and safe until your mood improves. Partial hospitalization or day treatment programs also are helpful for some people. These programs provide the support and counseling you need while you get symptoms under control.

Other treatments
Other options include:

  • Electroconvulsive therapy (ECT). In ECT, electrical currents are passed through the brain. This procedure is thought to affect levels of neurotransmitters in your brain and typically offers immediate relief of even severe depression when other treatments don't work. The most common side effect is confusion, which can last from a few minutes to several hours. Some people also have memory loss, which is usually temporary. ECT is usually used for people who don't get better with medications, can't take antidepressants for health reasons or are at high risk of suicide.
  • Transcranial magnetic stimulation (TMS). TMS may be an option for those who haven't responded to antidepressants. During TMS, you sit in a reclining chair with a treatment coil placed against your scalp. The coil sends brief magnetic pulses to stimulate nerve cells in your brain that are involved in mood regulation and depression. Typically, you'll have five treatments each week for up to six weeks.
  • Vagus nerve stimulation. This treatment uses electrical impulses with a surgically implanted pulse generator to affect mood centers of the brain. This may be an option if you have long-term, treatment-resistant depression.
Lifestyle and home remedies Tests and diagnosis
References
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DS01181 Sept. 20, 2012

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