People don’t typically wake up one day and decide to start an antidepressant.
It usually comes after a long, debilitating period of feeling ‘off’ — you’re still coming to work and checking emails, but everything is denser and harder than it should be. Dinner is cereal. Laundry sits in the washer for two days. You can’t remember what you did last weekend.
Is this depression or a bad moment?
That’s a good question.
Antidepressants aren’t for everyone, every day or every situation. They’re not a magic pill for people who have ‘gone down’ — it’s about duration, damage and disability, and whether you feel like this is something you can’t recover from on your own.
When does a bad moment become depression?
Sadness has its ups and downs. You might feel depressed for a few days after your heart is broken, dumped, or gets laid off, but there’s still a sense of lightness, hope, or possibility that things will get better.
Depression is more diffuse and less reactive. Your usual coping mechanisms fail you, and sources of pleasure and productivity become inaccessible. You have no interest in seeing friends but feel incredibly lonely. You can’t stand being around your family. You eat too much and then nothing, or nothing and then too much. You sleep 12 hours a day and feel like garbage, or you can’t sleep at all at 3 a.m. and spend the whole night reliving your mistakes from 2009.
Some people are consistently tearful and melodramatic, others are emotionally constipated, others are more irritable, withdrawn, or detached.
If this has been going on for weeks and it’s affecting your work, relationships, or basic functioning, you should set up an evaluation. Our guide to all the symptoms of depression can help with that.
Physicians should also rule out other medical causes for depressive symptoms, including hormonal imbalances, anemia, sleep apnea, chronic pain, substance abuse, and certain medications.
What can you expect from an antidepressant?
They won’t make you happy. You won’t wake up one day after starting them and think, ‘Oh, this is nice.’
When they start working, the first effects are often incredibly dull. You shower. You answer your friend’s texts instead of ignoring them. You clean your kitchen before it becomes a crime scene. Mood lifts later, after sleep, appetite, and focus have begun to return.
The most common medications take several weeks to months to demonstrate noticeable effects, albeit with side effects that may appear right away. It’s incredibly frustrating to have the queasiness without the happiness — that’s why it’s important to go back to your doctor.
A return visit is also crucial if you’re considering psychotherapy as an alternative. Sometimes, depression is mild enough that it’s reasonable to start there first.
Cognitive behavioral therapy addresses distorted thought patterns that make depression persist, while other talk therapies can help you untangle depression from complicated grief, trauma, or difficult relationships.
On the other hand, if you have moderate to severe depression or it’s impacting your ability to work or enjoy life, therapy may be a good addition to antidepressants.
Medications and psychotherapy are not mutually exclusive. You may want to use both to get the most out of each, as therapy can be difficult to engage with when your brain is in anhedonic overdrive. Sleep, exercise, and sunlight help too, but you wouldn’t tell a lung cancer patient to ‘just exercise.’ Lifestyle changes are an important part of any treatment, but they don’t make other approaches irrelevant.
Choosing an antidepressant is more personal than you might think
When in doubt, your doctor will most likely start with an SSRI like sertraline, escitalopram, fluoxetine, or paroxetine.
They’re versatile, generally well-tolerated, and effective at treating a range of anxiety and mood disorders.
That doesn’t mean they’re all the same.
Suppose one patient is already sleeping too much and doesn’t need additional sedation, while another hasn’t been able to eat and would benefit from the antidepressant’s appetite stimulation. Another patient had a previous SSRI and couldn’t have sex for months after quitting. These are all valid considerations when choosing between medications.
Bupropion is much less likely to cause sexual dysfunction but can make some people feel restless or unable to sleep. It’s also not right for everyone or every depression. Our Wellbutrin guide goes more into depth on what it is and who might benefit from it.
Finding the right medication sometimes involves trial and error. This doesn’t mean psychiatry is voodoo — it means there’s no blood test available to tell you which one your brain will respond to best.
The side effects you actually want to know about
Nausea, headaches, diarrhea, dry mouth, sleepiness, and insomnia can come with antidepressants — usually early on and ease after a couple of weeks. Some people experience these for the entire time they’re on the medication, which can be a reason to switch.
Sexual dysfunction is much more common with serotonin-specific antidepressants, especially at higher doses. Libido can plummet, erections can be unreliable, and orgasms can be delayed or absent. People often hide this because they feel awful about it — if the antidepressant made them feel better, they’ll suffer in silence rather than complain about sex. Don’t do that. Sex is an important part of many people’s lives, and there are options to help with this.
Some patients also report emotional numbness as a side effect, in which they can’t feel happy or sad. You shouldn’t put up with that either. Depression isn’t supposed to make you emotionally dead; it’s supposed to make things feel heavier and harder to get through. A proper conversation with your doctor is necessary to address these concerns, because there are ways to help.
An important conversation before you start
Before you start antidepressants, your doctor should ask you if you’ve ever experienced manic episodes — periods of abnormally elevated mood, excessive talking, low need for sleep, racing thoughts, reckless spending, and impulsive decisions.
Depression and bipolar disorder often overlap, and antidepressants shouldn’t be prescribed to people with untreated bipolar disorder, as they can make it worse.
Age is another factor. Children, adolescents, and young adults are much more likely to experience an increase in suicidal thoughts or behaviors when they first start an antidepressant or when the dosage is adjusted.
This doesn’t happen to everyone, but it’s a serious risk that should be considered before starting treatment. If this occurs, new agitation or impulsive behaviors should be reported to a doctor immediately, as should any worsening of suicidal ideation.
Do I stop when I feel better?
You shouldn’t just stop, but many people find that continuing medication for a while after symptoms disappear prevents a relapse, especially if they’ve had multiple episodes. It can be discussed with your doctor when it’s a good time to wean yourself off the medication.
Abrupt discontinuation can cause unpleasant side effects like dizziness, nausea, vivid dreams, anxiety, irritability, and strange electrical sensations throughout the body. It can also bring on withdrawal symptoms specific to the medication you’re taking. Tapering helps your brain adjust to the gradual loss of the drug. It’s much safer than quitting cold turkey, and it’s another reason not to copy your friend’s quit timeline.
Depression and the Decision to Use an Antidepressant
If your life has shriveled up over the past several weeks and you can barely manage day-to-day tasks, you probably want to consider getting help. You could start with therapy and explore other options if that doesn’t work. You might find out you have a medical condition that needs to be treated instead. None of these are wrong, and all of them are good options.
If you’re thinking about suicide, have a plan, or don’t feel safe, your first priority should be to get emergency help. In the U.S., you can contact 988. International visitors can contact local emergency services or crisis lines.
