Table of Contents (hide)
- 1. Class Warfare
- 2. Reuptake Inhibitors
- 3. Monoanime Oxidase Inhibitors (MAOIs)
- 4. Tricyclic & Tetracyclic Antidepressants
- 5. Miscellaneous Antidepressants
- 6. Antidepressant Dosage Equivalents
- 7. Where do We Go from Here?
Like anticonvulsants (ACs) / antiepileptic drugs (AEDs) antidepressants (ADs) are broken up into different classes based upon things like their chemical structure and how they work in your brain. Unlike AEDs the classification of ADs is relatively simple and straightforward.
Antidepressants are all essentially classified by their pharmacodynamics, or what they do in your brain. Practically all drugs currently classified as (but not all drugs used as) antidepressants are based on the monoamine hypothesis (AKA the chemical imbalance theory) of depression1, or my new and improved the Communications Interference Hypothesis of psychiatric and neurological conditions.
Reuptake inhibitors keep your brain from recycling specific neurotransmitters as quickly as it otherwise would, so those neurotransmitters stay at specific receptors longer.2 Reuptake inhibitors currently on the market to treat depression are:
2.1 Serotonin-Selective Reuptake Inhibitors (SSRIs)
- Celexa / Cipramil (citalopram)
- Lexapro / Cipralex (escitalopram)
- Luvox / Floxyfral / Faverin (fluvoxamine)
- Paxil / Seroxat (paroxetine) & Pexeva (paroxetine mesylate)
- Prozac (fluoxetine)
- Zoloft / Lustral (sertraline)
2.2 Norepinephrine-Selective Reuptake Inhibitors (NSRIs)
We pretty much have a choice of two Norepinephrine-Selective Reuptake Inhibitors (NSRIs) (viloxazine isn’t available
in many places practically everywhere), and usually if one is available where you live, the other isn’t. Only recently has Strattera become available in countries - Canadia e.g. - where Edronax (reboxetine) was the only option.
Strattera doesn’t have FDA approval to treat depression, rather it’s approved to treat ADD/ADHD. But it looks and acts so much like reboxetine that it may as well be an antidepressant. See the NSRI page for more information about NSRIs as a class.
2.3 Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)
- Effexor (venlafaxine)
- Pristiq (desvenlafaxine)
- Cymbalta (duloxetine)
- Savella (milnacipran) - currently approved in the US to treat fibromyalgia, but not depression. Everywhere else in the world it’s an antidepressant that is sometimes approved as a treatment for fibro or other pain-related conditions as well.
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Monoanime Oxidase Inhibitors (MAOIs) are the original modern antidepressants, and usually the most effective. Being old and a real pain in the ass to take keeps them from being prescribed more often.
- Emsam (selegiline transdermal system)
- Eldepryl (selegiline)
- Aurorix / Manerix (moclobemide)
- Marplan (isocarboxazid)
- Nardil (phenelzine)
- Parnate (tranylcypromine)
See the MAOI page for more information about MAOIs as a class. There might be some useful information there one day.
4.1 Tricyclic Antidepressants (TCAs)
Tricyclic Antidepressants ( TCAs) Defined by their three-ring chemical structure, almost all TCAs work in pretty much the same way: norepinephrine reuptake inhibition, alpha-1, H1 and M1 antagonism, and sodium voltage channel blocking. Some also do serotonin reuptake inhibition and some are also 5HT2A and 5HT2C antagonists.
- Anafranil (clomimpramine)
- Elavil (amitriptyline)
- Asendin (amoxapine)
- Tofranil (imipramine)
- Tofranil-PM (imipramine pamoate)
- Pamelor (nortriptyline)
- Vivactil (protriptyline)
- Surmontil (trimipramine)
- dosulepin / dothiepin
Like Tricyclic ADs, Tetracyclic Antidepressants are defined by their four-ring chemical structure, and both classes are usually lumped together3. Unlike tricyclics, the tetracyclics don’t all work the same way. Remeron and mianserin are also classified as noradrenergic and specific serotonergic antidepressants (NaSSAs)
Some are alike, some are unique.
Symbyax may be recent, but they’ve been around for a long, long time.
- Etrafon/Triavil (amitriptyline HCl and perphenazine)
- Symbyax (olanzapine and fluoxetine HCl)
- Valdoxan (agomelatine)
- Stablon (tianeptine)
- Lovaza (omega-3-acid ethyl esters) - AKA prescription-strength omega-3 fish oil. Treating depression is an off-label application, and practically everyone buys decent fish oil from a supplements retailer.
- FDA-approved, or otherwise generally accepted, non-medication treatments for depression-spectrum disorders
- Electroconvulsive therapy (ECT)
- Repetitive Transcranial Magnetic Stimulation (rTMS)
- Vagal Nerve Stimulator (VNS)
- Cognitive Behavioral Therapy (CBT)
- Light Therapy.
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20mg Celexa (citalopram hydrobromide) = 10mg Lexapro (escitalopram oxalate) = 50mg Luvox (fluvoxamine maleate) = 10mg Paxil (paroxetine hydrochloride) = 20mg Prozac (fluoxetine hydrochloride) = 50mg Zoloft (sertraline hydrochloride) = 75mg Effexor (venlafaxine hydrochloride)
See the SSRI equivalencies section on the SSRI Poop-Out / Tachyphylaxis & Dosage Equivalents page for greater detail and how those numbers were reached.
You’d think this would be fairly easy to put together, as there are three essential components of a tricyclic antidepressant’s mechanism of action: norepinephrine and serotonin reuptake inhibition, and alpha-1 norepinephrine antagonism. They do more, but those are the main three for AD action. Turns out only three come close where raw potency is concerned - desipramine HCl, my dear friend protriptyline HCl, and nortriptyline HCl. So while 10mg of desipramine = 10mg of nortriptyline, protriptyline’s pharmacokinetics are so loopy that I wouldn’t put any money on 20mg of protriptyline being equivalent to two 10mg doses of protriptyline. Then we start getting into some meds being the active metabolites of others and a hell of a lot of other complexities.
In theory: possible. In practice: you don’t want to mess around with it, the risk of something seriously going wrong is too great.
For the history, further explanations, where it stands, and what the future of pharmacology based on the monoamine hypothesis is, see:
The Future of Depression Psychopharmacology
The molecular neurobiology of depression
Depression research: where are we now?
PATHOPHYSIOLOGY OF DEPRESSION: DO WE HAVE ANY SOLID EVIDENCE OF INTEREST TO CLINICIANS?
The monoamine hypothesis of depression (i.e. you’re messed up due to an imbalance of one or more of three of the best understood neurotransmitters: serotonin, norepinephrine, and/or dopamine) is hardly the only neurobiological hypothesis of brain cooties, it’s just the most well-established.
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2 It's actually way more complicated than that, but that's close enough for now.
3 We categorize any tetracyclic AD that works more-or-less like a TCA as a TCA. They have to do something really different, like Remeron, to not be classified as a TCA.
Classifications of Antidepressants by Jerod Poore is copyright © 2010 Jerod Poore
|Last modified on Friday, 08 May, 2015 at 11:29:11 by JerodPoore||Page Author: Jerod Poore||Date created: 21 November 2010|
All drug names are the trademarks of someone else. Look on the appropriate PI sheets or ask Google who the owners are. The way pharmaceutical companies buy each other and swap products like Monopoly™ real estate, the ownership of any trademarks may have changed without my noticing.
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Almost all of the material on this site is by Jerod Poore and is copyright © 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014, and 2015 Jerod Poore. Except, of course, the PI sheets - those are the property of the drug companies who developed the drugs the sheets are about - and any documents that are written by other people which may be posted to this site will remain the property of the original authors. You cannot reproduce this page or any other material on this site outside of the boundaries of fair use copying without the express permission of the copyright holder. That’s usually me, so just ask first. That means if want to print out a few pages to take to your doctor, therapist, counselor, support group, non-understanding family members or something like that - then that’s OK to just do. Go for it! Please. As long as you include this copyright notice and something along the lines of following disclaimer, I’m usually cool with it.
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1 While there are plenty of books to help you with hypochondria, for some reason there’s not much in the way of websites. Then again, staying off of the Internet is a large part of curing/managing the disorder.
2 Remember kids, Microsloth operating systems are like TOS Star Trek movies with in that every other one sucks way, way more. With TOS Star Trek movies you don’t want to bother watching the odd-numbered ones. With Microsloth OS you don’t want to buy and install the even-numbered ones. Anyone who remembers ME and Vista knows what I mean.
3 Have I mentioned how open source operating systems for commercial applications is one of the dumbest ideas in the history of dumb ideas?* I don’t even need my big-ass rant any more. Heartbleed has made my case for me. And that’s just the one that got all the media attention. The very nature of an open source operating system makes security as much of an illusion as anonymity on teh Intergoogles. Before you flip out too much: the domain Crazymeds is hosted on uses a version of SSL that is not affected by the Heartbleed bug. That’s one of the many reasons why I pay a lot of money and keep this site on Lunarpages.
* Yes, I know I’m using open source browsers. I also test the site using the now-defunct IE and Safari browsers. Their popularity - and superiority - killed IE and Safari, so that’s why I rely on the open source browsers. It’s like brand vs. generic meds. Sometimes the generic is better than the brand.