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List of MDD Treatment Options | AD Topic Index | SSRIs and SNRIs

1.  Class Warfare

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.

2.  Reuptake Inhibitors

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)

Serotonin-Selective Reuptake Inhibitors (SSRIs) are by far the most popular ADs on the planet. The most prescribed, even if they aren’t necessarily the most effective. SSRIs include:

See the SSRI page for more information about SSRIs as a class.

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)

Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) are the antidepressants people love to hate. Usually more effective than SSRIs, but for some people they can be a nightmare to stop taking.

  • 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.

See the SNRI page for more information about SNRIs as a class.

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3.  Monoanime Oxidase Inhibitors (MAOIs)

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.  Tricyclic & Tetracyclic Antidepressants

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)
  • clomipramine
  • desipramine
  • doxepin
  • Tofranil (imipramine)
  • Tofranil-PM (imipramine pamoate)
  • Pamelor (nortriptyline)
  • Vivactil (protriptyline)
  • Surmontil (trimipramine)
  • dosulepin / dothiepin

4.2  Tetracyclic Antidepressants

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)

See the TCA page for more information about TCAs as a class.

5.  Miscellaneous Antidepressants

Some are alike, some are unique.

5.1  Other Multiple Reuptake Inhibitors

5.2  Serotonin Antagonist and Reuptake Inhibitors (SARIs)

5.3  Antidepressant and Antipsychotic combinations

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)

5.4  Everything else

  • 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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6.  Antidepressant Dosage Equivalents

Unlike most AEDs, you can substitute many ADs for another if you absolutely have to.

6.1  SSRI Equivalents

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.

6.2  SNRI Equivalences

75 mg Effexor (venlafaxine hydrochloride) = 50mg Pristiq (desvenlafaxine succinate) = 20mg of Cymbalta (duloxetine hydrochloride)

6.3  TCA Equivalences

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.

6.4  MAOI Equivalences

In theory: possible. In practice: you don’t want to mess around with it, the risk of something seriously going wrong is too great.

7.  Where do We Go from Here?

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?

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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List of MDD Treatment Options | AD Topic Index | SSRIs and SNRIs

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1 Put simply: you're depressed, anxious, or whatever because you don't have enough of, or may even have too much of, one or more of these monoamine neurotransmitters: serotonin, norepinephrine, dopamine, histamine, GABA, or melatonin. Usually the first three.

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 Monday, 18 April, 2016 at 00:16:22 by JerodPoorePage Author: Jerod PooreDate 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.

Page design and explanatory material by Jerod Poore, copyright © 2003 - 2016. All rights reserved.
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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, 2015, and 2016 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.

All rights reserved. No warranty is expressed or implied in this information. Consult one or more doctors and/or pharmacists before taking, or changing how you take any neurological and/or psychiatric medication. Your mileage may vary. What happened to us won’t necessarily happen to you. If you still have questions about a medication or condition that were not answered on any of the pages you read, please ask them on Crazy Talk: the Crazymeds Forum.
The information on Crazymeds pertains to and is intended for adults. While some information about children and adolescents is occasionally presented (e.g. US FDA approvals), pediatric-specific data such as dosages, side effects, off-label applications, etc. are rarely included in the articles on drugs or discussed on the forum. If you are looking for information regarding meds for children you’ll have to go somewhere else. Plus we are big pottymouths and talk about S-E-X a lot.
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All information on this site has been obtained from the medications’ product information / summary of product characteristic (PI/SPC) sheets and/or medication guides - which is all you get from sites like WebMD, RxList, NAMBLA NAMI, etc., the sources that are referenced throughout the site, our personal experience and the experiences family, friends, and what people have reported on various reputable sites all over teh intergoogles. As such the information presented here is not intended as a substitute for real medical advice from your real doctor, just a compliment to it. You should never, ever, replace what a real doctor tells you with something from a website on the Internet. The farthest you should ever take it is getting a second opinion from another real doctor. Educate yourself - always read the PI/SPC sheet or medication guide/patient information leaflet (PIL) that comes with your medications and never ever throw them away. OK, you can throw away duplicate copies, but keep at least one, as that’s your proof of purchase of having taken a med in case a doctor doubts your medical history. Plus they take up less space than a bottle, although keeping one inside of a pill bottle is even better.
Crazymeds is not responsible for the content of sites we provide links to. We like them, or they’re paid advertisements, or they’re something else we think you should read to help you make an informed decision about a particular med. Sometimes they’re more than one of those things. But what’s on those sites is their business, not ours.
Very little information about visitors to this site is collected or saved. From time to time I look at search terms used and which pages they bring up in an effort to make the information I present more relevant. And the country of origin, just because I’m geeky like that. That’s about it. Depending on how you feel about Schrodinger, our privacy policy should either assuage or exacerbate your paranoia.
Crazymeds is optimized for ridiculously large screens and browsers that don’t block ads. I use Firefox and Chrome, running under Windows 72. On a computer that sits on top of my desk. With a 23 inch monitor. Hey, at least you can make the text larger or smaller by clicking on the + or - buttons in the upper right hand corner. If you have Java enabled. Like 99% of the websites on the planet, Crazymeds is hosted on domain running an open source operating system with a variety of open source applications, including the software used to display what you’ve been reading. As such Crazymeds is not responsible for whatever weird shit your browser does or does not do when you read this site3.
Crazymeds now uses a secure server, but it is not so secure that you can discuss anything having to do with nuclear power facilities, air traffic control systems, aircraft navigation systems, weapons control systems, or any other system requiring failsafe operation whose failure could lead to injury, death or environmental damage. Just so you know. So if you’re mentally interesting and have a job that deals with that sort of thing, talk about said job elsewhere. Otherwise feel free to discuss your meds and brain cooties.
No neurologists, psychiatrists, therapists or pharmacists were harmed in the production of this website. Use only as directed. Void where prohibited. Contains nuts. Certain restrictions may apply. All data are subject to availability. Not available on all mobile devices, in the 12 Galaxies Guiltied to a Zegnatronic Rocket Society, or in all dimensions of reality. Hail Xenu!

‘Everything is true, nothing is permitted.’ - Jerod Poore

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.

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