For many people, treating depression isn't as simple as popping a pill. For about half of people with depression, the first medication they try isn't the right fit. Even an antidepressant that works to relieve symptoms could cause unpleasant side effects like drowsiness, nausea, weight gain, or problems with your sex drive.
You might need to change drugs or change doses -- maybe more than once. Your doctor could have you try a combination of medications. If you're not already doing talk therapy, they may suggest you add it to the mix. Therapy and antidepressants work about equally well to relieve depression symptoms.
Your doctor needs to monitor this process closely. It takes time and patience. And patience isn't easy when you're still having depression symptoms or dealing with medication side effects. But it pays off when you and your doctor zero in on the treatment that's right for you.
How to Find the Right Antidepressant for You
Choosing an antidepressant is more nuanced than you might think.
"Everyone is unique," says Michelle Riba, MD, clinical professor of psychiatry at the University of Michigan. "Just picking a medication off the shelf won't do it. … You have to do a really good evaluation and medical examination and look at the medical history."
Before prescribing one, your doctor will ask a lot of questions. One might be what antidepressants you or other family members with depression have taken before, and how well they worked. The answer could predict how you'll respond to the same drug or drugs.
They'll also consider other medical and mental health conditions (bipolar disorder, PTSD, anxiety) you may have. For example, your doctor might avoid selective serotonin reuptake inhibitors (SSRIs) if you have a bleeding disorder. This type of antidepressant slightly increases your risk for bleeding.
"And if you've got bipolar disorder, you shouldn't take an antidepressant by itself," says Michael E. Thase, MD, chief of the Mood and Anxiety Section and professor of psychiatry at the Perelman School of Medicine of the University of Pennsylvania. "You'd want to take a mood stabilizer first."
Your doctor will also consider any other medications you're taking, to avoid interactions. If you're pregnant or breastfeeding, they'll avoid drugs that aren’t safe for you.
Learn as You Go
When you start on a new antidepressant, your doctor will check in at regular intervals to ask how you feel and whether you have any side effects. "You're learning as you're going," Thase says.
You may need to take a new drug for up to 6 weeks to give it enough time to work. Side effects often go away over time, too.
If your symptoms are a little better but still there, your doctor might bump up the dose. Or they might put you on a different antidepressant in the same class, to see if it's a better match.
But if a particular drug didn't help or caused annoying side effects, your doctor will likely switch you to a different type. Your response to the previous medication helps your doctor choose which one you get next. "If you had too many stomach side effects with an SSRI, your next choice of medicine would not be an SSRI," Thase says.
Sometimes, adding another type of medication to the antidepressant helps it work better. Another option is to add a newer antipsychotic drug to the mix. The upside is that the antipsychotics work quickly -- within a week or two. The downside is that they can cause more side effects than SSRIs or serotonin and norepinephrine reuptake inhibitors (SNRIs), Thase says.
Treating depression isn't much different than treating a medical condition like high blood pressure. Not only might you need to try different medications and dosages, you also may need to make changes to your lifestyle to see an improvement.
"With high blood pressure you have to change your diet, exercise, and stop eating salt. You try medication and you may have to increase or change it. It takes time," Riba says.
Research shows that these lifestyle changes may help people with depression:
Could a Genetic Test Match You to the Right Antidepressant?
Your genes offer important clues to help your doctor narrow down the search for the right antidepressant.
New genetic tests use a sample of DNA from your blood or saliva to predict how your body might respond to a certain type of drug. These tests can't tell you which antidepressant will definitely work for you. But they can give your doctor an idea of how your body processes certain drugs, or if a certain type of antidepressant might cause side effects for you.
But the tests can be expensive, costing up to $2,000. Some insurance companies will pay for genetic tests, but may want you to try a few antidepressants first. Most people don’t get this testing unless they're having trouble finding an effective treatment, Thase says.
Stick With It
You've got a 50-50 chance of finding the right antidepressant on the first try, Thase says. If that one doesn't work, there's about a 40% chance of getting it right the second time. Each time you switch to a new med, your odds of success drop slightly.
When you're dealing with depression symptoms even after getting treatment, you may be tempted to stop the medication completely. But there are benefits to sticking with it. About 9 out of 10 people who stay on their depression treatment for a year eventually do feel better, Thase says.
Each time a medication doesn't work, your doctor will dig into the reasons why.
"Sometimes there's a point at which you have to go back and ask, 'Is this the right diagnosis? Are we missing something?'" Riba says.
If your depression is stubborn, it may be time to rethink your treatment plan. Your doctor could try a different type of treatment, such as transcranial magnetic stimulation (TMS), electroconvulsive therapy (ECT), or ketamine.
In TMS, doctors use an electromagnet to stimulate nerve cells in certain areas of your brain. These regions of your brain are thought to have less activity when you have depression. Scientists aren't sure exactly how TMS works, but it can ease depression symptoms.
ECT is a procedure in which a doctor sends low-voltage electric currents through your brain, causing a brief seizure. This causes brain changes that relieve symptoms for some people. Ketamine is an anesthetic, once known as a club drug, that doctors can prescribe for treatment-resistant depression.
"The most important thing is to collaborate and be open and willing to learn from your experiences," Thase says. "Your chances of being on the good side of the 50-50 really do go up."
Once you get on the right medicine and dose, follow your doctor's directions for taking it. And stay on it for as long as your doctor recommends. Depression is a chronic condition, and it can come back if you stop treatment too soon.