Medication Summary
The data are limited with regard to psychoactive medications and their use in the treatment of seasonal affective disorder. At the present time, the serotonin reuptake inhibitors (SSRIs) fluoxetine and sertraline have been the most studied and appear to be effective. [3]
According to the American Psychiatric Association, SAD (Major Depressive Disorder, with seasonal pattern) can be treated with the entire range of medication treatments available to treat Major Depressive Disorder. [18]
Of note, while bupropion XL is an established treatment for the prevention of SAD (and is FDA approved for this indication), the evidence for the treatment of SAD is more limited. [3]
Antidepressants, SSRIs
Class Summary
SSRIs potentiate the pharmacologic effects of serotonin (5-hydroxytryptamine [5-HT]) in the central nervous system (CNS).
Fluoxetine (Prozac, Prozac Weekly)
Fluoxetine is an antidepressant agent that is chemically unrelated to the tricyclic, tetracyclic, or other available antidepressants. It selectively inhibits presynaptic serotonin reuptake with minimal or no effect on the reuptake of norepinephrine or dopamine.
Paroxetine (Paxil, Paxil CR, Pexeva)
Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake. It also has a weak effect on norepinephrine and dopamine neuronal reuptake. For maintenance therapy, adjust the dosage to maintain the patient on the lowest effective dosage, and reassess the patient periodically to determine the need for continued treatment.
Sertraline (Zoloft)
Sertraline selectively inhibits presynaptic serotonin reuptake, with minimal or no effect on reuptake of norepinephrine or dopamine.
Citalopram (Celexa)
Citalopram is an SSRI used to treat depression. It is similar to fluoxetine, sertraline, and paroxetine. A highly selective reuptake inhibitor of serotonin, citalopram has little effect on other neurotransmitters.
Escitalopram (Lexapro)
Escitalopram is an SSRI and an S-enantiomer of citalopram. It is used for the treatment of depression. The drug’s mechanism of action is thought to be the potentiation of serotonergic activity in the CNS resulting from the inhibition of CNS neuronal reuptake of serotonin.
Antidepressants, SNRIs
Class Summary
The mixed serotonergic and noradrenergic drugs have effects on serotonin, norepinephrine, and, in some cases, dopamine and even on nicotinic acetylcholine systems. Because of the empirical nature of psychopharmacology, they may be used as first-line drugs or as follow-up agents when SSRIs fail.
Duloxetine (Cymbalta)
Duloxetine is a potent inhibitor of neuronal serotonin and norepinephrine reuptake. Its antidepressive action is theorized to be due to serotonergic and noradrenergic potentiation in the CNS.
Venlafaxine (Effexor XR)
Venlafaxine is structurally unrelated to other available antidepressants. It inhibits serotonin reuptake at select receptors, as well as the reuptake of norepinephrine.
Desvenlafaxine (Khedezla, Pristiq)
Desvenlafaxine is a strong and selective serotonin and norepinephrine reuptake inhibitor.
Levomilnacipran (Fetzima)
Active enantiomer of milnacipran. A strong inhibitor of norepinephrine and serotonin reuptake.
Antidepressants, Dopamine/Norepinephrine Reuptake Inhibitors
Class Summary
The mixed serotonergic and noradrenergic drugs have effects on serotonin, norepinephrine, and, in some cases, dopamine and even on nicotinic acetylcholine systems. They may be used as first-line drugs or as alternative agents when other antidepressants cause undesired side effects.
Bupropion (Aplenzin, Wellbutrin XL, Wellbutrin SR, Forfivo XL)
Bupropion inhibits neuronal dopamine reuptake, but it is also a weak blocker of serotonin and norepinephrine reuptake. A low incidence of sexual dysfunctions occurs with this medication.
Antidepressants, TCAs
Class Summary
TCAs are used when SSRIs are ineffective. They are structurally related to the phenothiazine antipsychotic agents and exhibit 3 major pharmacologic actions in varying degrees: amine pump inhibition, sedation, and anticholinergic action (peripheral and central). They inhibit reuptake of norepinephrine or serotonin at the presynaptic neuron.
Imipramine (Tofranil)
Imipramine inhibits the reuptake of norepinephrine or serotonin (5-hydroxytryptamine, 5-HT) in the central nervous system by inhibition of their reuptake by the presynaptic neuronal membrane.
Nortriptyline (Pamelor)
Nortriptyline works by inhibiting the reuptake of serotonin and/or norepinephrine by the presynaptic neuronal membrane, thus increasing the synaptic concentration of these neurotransmitters in the central nervous system (CNS). Pharmacodynamic effects such as the desensitization of adenyl cyclase and down-regulation of beta-adrenergic receptors and serotonin receptors also appear to play a role in its mechanisms of action.
Amitriptyline (Elavil)
Amitriptyline inhibits the reuptake of serotonin and/or norepinephrine at the presynaptic neuronal membrane, thus increasing the concentration of these neurotransmitters in the CNS.
Doxepin
Increases concentration of serotonin and norepinephrine in the CNS by inhibiting their reuptake by presynaptic neuronal membrane. Inhibits histamine and acetylcholine activity and has proven useful in treatment of various forms of depression associated with chronic pain.
Trimipramine (Surmontil)
Antidepressant effects may result from postsynaptic sensitization to serotonin.
Desipramine (Norpramin)
Desipramine my inhibit the reuptake of norepinephrine, and possibly, serotonin in the central nervous system, thereby increasing their synaptic concentration. May also desensitize adenyl cyclase, down regulate beta-adrenergic receptors, and down regulate serotonin receptors.
Protriptyline (Vivactil)
Protriptyline has efficacy for migraine prophylaxis that is independent of its antidepressant effect. It inhibits activity of such diverse agents as histamine, 5-HT, and acetylcholine.
Antidepressants, MAO Inhibitors
Class Summary
Their main advantages are a low risk of dependence and a lesser anticholinergic effect than is seen with TCAs. Their main disadvantage is the higher number of adverse effects, including sexual difficulty, hypotension, and weight gain. A diet low in tyramine must be followed to avoid a hypertensive crisis. Over-the-counter medications should be used with great caution.
Tranylcypromine (Parnate)
Tranylcypromine inhibits the enzyme monoamine oxidase, which is responsible for the breakdown of neurotransmitters, thereby increasing endogenous concentrations of epinephrine, norepinephrine, and serotonin.
Phenelzine (Nardil)
Phenelzine is the most commonly used MAOI for anxiety disorders. Phenelzine is usually reserved for patients who cannot tolerate or do not respond to TCAs or SSRIs. Inhibits the enzyme monoamine oxidase, which is responsible for the breakdown of neurotransmitters, thereby increasing endogenous concentrations of epinephrine, norepinephrine, and serotonin.
Isocarboxazid (Marplan)
Inhibits the enzyme monoamine oxidase, which is responsible for the breakdown of neurotransmitters, thereby increasing endogenous concentrations of epinephrine, norepinephrine, and serotonin.
Selegiline (Eldepryl, Zelapar, Emsam)
Selective inhibitor of MAO type B, which plays a major role in metabolism of dopamine. May also increase dopaminergic activity by interfering with dopamine reuptake at the synapse.
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VITAclock 200, a dawn simulator by Davita, at full brightness (in daylight) on left and at full brightness (in a darkened room) on right. Courtesy of Wikimedia Commons (https://commons.wikimedia.org/wiki/File:Davita_vitaclock_200.jpg and https://commons.wikimedia.org/wiki/File:Davita_vitaclock_200_night.jpg).
