What you should know before switching antidepressants

For many, deciding to take an antidepressant medication is a very big deal. You spend a lot of time thinking about it, weighing the pros and cons, and talking to your healthcare provider about options, before deciding to try a prescription medication.

Finding the right antidepressant can require some trial and error, some fine-tuning. You may have to change medications at some point to find one that works well for you. If you’re concerned that your current prescription isn’t as effective as it should be, talk to your doctor about switching antidepressants.

RELATED: List of antidepressants

Common reasons for switching antidepressants

How do you know if you need to change your antidepressant? One of the most common reasons that people switch antidepressants is they feel their current medication isn’t really helping them. Antidepressants can be ineffective in a variety of ways.

1. Time

Antidepressants need time to reach their maximum effectiveness. The length of time can vary.

Six weeks can usually provide insight, one way or another, suggests Gonzalo Laje, MD, MHSc, director at Washington Behavioral Medicine Associates and clinical associate professor at George Washington University.

2. Dosage

If an antidepressant isn’t working after approximately six weeks, it could be that the dose is too low. Consult your healthcare provider, who can slowly and carefully increase the dose. If you’re not feeling better when taking a higher (or even the maximum) dose, it might be time to discuss trying something else—or adding another medication.  

3. Side effects

Not everyone experiences side effects, and some people are willing to tolerate certain side effects from medication if it’s helping their depression. But for other people, side effects like a low libido, dry mouth, or nausea are deal breakers. If you’re struggling to cope with the side effects—it may be time to schedule an appointment with your healthcare provider.  

Don’t try stopping or changing medications on your own. You might experience some withdrawal symptoms, especially if you stop abruptly. “It’s always better to talk to your doctor about (making) these changes,” Dr. Laje says. Withdrawal symptoms of antidepressants typically include:

• Anxiety
• Trouble sleeping
• “Head buzzing”
• Headaches
• Dizziness
• Fatigue
• Flu-like symptoms
• Nausea
• Irritability

Choosing a new antidepressant that is best for you

Then the question becomes: What is the best medication to switch to? There are many potential choices from these categories of antidepressants: 

• Selective serotonin reuptake inhibitors (SSRIs): This category includes commonly prescribed medications like Prozac (fluoxetine), Celexa (citalopram), Lexapro (escitalopram), Paxil (paroxetine), Zoloft (sertraline), and Viibryd (vilazodone).
• Serotonin and norepinephrine reuptake inhibitors (SNRIs): This category includes Effexor XR (venlafaxine), Pristiq (desvenlafaxine), Cymbalta (duloxetine), and Fetzima (levomilnacipran).
• Tricyclic antidepressants (TCAs): TCAs are an older category of antidepressant with more side effects than newer antidepressants. This class includes drugs such as Tofranil (imipramine), Elavil (amitriptyline), Pamelor (nortriptyline), and Norpramin (desipramine).
• Monoamine oxidase inhibitors (MAOIs): MAOIs are another older category of medication not used as first-line treatments anymore, and include Nardil (phenelzine),  and Parnate (tranylcypromine)
• Other antidepressants: This category includes medications that may not fit precisely into another category, such as Wellbutrin (bupropion), which is a norepinephrine-dopamine reuptake inhibitor (NDRI), and Desyrel (trazodone), which is known as a serotonin antagonist and reuptake inhibitor (SARI).

All antidepressants come with benefits and downsides, so it may become a question of what works well for you. “We usually go for something that has the least amount of side effects in general,” says psychiatrist Samuel Mowerman, MD, faculty member at the University of Miami Miller School of Medicine.

According to Dr. Mowerman, the features of your particular kind of depression will also affect the choice. For example, if you also live with anxiety, your doctor might recommend an antidepressant with a success rate for addressing anxiety, too.

Your doctor may choose to switch you from one category of antidepressant to another. Or your doctor might suggest that you stick with a medication from the same category of drug that you’ve been taking. For example, if you’re already taking one SSRI, your doctor might suggest trying another one, like switching from Prozac to Zoloft or switching from Lexapro to Zoloft.

How to switch antidepressants

When you do make the switch, there are several possible processes for doing it:

• Cross tapering: You decrease the original medication dose while starting the new medication at a low dose and gradually increasing it.
• Direct switch: This could involve stopping the old drug and then starting the new one on the following day.
• Taper down and stop, before starting the new drug: You gradually decrease the amount of your original antidepressant, then start taking the new medication immediately after stopping the original medication.
• Taper, washout, and switch. You gradually decrease the amount of your original antidepressant, then stop taking it altogether. Your healthcare provider will advise a “washout period” of days or weeks to wait before starting the new medication.

“MAOIs and tricyclics are two classes of antidepressants that should be tapered off first with time for the blood levels to go to zero before starting a new antidepressant,” Dr. Israel says.

More about cross-tapering

Cross-tapering is a standard approach in many cases, says psychiatrist Lindsay Israel, MD, chief medical officer at Success TMS. For example, it’s often used when you switch an SSRI to a drug in another class. Why? Because it takes time for the original medication to leave your system, just as it takes a while for the new medication to take effect. 

A cross-taper allows you to gradually ramp up the new med while slowly decreasing the original one, which should help to minimize any symptoms of what Israel calls “discontinuation syndrome” due to any overlap, especially if the medications have similar properties, says Dr. Israel.

Common symptoms of discontinuation syndrome include fatigue, nausea, insomnia, vertigo, dizziness, and fogginess.

How long does it take to adjust to a new antidepressant?

It depends in part on the dosage you have been taking. A higher dose may take a little longer. “Depending on the half-life of the medications in question and the current dosage, this cross taper can take anywhere from one week to four-to-six weeks,” Dr. Israel says.

Side effects of switching antidepressants

As previously mentioned, you may experience symptoms of withdrawal or discontinuation syndrome. 

It’s also important to note symptoms of serotonin syndrome, which is a life-threatening condition that can happen when you take more than one antidepressant medication (or more than one medication, antidepressant or other) that affects serotonin levels. Serotonin syndrome requires emergency medical attention. Symptoms of serotonin syndrome include:

• Mood changes, agitation, or anxiety
• Restlessness
• Confusion
• Muscle changes, such as lack of coordination, stiffness, rigidity, or muscle jerks (especially in the legs)
• Sweating, shivering, flushed skin, fever, or hyperthermia
• Increased heart rate or blood pressure
• Nausea, vomiting, diarrhea
• Tremor
• Hyperactive reflexes
• Dilated pupils

You should also be aware of the side effects to expect from your new antidepressant, as they may differ from those of the original antidepressant. Ask your healthcare provider or pharmacist for a complete list of side effects associated with the new medication.

Are antidepressants worth switching?

Ultimately, the goal of switching antidepressants is to find a medication that works for you.

Dr. Mowerman’s advice: “Give it time.” Let the new medication work, he adds. It may take some time to ramp up to the dose that’s most effective for you, or to find the right medication. Don’t give up if you don’t feel great right away or have to try a few prescriptions. 

And don’t be afraid to speak up. If you have any questions or concerns about side effects, be sure to ask. For example, don’t be embarrassed to raise any concerns about the effect of an antidepressant on your sex drive, Dr. Mowerman says. They’re real, and valid concerns.