Literary Review

Depression is a disease that affects 9.5% of Americans every year, making it a problem of great importance in the United States. There are many ways to treat depression without medication; however, I chose to examine the two most widely used types of medication. TCAs (tricyclic antidepressants) and SSRIs (selective serotonin reuptake inhibitors) are both antidepressants that work by inhibiting the reuptake of serotonin. Margaret Stone says "Serotonin is a neurotransmitter in the brain that is directly correlated with regulating moods" (Stone, 2010, 1). They both sound okay in theory, however, the controversy arises when choosing which type of medication is the most appropriate to use. Most psychiatrists feel very strongly one way or the other. Some claim that TCAs are more effective in treatment, but have worse side effects (Perry, 1996, 4). While others claim that SSRIs are a huge advancement in treatment and should always be chosen over TCAs (Ferguson, 2001, 1). I believe that for the time being, SSRIs should be prescribed, but we should continue to work towards a medicine without side effects.

James Ferguson, a psychiatrist from Stanford University, is very much in favor of SSRIs. He said "Because of their overall efficacy, safety, and tolerability, they have become widely prescribed by primary care physicians" (Ferguson, 2001, 1). He emphasizes that sexual dysfunction is the biggest problem related to SSRIs, with up to 75% of users experiencing problems (Ferguson, 2001, 1). However, by conducting post-marketing clinical trials he concluded that while SSRIs do have side effects, they can usually be reduced by decreasing dosages. Originally SSRIs were thought to have no side effects, however, with more research that was found to be false. One of Ferguson's research studies proved their side effects were originally thought to be lesser because SSRIs were not prescribed in very high doses when they first were introduced. Now, after being studied for many years, we see that they do in fact have side effects, but patients taking the medicine are reporting fewer side effects than those taking TCAs (Ferguson, 2001, 1).

Paul J. Perry, a psychiatrist from the University of Iowa, is very much in favor of TCAs. The use of tricyclic antidepressants began in the late 1950s. They were the first attempt in regulating chemicals in the brain thought to be associated with depression. In the past years, many scientists claimed that TCAs are hardly ever prescribed anymore. However In 1996, a mere ten years after the new SSRI drugs were introduced, a study proved that the majority of prescriptions for depression were in fact still for TCAs (Perry, 1996, 1). In response, Perry said that people who think that TCAs are nearly nonexistent are "overly naïve" (Perry, 1996, 1). Before formulating an opinion he reviewed many professional studies like the Hamilton Depression Rating. By using this data from controlled trials, Perry concluded that TCAs are consistently more effective than the SSRIs. Every doctor interested in this issue must take a stand on what is more important to them, efficacy, or the patient's comfort. He proceeds to list symptoms of TCA, paying no regard to their extremity, implying that it is more important for the medicine to be effective than for the patient to be comfortable while taking it.

William Schaefer, a Biology professor at the University of California, spent most of his article discussing the side effects of TCAs. He talks about how TCAs are extremely strong inhibitors, allowing for their extreme side effects. People taking TCAs complain of: weight gain, dry mouth, constipation, drowsiness, and dizziness (Schaefer, 1999, 1). He stresses that people who experience these extreme side effects are likely to stop taking the medicine. On the other hand, in the article "Are SSRIs Better than TCAs? Comparison of SSRIs and TCAs: A Meta-analysis" we hear about the side effects of SSRIs. The authors talk about how people taking SSRIs frequently complain of gastrointestinal problems and sexual dysfunction. They came to this conclusion by analyzing data from "Medline" (Steffens, Krishnan, Helms, 1997, 1). They located 36 clinical trials of TCAs and SSRIs in a double-blind comparison and performed a meta-analysis on the data they found. They found that 30% of people treated with TCAs and 24.7% of people treated with SSRIs dropped out of treatment because of the adverse side effects. They very much emphasized this as a huge difference in percentages. They strongly advocate for the trial of SSRIs as the first option.

The question of TCAs vs. SSRIs is one I predict we will battle for a long time. Many doctors are certain that TCAs work much better, therefore the side effects will just have to be tolerated. However, other doctors believe that the ultimate concern is the comfort of the patient and that they will never stay on the medication if they are uncomfortable. My opinion lies with those in favor of lessening the side effects. I have been on medication before with terrible side effects and it made me just stop taking the medicine all together. I never went back to the doctor to get another prescription; I just decided that dealing with the original problem would be better than dealing with the side effects and making another appointment. In conclusion, I think that since SSRIs have been proven to have lesser side effects, we should continue to prescribe them and discontinue the prescription of TCAs. However, I do think that our ultimate goal should be to continue to work towards a medicine that provides both efficacy and comfort.

How Do SSRIs and