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Health Guide / Depression

Depression: symptoms, causes, diagnosis, and treatment

chimene richaTzvi Doron

Reviewed by Chimene Richa, MD, written by Tzvi Doron, DO

Last updated: May 25, 2021
14 min read

table of contents

  1. What is depression?
  2. Signs and symptoms of depression
  3. Types of depression
  4. Risk factors for depression
  5. Health risks of depression
  6. Treatments for depression
  7. Treatment-resistant depression
  8. Get the help you need

Disclaimer

If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.

Depression not only robs people of years of their lives but also severely decreases their quality of life. Many people will experience at least one depressive episode at some point in their lives. Depression is still one of the most overlooked causes of death and suffering in the U.S. 

It’s important to understand the far-reaching negative impacts of depression. Even if you’re not struggling with this illness, chances are, someone you know is grappling with this silent killer. They just haven’t told you about it.

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What is depression?

Most people would describe depression as feelings of sadness or loss. But it is more than just feeling “down.” Depression is a mental health condition that affects many Americans. In 2019, the Centers for Disease Control and Prevention (CDC) reported that 18.5% of adults had symptoms of depression in the previous two weeks (Villarroel, 2019).

The harmful effects of depression extend to all facets of people’s lives, including their personal life and work environments. Depression is even a major cause of lost work productivity due to chronic absenteeism and even “presenteeism.” Presenteeism is when you’re technically at your desk, but you’re either too sick or too out of it to get much done (Rost, 2014). 

It’s important to note the distinction between feeling sad and clinical depression. People with depression aren’t just having a bad day or even a tough week. When you’re going through a depressive episode, it changes everything about your life. Depression disrupts your sleep patterns, diet, social interactions, energy levels, motivation, and thoughts of self-worth. 

Depression isn’t something you can “power through”—nor should you. It’s important to reach out and get help, so a depressive episode doesn’t spiral out of control. It’s also essential to recognize signs or symptoms of depression in your friends and family because people who are depressed often don’t reach out for help. Nearly 60% of people with depression do not seek medical help—and the consequences can be deadly (Chand, 2020-a).

Signs and symptoms of depression

The Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) defines major depressive disorder (MDD) as “two or more weeks of 5 of the following symptoms that cause problems with social, occupational, or other areas of functioning” (at least one of the first two is necessary) (Chand, 2020-a):

  • Depressed mood
  • Decreased interest or pleasure in doing things
  • Weight loss or weight gain, or increased or decreased appetite
  • Insomnia or sleeping too much
  • Moving slowly, or being fidgety or restless
  • Fatigue or loss of energy
  • Feelings of excessive guilt, worthlessness, or low self-esteem
  • Difficulty concentrating or making decisions
  • Recurrent thoughts of death or suicide

If you have experienced any of these symptoms, know that you are not alone—in a 2019 study, the CDC found that nearly 20% of American adults experienced some symptoms of depression within the previous two weeks (Villarroel, 2019).

It’s important to note that having one or two symptoms of depression is normal. Don’t panic if you recognize some of these criteria in your own life. It’s even normal to have several symptoms for a day or two. That doesn’t make you depressed. It makes you a human being. You’re allowed to experience a full range of emotions—even the bad ones.

It’s also common for people to go through similar feelings after a major loss, such as losing a loved one or losing your job. These don’t qualify as depression either—unless those feelings last for longer than the expected amount of time. Other types of depression differ by the cause and the degree/duration of symptoms.

Types of depression

Depression is a mood disorder that can be divided into different types, including (NIMH, 2018): 

  • Major depressive disorder (MDD)
  • Persistent depressive disorder (dysthymia)
  • Postpartum depression
  • Seasonal affective disorder
  • Psychotic depression

Major depressive disorder (MDD) 

Major depressive disorder is the one that most people think of when they talk about depression. As mentioned above, MDD is a clinical diagnosis that requires five or more symptoms to be present for two weeks or longer. 

Persistent depressive disorder

Persistent depressive disorder (also called dysthymia) is a depressed mood that lasts for at least two years —it used to be called chronic depression.

This is not a well-understood form of depression and has only been recently recognized as a mood disorder rather than a personality disorder. Approximately 3% of American adults have persistent depressive disorder.

You can have persistent depressive disorder and major depression, but the symptoms have to last for at least two years to be considered persistent depressive disorder (Patel 2020).

Postpartum depression

Postpartum depression (PPD) is often confused with the “baby blues,” but it is a more serious condition. Baby blues are mild depression and/or anxiety symptoms that usually resolve within a few weeks after giving birth—many women experience these feelings. Still, they go away on their own (Mughal, 2020). 

Postpartum depression is a type of major depression that doesn’t improve after delivery. The feelings of anxiety, sadness, loss of interest and energy, and suicidal thoughts in some cases may make getting through the day and taking care of themselves and their babies difficult.

Around one in seven women develop postpartum depression, and as many as half don’t tell their families about their struggles (Mughal, 2020).  

Seasonal affective disorder

Many people feel down, gloomy, or lethargic during the darker days of winter—some call this feeling the “winter blues.” However, if these depressed feelings start to affect your ability to do normal activities, like sleep and social interactions, you may have seasonal affective disorder (SAD).

Seasonal affective disorder is an episodic depression that affects people when there is less natural sunlight, i.e., during the winter months. Your mood improves in the spring and summer, and treatment often involves light therapy, in addition to other options (Munir, 2021).  

Psychotic depression

If someone has a form of psychosis plus depression, it is considered psychotic depression.

Psychotic episodes usually involve seeing or hearing something that is not there (hallucinations) or having fixed false beliefs (delusions). People with psychotic depression usually have depressive symptoms, like feelings of worthlessness or guilt, along with their psychosis (Rothschild, 2020).

Risk factors for depression

Several genetic and environmental factors seem to increase the likelihood that you develop depression, including (Chand, 2020-a):

  • A family history of a first-degree relative (a parent, sibling, or child) with depression 
  • Certain medical conditions, like Alzheimer’s disease, Parkinson’s disease, stroke, multiple sclerosis, thyroid disease, and chronic pain 
  • Traumatic life events or history of trauma
  • Drug abuse

Triggers for depression

As mentioned earlier, it is expected that people will go through some of the symptoms of depression after a major loss or traumatic life event. However, depression becomes a medical condition when these feelings last too long or prevent you from functioning. 

Triggers for the development of depression include a lack or loss of social support, caregiver burden, personal conflicts, financial or employment problems, among others. 

Health risks of depression

While suicide is the worst result of depression, depressive episodes can harm you in several other ways.

For example, insomnia alone contributes to all types of health risks, like diabetes, hormone imbalance, and hypertension (which can lead to heart attacks and stroke). Clinical depression is a risk factor for many illnesses and even all-cause mortality (death from any cause).

Depression and heart disease, diabetes, and stroke

Depression can increase your risk of high blood pressure, heart disease, and heart attacks—this includes an increased risk of fatal heart attacks (Charlson, 2013). Even worse, if you’ve already had a heart attack, depression increases the risk of actually dying from the next one (Lichtman, 2014). 

Similarly, depressed people with diabetes face an increased risk of cardiovascular disease and an almost 50% increased risk of dying from all causes (Dooren, 2013). Depression is also associated with a higher risk of stroke and death from stroke and a higher risk of heart failure (Pan, 2011; Freedland, 2011). 

It’s important to note that while depression is associated with higher risks for heart disease, stroke, and heart failure, we don’t know if it’s a risk factor or simply a risk marker (it’s associated with the diseases, but it’s not the cause). Either way, depressive episodes are bad for your health, especially if you’re at risk for stroke, heart disease, or diabetes.

Depression and cancer

There may be a small increased risk of cancer in people with depression, but more studies are needed to support this association (Jia, 2017). Depression may also increase the risk of dying in those who already have cancer (Wang, 2020). 

Again, it’s not clear whether depression itself is the cause of this increased mortality or simply a marker for it. For example, it’s completely plausible that people struggling with cancer are more likely to be depressed—especially as their illness progresses.

Depression and dementia

The part of the brain associated with memory shrinks in people with depression. Both early- and late-life depression are associated with an increased risk of various types of dementia, including the most common type of dementia—Alzheimer’s disease (da Silva, 2013). 

However, it’s not clear why people with depression have higher rates of dementia. Some theories include the toxic effects of cortisol on parts of the brain, like the hippocampus. The hippocampus is involved with memory and actually gets smaller in people with depression.

At the same time, inflammation in different parts of the brain and a decrease in neurotrophins (chemicals that keep the brain healthy) are other likely culprits for this loss of brain function (Rakesh, 2017).

Depression and mortality

While heart disease is the leading cause of death in the United States, depression is responsible for damaging thousands of lives and ending many of those lives prematurely. Clinical depression is a silent killer, and it’s reaching epidemic levels in the U.S.

The most direct way that depression kills is suicide. Suicide is the tenth most common cause of death in the U.S. and the second most common cause of death in 15 to 34-year-olds. That’s more than twice the number of homicides.

In addition, while women are more likely to attempt suicide than men, men are almost four times as likely to die of suicide. And suicide rates have been climbing over the last two decades (NIMH, 2021). Depression is the number one cause of suicide (Olfson, 2016).

But it’s not just suicide affecting mortality. An extensive Journal of American Medicine analysis of over 2,000 studies showed that depression (and other mental disorders) increases your risk of mortality from any cause—in other words, people with depression don’t live as long, on average. In fact, the study found that depression shortened life expectancy across the board by ten years (Walker, 2015). 

Treatments for depression

Although we don’t know for sure whether depression itself is the cause of increased mortality in all of these patient populations, we know it’s an important risk factor.

Thankfully, there are effective treatments available to decrease the suffering caused by this disease and perhaps lower the risks of depression’s interaction with the other diseases discussed.

Rule out medical causes

If you or a loved one have depression, see a healthcare provider. Your health professional can rule out medical causes of depression like hypothyroidism, vitamin B12 deficiency, low testosterone, and other complications and side effects of medications. If a potential medical cause is found, it’s important to treat the cause before starting depression-specific treatment.

Unfortunately, depression isn’t often caused by the straightforward medical issues listed above. If your depression doesn’t have a diagnosable medical cause, the two mainstays for treating depression are medication and psychotherapy.

Antidepressant medications

The most common antidepressant medications are selective serotonin reuptake inhibitors (SSRIs), which include drugs like fluoxetine (brand name Prozac; see Important Safety Information), sertraline (brand name Zoloft; see Important Safety Information), and escitalopram (brand name Lexapro; see Important Safety Information), to name a few.

Serotonin-norepinephrine reuptake inhibitors (SNRIs) are also popular, including drugs like venlafaxine (brand name Effexor; see Important Safety Information), duloxetine (brand name Cymbalta; see Important Safety Information), and desvenlafaxine (brand name Pristiq) (Rush, 2020). 

Talk to your healthcare provider about potential interactions and side effects before beginning treatment with these drugs. Not everyone reacts favorably to each prescription, so work with your healthcare provider to find the right medication for you.

Psychotherapy

Psychotherapy is another important part of managing depression. Research shows that antidepressants and cognitive behavioral therapy (CBT) are equally effective, but you may achieve long-term benefits from CBT (Boschloo, 2019; Rush, 2020).

However, using CBT and medication together may be better than either treatment alone (Chand, 2020-b). CBT treats depression by encouraging people to replace harmful thoughts with more positive ones. 

CBT is the most well-researched form of psychotherapy for depression. What’s more, there’s a growing body of research around the potential of mindfulness-based cognitive therapy (MBCT) for treating depression.

MBCT and CBT are akin to meditation therapy. They combine mindfulness practices aimed at experiencing the present moment with breathing exercises and awareness (Hofmann, 2017).

Treating depression with diet and exercise

What’s good for your physical health is also good for your mental health. So it should come as no surprise that increased physical activity can help relieve depression (Schuch, 2019). 

Similarly, a healthy diet may also decrease the health risks of depression. In some studies, researchers have found that the Mediterranean diet (olive oil, “good” fatty foods, nuts, fruits, and legumes) is associated with a lower rate of depression (Parletta, 2019). 

Other factors that may impact the risk for depression include poor sleep, lack of social interaction, and excessive use of alcohol and tobacco. But it’s worth noting that a healthy diet and regular exercise can have a positive effect on depression.

Treatment-resistant depression

One challenge of depression is that it’s a moving target and highly personalized. Unfortunately, some people don’t respond to multiple treatments for their depression, a condition called treatment-resistant depression (Akil, 2018).

If you have other mental health issues, like anxiety disorders, bipolar disorder, substance use, etc., you may be at higher risk for having treatment-resistant depression. But that doesn’t mean you should give up after the first failed attempt (Thase, 2020). 

Many people respond to variations in treatment and even a combination of medication, therapy, and lifestyle changes. There are even several non-conventional treatments available for people who don’t respond to the more standard options (Thase, 2020).

Electroconvulsive therapy

Probably the oldest alternative treatment method for depression is electroconvulsive therapy (ECT) (Salik, 2020). Unfortunately, most people have only seen ECT in the context of old horror films, but it’s an effective and safe treatment.

ECT works by placing electrodes on specific parts of the scalp and applying enough current to produce a seizure that affects neurons and chemicals in the brain.

It sounds grizzly, but the procedure is done under general anesthesia (people are asleep during the procedure) and has been upgraded significantly since it first came into practice in the 1930s. ECT is more effective than medication and is generally safe, but its main undesirable side effect is short-term memory loss (Salik, 2020).

A leading theory for how ECT works is that it increases the growth of neurons and the connections between neurons through increasing levels of brain-derived neurotrophic factor (BDNF). People who receive ECT can still struggle with depression.

However, electroconvulsive therapy is very effective at abruptly stopping an episode of depression and may be very useful in severely depressed and acutely suicidal people. Most people undergo 4–6 treatments before they see major improvement (Salik, 2020).

Repetitive transcranial magnetic stimulation

Although ECT is very effective, it does have a few downsides, including the need for general anesthesia and short-term memory loss.

These shortcomings, along with the public opinion of ECT, have led to developing other ways to stimulate the brain to produce an antidepressant effect. The most popular method of alternative brain stimulation is repetitive transcranial magnetic stimulation (rTMS) (Downar, 2016).

This treatment uses magnets to stimulate certain areas of the brain instead of an electric current. The method is different from ECT, but the goal is the same—neural growth and connection.

rTMS has been found to be somewhat effective for treatment-resistant depression, but it’s still not as effective as ECT (Micallef-Trigona, 2014). Therefore, for acutely suicidal hospitalized patients, ECT is usually the route that is taken when medication isn’t effective, or patients want faster results.

Ketamine treatment

Ketamine is another really interesting option for treatment-resistant depression. Generally used in the hospital for anesthesia, smaller doses of ketamine appear to have rapid antidepressant effects—especially in suicidal patients. 

The downside is that the antidepressant effects of ketamine aren’t permanent. The other problem is that ketamine is a drug that’s often sold illegally and routinely abused. It’s extremely important that you get ketamine treatment for depression from an experienced healthcare provider if you decide to explore this option (Corriger, 2019).

Get the help you need

Depression not only robs people of years of their lives but also severely decreases quality of life.

Many people will experience at least one major depressive episode at some point in their lives. However, there are numerous things you can do to decrease your risk of developing clinical depression—like eating a healthy diet, exercising, getting regular checkups, and cultivating active relationships with friends and loved ones.

Many conventional and alternative treatments exist for depression. If you or a loved one are experiencing depression, help is out there. You don’t have to suffer in silence, and depression doesn’t have to end your life early.

Suicide Prevention Lifeline

Anxiety and Depression Association of America: List of Support Groups by Region

References

  1. Akil, H., Gordon, J., Hen, R., Javitch, J., Mayberg, H., McEwen, B., et al. (2018). Treatment resistant depression: a multi-scale, systems biology approach. Neuroscience and Biobehavioral Reviews, 84, 272–288. doi:10.1016/j.neubiorev.2017.08.019. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28859997/
  2. Bains N, Abdijadid S. (2020). Major depressive disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK559078/
  3. Boschloo, L., Bekhuis, E., Weitz, E. S., Reijnders, M., DeRubeis, R. J., Dimidjian, S., et al. (2019). The symptom-specific efficacy of antidepressant medication vs. cognitive behavioral therapy in the treatment of depression: results from an individual patient data meta-analysis. World Psychiatry:Official Journal of the World Psychiatric Association (WPA), 18(2), 183–191. doi:10.1002/wps.20630. Retrieved from https://pubmed.ncbi.nlm.nih.gov/31059603/
  4. Chand SP, Arif H. (2020-a). Depression. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430847/
  5. Chand SP, Kuckel DP, Huecker MR. (2020-b). Cognitive behavior therapy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK470241/
  6. Charlson, F. J., Moran, A. E., Freedman, G., Norman, R. E., Stapelberg, N. J., Baxter, A. J., et al. (2013). The contribution of major depression to the global burden of ischemic heart disease: a comparative risk assessment. BMC Medicine, 11(1). doi: 10.1186/1741-7015-11-250. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4222499/
  7. Corriger, A., & Pickering, G. (2019). Ketamine and depression: a narrative review. Drug Design, Development and Therapy, 13, 3051–3067. doi: 10.2147/DDDT.S221437. Retrieved from https://pubmed.ncbi.nlm.nih.gov/31695324/
  8. da Silva, J., Gonçalves-Pereira, M., Xavier, M., & Mukaetova-Ladinska, E. (2013). Affective disorders and risk of developing dementia: Systematic review. British Journal of Psychiatry, 202(3), 177-186. doi: 10.1192/bjp.bp.111.101931. Retrieved from https://pubmed.ncbi.nlm.nih.gov/23457181/
  9. Dooren, F. E. P. V., Nefs, G., Schram, M. T., Verhey, F. R. J., Denollet, J., & Pouwer, F. (2013). Depression and risk of mortality in people with diabetes mellitus: a systematic review and meta-analysis. PLoS ONE, 8(3). doi: 10.1371/journal.pone.0057058. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3589463/
  10. Downar, J., Blumberger, D. M., & Daskalakis, Z. J. (2016). Repetitive transcranial magnetic stimulation: an emerging treatment for medication-resistant depression. Canadian Medical Association Journal, 188(16), 1175–1177. doi: 10.1503/cmaj.151316. Retrieved from https://pubmed.ncbi.nlm.nih.gov/27551033/
  11. Freedland, K. E., Carney, R. M., & Rich, M. W. (2011). Effect of depression on prognosis in heart failure. Heart Failure Clinics, 7(1), 11–21. doi: 10.1016/j.hfc.2010.08.003. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3032411/
  12. Hofmann, Stefan G, and Angelina F Gómez. (2017). Mindfulness-based interventions for anxiety and depression. The Psychiatric Clinics of North America, vol. 40,4: 739-749. doi: 10.1016/j.psc.2017.08.008. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5679245/
  13. Jia, Y., Li, F., Liu, Y. F., Zhao, J. P., Leng, M. M., & Chen, L. (2017). Depression and cancer risk: a systematic review and meta-analysis. Public Health, 149, 138–148. doi: 10.1016/j.puhe.2017.04.026. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28641155/
  14. Lichtman, J. H., Froelicher, E. S., Blumenthal, J. A., Carney, R. M., Doering, L. V., Frasure-Smith, N., et al. (2014). Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations. Circulation, 129(12), 1350–1369. doi: 10.1161/cir.0000000000000019. Retrieved from https://pubmed.ncbi.nlm.nih.gov/24566200/
  15. Micallef-Trigona, B. (2014). Comparing the effects of repetitive transcranial magnetic stimulation and electroconvulsive therapy in the treatment of depression: a systematic review and meta-analysis. Depression Research and Treatment, 2014, 1–8. doi: 10.1155/2014/135049. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4131106/
  16. Mughal S, Azhar Y, Siddiqui W. (2020). Postpartum depression. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK519070/
  17. Munir S, Abbas M. (2021). Seasonal depressive disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK568745/
  18. National Institute of Mental Health (NIMH). (2018). Depression. Retrieved on May 18, 2021 from https://www.nimh.nih.gov/health/topics/depression
  19. National Institute of Mental Health (NIMH). (2021). Suicide. Retrieved on May 18, 2021 from https://www.nimh.nih.gov/health/statistics/suicide
  20. Olfson, M., Wall, M., Wang, S., Crystal, S., Liu, S.-M., Gerhard, T., et al. (2016). Short-term suicide risk after psychiatric hospital discharge. JAMA Psychiatry, 73(11), 1119. doi: 10.1001/jamapsychiatry.2016.2035. Retrieved from https://pubmed.ncbi.nlm.nih.gov/27654151/
  21. Pan, A., Sun, Q., Okereke, O. I., Rexrode, K. M., & Hu, F. B. (2011). Depression and risk of stroke morbidity and mortality. JAMA, 306(11), 1241. doi: 10.1001/jama.2011.1282. Retrieved from https://pubmed.ncbi.nlm.nih.gov/21934057/
  22. Parletta, N., Zarnowiecki, D., Cho, J., Wilson, A., Bogomolova, S., Villani, A., et al. (2019). A Mediterranean-style dietary intervention supplemented with fish oil improves diet quality and mental health in people with depression: A randomized controlled trial (HELFIMED). Nutritional Neuroscience, 22(7), 474–487. doi:10.1080/1028415X.2017.1411320. Retrieved from https://pubmed.ncbi.nlm.nih.gov/29215971/
  23. Patel RK, Rose GM. (2020). Persistent depressive disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK541052/
  24. Rakesh, G., Szabo, S. T., Alexopoulos, G. S., & Zannas, A. S. (2017). Strategies for dementia prevention: latest evidence and implications. Therapeutic Advances in Chronic Disease, 8(8-9), 121–136. doi: 10.1177/2040622317712442. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5546647/
  25. Rost, K. M., Meng, H., & Xu, S. (2014). Work productivity loss from depression: evidence from an employer survey. BMC Health Services Research, 14, 597. doi: 10.1186/s12913-014-0597-y. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4307989/
  26. Rothschild, A.J. (2020). Unipolar major depression with psychotic features: Epidemiology, clinical features, assessment, and diagnosis. In UptoDate. Roy-Byrne, P.P. and Solomon, D. (Eds.). Retrieved from https://www.uptodate.com/contents/unipolar-major-depression-with-psychotic-features-epidemiology-clinical-features-assessment-and-diagnosis
  27. Rush, J.A. (2020). Unipolar major depression in adults: choosing initial treatment. In UptoDate. Roy-Byrne, P.P & Solomon, D. (Eds.). Retrieved from https://www.uptodate.com/contents/unipolar-major-depression-in-adults-choosing-initial-treatment
  28. Salik I, Marwaha R. (2020). Electroconvulsive therapy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK538266/
  29. Schuch, F. B., & Stubbs, B. (2019). The role of exercise in preventing and treating depression. Current Sports Medicine Reports, 18(8), 299–304. doi: 10.1249/JSR.0000000000000620. Retrieved from https://pubmed.ncbi.nlm.nih.gov/31389872/
  30. Thase, M. and Connoly, K.R. (2020). Unipolar treatment resistant depression in adults: epidemiology, risk factors, assessment, and prognosis. In UptoDate. Roy-Byrne, P.P. and Solomon, D. (Eds.). Retrieved from https://www.uptodate.com/contents/unipolar-treatment-resistant-depression-in-adults-epidemiology-risk-factors-assessment-and-prognosis
  31. Villarroel MA, Terlizzi EP. (2019) Symptoms of depression among adults: United States. NCHS Data Brief, no 379. Hyattsville, MD: National Center for Health Statistics. 2020. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db379.htm
  32. Walker, E. R., McGee, R. E., & Druss, B. G. (2015). Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA psychiatry, 72(4), 334–341. doi: 10.1001/jamapsychiatry.2014.2502. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4461039/
  33. Wang, Y. H., Li, J. Q., Shi, J. F., Que, J. Y., Liu, J. J., Lappin, et al. (2020). Depression and anxiety in relation to cancer incidence and mortality: a systematic review and meta-analysis of cohort studies. Molecular Psychiatry, 25(7), 1487–1499. doi: 10.1038/s41380-019-0595-x. Retrieved from https://pubmed.ncbi.nlm.nih.gov/31745237/
chimene richa
Chimene Richa, MD

Dr. Chimene Richa is a board-certified Ophthalmologist and Senior Medical Writer/Reviewer at Ro.

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Important Safety Information for Fluoxetine

Warning: Suicidal Thoughts and Behaviors

Suicide is a known risk of depression and certain other psychiatric disorders, and these disorders themselves are the strongest predictors of suicide. In short-term studies, antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults under age 24. These studies did not show an increase in the risk of suicidal thoughts and behavior with antidepressant use in patients over age 24; there was a reduction in risk in patients 65 and older.

Patients of all ages being treated with antidepressants should be observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially early during antidepressant treatment and when the dose is adjusted up or down. Families and caregivers of patients should look for the emergence of symptoms on a day-to-day basis, since changes may be abrupt.

Call your healthcare provider right away or 911 in an an emergency if you observe any of the following behaviors, especially if they are new, worse, unusual, or worry you: emergence of suicidality, worsening of depression, emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, inability to sit still or restlessness, racing thoughts that you can’t fully control, or becoming easily distracted.

What is the FDA-approved use of fluoxetine?

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used for acute and maintenance treatment of Major Depressive Disorder (MDD).

Who should not use fluoxetine?

Do not use fluoxetine if:

  • You are taking a class of medications called monoamine oxidase inhibitors (MAOIs). Examples of MAOIs include isocarboxazid (Marplan), phenelzine (Nardil), selegiline (Emsam), and tranylcypromine (Parnate), linezolid, or intravenous methylene blue. MAOIs may increase the risk of serotonin syndrome.
  • You are taking a medication called pimozide or thioridazine. Taking these medications with fluoxetine can increase the risk of prolonged QT interval, which is a potentially dangerous change to the electrical signals that make your heart beat.

How should I take fluoxetine?

You can take fluoxetine with or without food. 

You should take fluoxetine exactly as prescribed, and continue to take fluoxetine as prescribed even after your symptoms improve. You should not change your dosing regimen or stop taking fluoxetine without discussing with your provider first. A gradual reduction in dosage rather than abruptly stopping is recommended whenever possible.

If your symptoms are not improving or you have any questions about changing or stopping medication, reach out to your Ro-affiliated provider for guidance.

What should I tell my Ro-affiliated provider before using fluoxetine?

  • Fluoxetine has many drug interactions. It’s important to tell your Ro-affiliated provider all of the medications you are currently taking, including prescription, over-the-counter medications, vitamins, and herbal and dietary supplements. Some medications to watch out for include:
    • Monoamine oxidase inhibitors (MAOIs), including the antibiotic linezolid (Zyvox) and intravenous methylene blue (rare)
    • NSAIDs, such as ibuprofen or naproxen
    • Aspirin
    • Blood thinners, such as warfarin (Coumadin)
    • Migraine medications called triptans, such as sumatriptan (Imitrex)
    • Benzodiazepines, such as diazepam and alprazolam
    • Other or SSRIs or SNRIs, such as sertraline (Zoloft)
    • Tamoxifen
    • St. John’s Wort
  • It’s important to share your entire medical history with your provider. In particular, tell your provider if you have a past history of:
    • Suicidal thoughts or attempted suicide
    • Family history of Bipolar Disorder or family history of suicide
    • Seizures
    • Irregular heartbeat or heart issues
    • Bipolar Disorder
    • Glaucoma or eye problems
    • Diabetes
  • Tell your provider if you are pregnant, planning to become pregnant, or breastfeeding. SSRI use, particularly later in pregnancy, may increase risk of complications in the newborn. You should discuss with your provider if fluoxetine should be used during pregnancy. There have been reports of fluoxetine passing into breast milk. Talk to your provider about the best way to feed your baby while taking fluoxetine.

Withholding or providing inaccurate information about your health and medical history in order to obtain treatment may result in harm, including, in some cases, death.

What are the most serious side effects that I or a caregiver should monitor for when taking fluoxetine?

If you are experiencing a medical emergency, call 911 or seek immediate medical attention.

These serious side effects are rare, but can occur with fluoxetine. You or a caregiver should carefully monitor for these side effects, especially in the beginning of treatment and with dose changes.

  • Serotonin Syndrome: Serotonin syndrome is an uncommon, potentially life-threatening condition that occurs when taking too much of an SSRI or SNRI at once or when fluoxetine is taken along with other drugs that increase the activity of serotonin in the central nervous system. These medications may include MAOIs, triptans (a class of drugs used to treat migraines), tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, and St. John’s Wort. Monitor for symptoms of elevated body temperature, flushing, sweating, abdominal pain, diarrhea, agitation, and a racing heartbeat.
  • Allergic Reactions and Rash: Tell your provider if you develop a rash or hives. Discontinue use of fluoxetine and seek emergency care immediately if you have a severe allergic reaction. Signs and symptoms of a severe allergic reaction include swelling of the face, eyes, or mouth, or having trouble breathing. 
  • Activation of Mania/Hypomania: Especially at the beginning of treatment, monitor for changes in behavior such as an unusually elevated mood, feeling unusually irritable, a big increase in energy, being more talkative than usual, racing thoughts, or engaging in risky behaviors. These changes in behavior could be signs of undiagnosed Bipolar Disorder.
  • Abnormal Bleeding: Tell your provider if you experience any increased or unusual bruising, bleeding, or nose bleed. Fluoxetine may increase the risk of bleeding when taken with NSAIDs (such as ibuprofen or naproxen), aspirin, or blood thinners such as warfarin (Coumadin).
  • QT Prolongation: Tell your provider right away if you experience fast, slow, or irregular heart rate, shortness of breath, fainting, or dizziness, which may indicate serious cardiac arrhythmia.
  • Cognitive and Motor Impairment: Fluoxetine may impair judgment, thinking, and motor skills. Avoid driving a car or operating hazardous machinery until you know that your performance is not affected. Do not drink alcohol while you take fluoxetine.
  • Eye Effects: In rare instances, antidepressants may cause a certain type of eye problem called acute angle-closure glaucoma. Monitor for eye pain, changes in your vision, or swelling or redness in or around the eye.
  • Low Sodium in the Blood (Hyponatremia): Elderly people may be at greater risk for this condition. Symptoms may include headache, weakness or feeling unsteady, confusion, problems concentrating or thinking, and memory problems.

What are the most common side effects of fluoxetine?

  • Nausea, diarrhea
  • Lack of appetite, weight loss
  • Dry mouth
  • Headache
  • Sexual problems, including decreased sex drive, erectile dysfunction, or trouble ejaculating
  • Change in sleep habits, including insomnia or increased sleepiness
  • Nervousness, anxiety
  • Lack of energy, or feeling generally weak
  • Tremor
  • Sweating

You are encouraged to report negative side effects of prescription products to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

This information is not comprehensive. Please see the full Prescribing Information for complete safety information. 

Important Safety Information for Sertraline

Warning: Suicidal Thoughts and Behaviors

Suicide is a known risk of depression and certain other psychiatric disorders, and these disorders themselves are the strongest predictors of suicide. In short-term studies, antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults under age 24. These studies did not show an increase in the risk of suicidal thoughts and behavior with antidepressant use in patients over age 24; there was a reduction in risk in patients 65 and older.

Patients of all ages being treated with antidepressants should be observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially early during antidepressant treatment and when the dose is adjusted up or down. Families and caregivers of patients should look for the emergence of symptoms on a day-to-day basis, since changes may be abrupt.

Call your healthcare provider right away or 911 in an an emergency if you observe any of the following behaviors, especially if they are new, worse, unusual, or worry you: emergence of suicidality, worsening of depression, emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, inability to sit still or restlessness, racing thoughts that you can’t fully control, or becoming easily distracted. 

What is the FDA-approved use of sertraline?

Sertraline is a selective serotonin reuptake inhibitor (SSRI) indicated for the treatment of Major Depressive Disorder (MDD).

Who should not use sertraline?

Do not use sertraline if:

  • You are taking a class of medications called monoamine oxidase inhibitors (MAOIs). Examples of MAOIs include isocarboxazid (Marplan), phenelzine (Nardil), selegiline (Emsam), and tranylcypromine (Parnate), linezolid, or intravenous methylene blue. MAOIs may increase the risk of serotonin syndrome.
  • You are taking a medication called pimozide. Taking this medication with sertraline can increase the risk of prolonged QT interval, which is a potentially dangerous change to the electrical signals that make your heart beat.
  • You have a known allergic reaction to sertraline.

How should I take sertraline?

You can take sertraline with or without food. 

You should take sertraline exactly as prescribed, and continue to take sertraline as prescribed even after your symptoms improve. You should not change your dosing regimen or stop taking sertraline without discussing with your provider first. A gradual reduction in dosage rather than abruptly stopping is recommended whenever possible.

If your symptoms are not improving or you have any questions about changing or stopping medication, reach out to your Ro-affiliated provider for guidance.

What should I tell my Ro-affiliated provider before using sertraline?

  • Sertraline has many drug interactions. It’s important to tell your Ro-affiliated provider all of the medications you are currently taking, including prescription, over-the-counter medications, vitamins, and herbal and dietary supplements. Some medications to watch out for include:
    • Monoamine oxidase inhibitors (MAOIs), including the antibiotic linezolid (Zyvox) and intravenous methylene blue (rare)
    • NSAIDs, such as ibuprofen or naproxen
    • Aspirin
    • Blood thinners, such as warfarin (Coumadin)
    • Migraine medications called triptans, such as sumatriptan (Imitrex)
    • Other SSRIs or SNRIs, such as fluoxetine (Prozac)
    • St. John’s Wort
  • It’s important to share your entire medical history with your provider. In particular, tell your provider if you have a past history of:
    • Suicidal thoughts or attempted suicide
    • Bipolar Disorder
    • Family history of Bipolar Disorder or family history of suicide
    • Liver problems
    • Irregular heartbeat or heart problems
    • Stroke
    • High blood pressure
    • Seizures
    • Glaucoma or eye problems
  • Tell your provider if you are pregnant, planning to become pregnant, or breastfeeding. SSRI use, particularly later in pregnancy, may increase risk of complications in the newborn. You should discuss with your provider if sertraline should be used during pregnancy or while breastfeeding.

Withholding or providing inaccurate information about your health and medical history in order to obtain treatment may result in harm, including, in some cases, death.

What are the most serious side effects that I or a caregiver should monitor for when taking sertraline?

If you are experiencing a medical emergency, call 911 or seek immediate medical attention.

These serious side effects are rare, but can occur with sertraline. You or a caregiver should carefully monitor for these side effects, especially in the beginning of treatment and with dose changes.

  • Serotonin Syndrome: Serotonin syndrome is an uncommon, potentially life-threatening condition that occurs when taking too much of an SSRI or SNRI at once or when sertraline is taken along with other drugs that increase the activity of serotonin in the central nervous system. These medications may include MAOIs, triptans (a class of drugs used to treat migraines), tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, and St. John’s Wort. Monitor for symptoms of elevated body temperature, flushing, sweating, abdominal pain, diarrhea, agitation, and a racing heartbeat.
  • Increased risk of bleeding: Tell your provider if you experience any increased or unusual bruising, bleeding, or nose bleed. Sertraline may increase the risk of bleeding when taken with NSAIDs (such as ibuprofen or naproxen), aspirin, or blood thinners such as warfarin (Coumadin).
  • Activation of Mania/Hypomania: Especially at the beginning of treatment, monitor for changes in behavior such as an unusually elevated mood, feeling unusually irritable, a big increase in energy, being more talkative than usual, racing thoughts, or engaging in risky behaviors. These changes in behavior could be signs of undiagnosed Bipolar Disorder.
  • Eye Effects: In rare instances, antidepressants may cause a certain type of eye problem called acute angle-closure glaucoma. Monitor for eye pain, changes in your vision, or swelling or redness in or around the eye.
  • Low Sodium in the Blood (Hyponatremia): Elderly people may be at greater risk for this condition. Symptoms may include headache, weakness or feeling unsteady, confusion, problems concentrating or thinking, and memory problems.
  • QT Prolongation: Tell your provider right away if you experience fast, slow, or irregular heart rate, shortness of breath, fainting, or dizziness, which may indicate serious cardiac arrhythmia.
  • Cognitive and Motor Impairment: Fluoxetine may impair judgment, thinking, and motor skills. Avoid driving a car or operating hazardous machinery until you know that your performance is not affected. Do not drink alcohol while you take sertraline.

What are the most common side effects of sertraline?

  • Nausea, loss of appetite, diarrhea, or indigestion
  • Increased sweating
  • Tremor or shaking
  • Agitation
  • Change in sleep habits including increased sleepiness or insomnia
  • Sexual problems including abnormal ejaculation, erectile dysfunction, or decreased sex drive
  • Feeling tired or fatigued
  • Anxiety

You are encouraged to report negative side effects of prescription products to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

This information is not comprehensive. Please see the full Prescribing Information for complete safety information. 

Important Safety Information for Escitalopram

Warning: Suicidal Thoughts and Behaviors

Suicide is a known risk of depression and certain other psychiatric disorders, and these disorders themselves are the strongest predictors of suicide. In short-term studies, antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults under age 24. These studies did not show an increase in the risk of suicidal thoughts and behavior with antidepressant use in patients over age 24; there was a reduction in risk in patients 65 and older.

Patients of all ages being treated with antidepressants should be observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially early during antidepressant treatment and when the dose is adjusted up or down. Families and caregivers of patients should look for the emergence of symptoms on a day-to-day basis, since changes may be abrupt.

Call your healthcare provider right away or 911 in an an emergency if you observe any of the following behaviors, especially if they are new, worse, unusual, or worry you: emergence of suicidality, worsening of depression, emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, inability to sit still or restlessness, racing thoughts that you can’t fully control, or becoming easily distracted.

What are the FDA-approved uses of escitalopram?

Escitalopram is a selective serotonin reuptake inhibitor (SSRI) used for:

  • Acute and Maintenance Treatment of Major Depressive Disorder (MDD) 
  • Acute Treatment of Generalized Anxiety Disorder (GAD)

Who should not use escitalopram?

Do not use escitalopram if:

  • You are taking a class of medications called monoamine oxidase inhibitors (MAOIs). Examples of MAOIs include isocarboxazid (Marplan), phenelzine (Nardil), selegiline (Emsam), and tranylcypromine (Parnate), linezolid, or intravenous methylene blue. MAOIs may increase the risk of serotonin syndrome.
  • You are taking a medication called pimozide. Taking this medication with escitalopram can increase the risk of prolonged QT interval, which is a potentially dangerous change to the electrical signals that make your heart beat.
  • You have a known allergic reaction to escitalopram.

How should I take escitalopram?

You can take escitalopram with or without food.

You should take escitalopram exactly as prescribed, and continue to take escitalopram as prescribed even after your symptoms improve. You should not change your dosing regimen or stop taking escitalopram without discussing with your provider first. A gradual reduction in dosage rather than abruptly stopping is recommended whenever possible.

If your symptoms are not improving or you have any questions about changing or stopping medication, reach out to your Ro-affiliated provider for guidance.

What should I tell my Ro-affiliated provider before using escitalopram?

  • Escitalopram has many drug interactions. It’s important to tell your Ro-affiliated provider all of the medications you are currently taking, including prescription, over-the-counter medications, vitamins, and herbal and dietary supplements. Some medications to watch out for include:
    • Monoamine oxidase inhibitors (MAOIs), including the antibiotic linezolid (Zyvox) and intravenous methylene blue (rare)
    • NSAIDs, such as ibuprofen or naproxen
    • Aspirin
    • Blood thinners, such as warfarin (Coumadin)
    • Migraine medications called triptans, such as sumatriptan (Imitrex)
    • Other antidepressants, including SSRIs or SNRIs such as sertraline (Zoloft) or citalopram (Celexa)
    • St. John’s Wort
  • It’s important to share your entire medical history with your provider. In particular, tell your provider if you have a past history of:
    • Suicidal thoughts or attempted suicide
    • Bipolar Disorder
    • Family history of Bipolar Disorder or family history of suicide
    • Seizures
    • Heart problems
    • Glaucoma or eye problems
    • Liver problems
  • Tell your provider if you are pregnant, planning to become pregnant, or breastfeeding. SSRI use, particularly later in pregnancy, may increase risk of complications in the newborn. You should discuss with your provider if escitalopram should be used during pregnancy. There have been reports of escitalopram passing into breast milk. Talk to your provider about the best way to feed your baby while taking escitalopram.

Withholding or providing inaccurate information about your health and medical history in order to obtain treatment may result in harm, including, in some cases, death.

What are the most serious side effects that I or a caregiver should monitor for when taking escitalopram?

If you are experiencing a medical emergency, call 911 or seek immediate medical attention.

These serious side effects are rare, but can occur with escitalopram. You or a caregiver should carefully monitor for these side effects, especially in the beginning of treatment and with dose changes.

  • Serotonin Syndrome: Serotonin syndrome is an uncommon, potentially life-threatening condition that occurs when taking too much of an SSRI or SNRI at once or when escitalopram is taken along with other drugs that increase the activity of serotonin in the central nervous system. These medications may include MAOIs, triptans (a class of drugs used to treat migraines), tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, and St. John’s Wort. Monitor for symptoms of elevated body temperature, flushing, sweating, abdominal pain, diarrhea, agitation, and a racing heartbeat.
  • Activation of Mania/Hypomania: Especially at the beginning of treatment, monitor for changes in behavior such as an unusually elevated mood, feeling unusually irritable, a big increase in energy, being more talkative than usual, racing thoughts, or engaging in risky behaviors. These changes in behavior could be signs of undiagnosed Bipolar Disorder.
  • Low Sodium in the Blood (Hyponatremia): Elderly people may be at greater risk for this condition. Symptoms may include headache, weakness or feeling unsteady, confusion, problems concentrating or thinking, and memory problems.
  • Abnormal Bleeding: Tell your provider if you experience any increased or unusual bruising, bleeding, or nose bleed. Escitalopram may increase the risk of bleeding when taken with NSAIDs (such as ibuprofen or naproxen), aspirin, or blood thinners such as warfarin (Coumadin).
  • Cognitive and Motor Impairment: escitalopram may impair judgment, thinking, and motor skills. Avoid driving a car or operating hazardous machinery until you know that your performance is not affected. Do not drink alcohol while taking escitalopram.
  • Eye Effects: In rare instances, antidepressants may cause a certain type of eye problem called acute angle-closure glaucoma. Monitor for eye pain, changes in your vision, or swelling or redness in or around the eye.

What are the most common side effects of escitalopram?

  • Insomnia
  • Nausea, diarrhea
  • Increased sweating
  • Fatigue and drowsiness
  • Difficulty sleeping, insomnia
  • Headache
  • Decreased libido
  • Difficulty reaching orgasm, or abnormal ejaculation

You are encouraged to report negative side effects of prescription products to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

This information is not comprehensive. Please see the full Prescribing Information for complete safety information.

Important Safety Information for Venlafaxine Extended-Release

Warning: Suicidal Thoughts and Behaviors

Suicide is a known risk of depression and certain other psychiatric disorders, and these disorders themselves are the strongest predictors of suicide. In short-term studies, antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults under age 24. These studies did not show an increase in the risk of suicidal thoughts and behavior with antidepressant use in patients over age 24; there was a reduction in risk in patients 65 and older.

Patients of all ages being treated with antidepressants should be observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially early during antidepressant treatment and when the dose is adjusted up or down. Families and caregivers of patients should look for the emergence of symptoms on a day-to-day basis, since changes may be abrupt.

Call your healthcare provider right away or 911 in an an emergency if you observe any of the following behaviors, especially if they are new, worse, unusual, or worry you: emergence of suicidality, worsening of depression, emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, inability to sit still or restlessness, racing thoughts that you can’t fully control, or becoming easily distracted.

What are the FDA-approved uses of venlafaxine extended-release?

Venlafaxine extended-release is a serotonin and norepinephrine reuptake inhibitor (SNRI) for the treatment of:

  • Major Depressive Disorder (MDD)
  • Generalized Anxiety Disorder (GAD)

Who should not use venlafaxine extended-release?

Do not use venlafaxine extended-release if:

  • You are taking a class of medications called monoamine oxidase inhibitors (MAOIs). Examples of MAOIs include isocarboxazid (Marplan), phenelzine (Nardil), selegiline (Emsam), and tranylcypromine (Parnate), linezolid, or intravenous methylene blue. MAOIs may increase the risk of serotonin syndrome.
  • You have a known allergic reaction to venlafaxine hydrochloride or desvenlafaxine succinate.

How should I take venlafaxine extended-release?

You should take venlafaxine extended-release with food.

You should take venlafaxine extended-release exactly as prescribed, and continue to take venlafaxine extended-release as prescribed even after your symptoms improve. You should not change your dosing regimen or stop taking venlafaxine extended-release without discussing with your provider first. A gradual reduction in dosage rather than abruptly stopping is recommended whenever possible.

If your symptoms are not improving or you have any questions about changing or stopping medication, reach out to your Ro-affiliated provider for guidance.

What should I tell my Ro-affiliated provider before using venlafaxine extended-release?

  • Venlafaxine extended-release has many drug interactions. It’s important to tell your Ro-affiliated provider all of the medications you are currently taking, including prescription, over-the-counter medications, vitamins, and herbal and dietary supplements. Some medications to watch out for include:
    • Monoamine oxidase inhibitors (MAOIs)
    • Tricyclic Antidepressants (TCAs)
    • NSAIDs, such as ibuprofen or naproxen
    • Aspirin
    • Blood thinners, such as warfarin (Coumadin)
    • Migraine medications called triptans, such as sumatriptan (Imitrex)
    • Other antidepressants, including SSRIs or SNRIs such as sertraline (Zoloft)
    • St. John’s Wort
  • It’s important to share your entire medical history with your provider. In particular, tell your provider if you have a past history of:
    • Suicidal thoughts or attempted suicide
    • Bipolar Disorder
    • Family history of Bipolar Disorder or family history of suicide
    • Seizures
    • High blood pressure
    • High cholesterol
    • Heart problems
  • Tell your provider if you are pregnant, planning to become pregnant, or breastfeeding. SSRI or SNRI use, particularly later in pregnancy, may increase risk of complications in the newborn. You should discuss with your provider if venlafaxine extended-release should be used during pregnancy. Some venlafaxine extended-release may pass into breast milk. Talk to your provider about the best way to feed your baby while taking venlafaxine extended-release.

Withholding or providing inaccurate information about your health and medical history in order to obtain treatment may result in harm, including, in some cases, death.

What are the most serious side effects that I or a caregiver should monitor for when taking venlafaxine extended-release?

If you are experiencing a medical emergency, call 911 or seek immediate medical attention.

These serious side effects are rare, but can occur with venlafaxine extended-release. You or a caregiver should carefully monitor for these side effects, especially in the beginning of treatment and with dose changes.

  • Serotonin Syndrome: Serotonin syndrome is an uncommon, potentially life-threatening condition that occurs when taking too much of an SSRI or SNRI at once or when venlafaxine extended-release is taken along with other drugs that increase the activity of serotonin in the central nervous system. These medications may include MAOIs, triptans (a class of drugs used to treat migraines), tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, and St. John’s Wort. Monitor for symptoms of elevated body temperature, flushing, sweating, abdominal pain, diarrhea, agitation, and a racing heartbeat.
  • Increases in blood pressure: Your blood pressure should be well controlled prior to starting treatment. Your provider will monitor your blood pressure regularly. Consider monitoring your blood pressure at home.
  • Abnormal Bleeding: Tell your provider if you experience any increased or unusual bruising, bleeding, or nose bleed. Venlafaxine extended-release may increase the risk of bleeding when taken with NSAIDs (such as ibuprofen or naproxen), aspirin, warfarin, and other anticoagulants.
  • Eye Effects: In rare instances, antidepressants may cause a certain type of eye problem called acute angle-closure glaucoma. Monitor for eye pain, changes in your vision, or swelling or redness in or around the eye.
  • Activation of Mania/Hypomania: Especially at the beginning of treatment, monitor for changes in behavior such as an unusually elevated mood, feeling unusually irritable, a big increase in energy, being more talkative than usual, racing thoughts, or engaging in risky behaviors. These changes in behavior could be signs of undiagnosed Bipolar Disorder.
  • Low Sodium in the Blood (Hyponatremia): Elderly people may be at greater risk for this condition. Symptoms may include headache, weakness or feeling unsteady, confusion, problems concentrating or thinking, and memory problems.
  • Cognitive and Motor Impairment: Venlafaxine extended-release may impair judgment, thinking, and motor skills. Avoid driving a car or operating hazardous machinery until you know that your performance is not affected. Do not drink alcohol while you take venlafaxine extended-release.
  • Lung Disease and Inflammation (Pneumonitis): Venlafaxine extended-release may cause rare lung problems. Monitor for symptoms such as worsening shortness of breath, cough, or chest discomfort.

What are the most common side effects of venlafaxine extended-release?

  • Nausea, vomiting
  • Change in sleep habits including increased sleepiness or insomnia
  • Dry mouth
  • Sweating
  • Sexual problems including abnormal ejaculation, erectile dysfunction, or decreased sex drive
  • Decreased appetite, weight loss
  • Constipation
  • Abnormal dreams
  • Headache
  • Dizziness
  • Nervousness
  • Tremor

You are encouraged to report negative side effects of prescription products to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

This information is not comprehensive. Please see the full Prescribing Information for complete safety information. 

Important Safety Information for Duloxetine

Warning: Suicidal Thoughts and Behaviors

Suicide is a known risk of depression and certain other psychiatric disorders, and these disorders themselves are the strongest predictors of suicide. In short-term studies, antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults under age 24. These studies did not show an increase in the risk of suicidal thoughts and behavior with antidepressant use in patients over age 24; there was a reduction in risk in patients 65 and older.

Patients of all ages being treated with antidepressants should be observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially early during antidepressant treatment and when the dose is adjusted up or down. Families and caregivers of patients should look for the emergence of symptoms on a day-to-day basis, since changes may be abrupt.

Call your healthcare provider right away or 911 in an an emergency if you observe any of the following behaviors, especially if they are new, worse, unusual, or worry you: emergence of suicidality, worsening of depression, emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, inability to sit still or restlessness, racing thoughts that you can’t fully control, or becoming easily distracted.

What are the FDA-approved uses of duloxetine?

Duloxetine is a serotonin and norepinephrine reuptake inhibitor (SSRI) used for:

  • Acute and Maintenance Treatment of Major Depressive Disorder (MDD)
  • Generalized Anxiety Disorder (GAD)

Who should not use duloxetine?

Do not use duloxetine if:

  • You are taking a class of medications called monoamine oxidase inhibitors (MAOIs). Examples of MAOIs include isocarboxazid (Marplan), phenelzine (Nardil), selegiline (Emsam), and tranylcypromine (Parnate), linezolid, or intravenous methylene blue. Taking an MAOI at the same time as duloxetine may increase the risk of serotonin syndrome.

How should I take duloxetine?

You can take duloxetine with or without food.

You should take duloxetine exactly as prescribed, and continue to take duloxetine as prescribed even after your symptoms improve. You should not change your dosing regimen or stop taking duloxetine without discussing with your provider first. A gradual reduction in dosage rather than abruptly stopping is recommended whenever possible.

If your symptoms are not improving or you have any questions about changing or stopping medication, reach out to your Ro-affiliated provider for guidance.

What should I tell my Ro-affiliated provider before using duloxetine?

  • Duloxetine has many drug interactions. It’s important to tell your Ro-affiliated provider all of the medications you are currently taking, including prescription, over-the-counter medications, vitamins, and herbal and dietary supplements. Some medications to watch out for include:
    • Monoamine oxidase inhibitors (MAOIs)
    • NSAIDs, such as ibuprofen or naproxen
    • Aspirin
    • Blood thinners, such as warfarin (Coumadin)
    • Migraine medications called triptans, such as sumatriptan (Imitrex)
    • Other antidepressants, including SSRIs or SNRIs such as sertraline (Zoloft) or citalopram (Celexa)
    • St. John’s Wort
  • It’s important to share your entire medical history with your provider. In particular, tell your provider if you have a past history of:
    • Suicidal thoughts or attempted suicide
    • Bipolar Disorder
    • Family history of Bipolar Disorder or family history of suicide
    • Liver problems
    • Heavy alcohol use
    • Kidney problems
    • Seizures
    • Heart problems
    • Glaucoma or eye problems
    • Diabetes
  • Tell your provider if you are pregnant, planning to become pregnant, or breastfeeding. SSRI use, particularly later in pregnancy, may increase risk of complications in the newborn. Use of duloxetine during the month before delivery may lead to an increased risk for postpartum hemorrhage. You should discuss with your provider if duloxetine should be used during pregnancy. There have been reports of duloxetine passing into breast milk. Talk to your provider about the best way to feed your baby while taking duloxetine.
    • There is a pregnancy exposure registry that monitors the pregnancy outcomes in women exposed to duloxetine during pregnancy. To enroll, contact the Cymbalta (duloxetine) Pregnancy Registry at 1-866-814-6975 or https://lillypregnancyregistry.com/ 

Withholding or providing inaccurate information about your health and medical history in order to obtain treatment may result in harm, including, in some cases, death.

What are the most serious side effects that I or a caregiver should monitor for when taking duloxetine?

If you are experiencing a medical emergency, call 911 or seek immediate medical attention.

These serious side effects are rare, but can occur with duloxetine. You or a caregiver should carefully monitor for these side effects, especially in the beginning of treatment and with dose changes.

  • Liver Failure: Severe liver problems, sometimes fatal, have been reported with duloxetine. Talk to your provider if you develop itching, right upper belly pain, dark urine, or yellow skin/eyes, which may be signs of liver problems. Heavy alcohol consumption may be associated with severe liver injury.
  • Decrease in blood pressure when standing up, falls, and fainting: Monitor especially during the beginning of treatment and with any dose increases. Your provider may consider lowering your dosage.
  • Serotonin Syndrome: Serotonin syndrome is an uncommon, potentially life-threatening condition that occurs when taking too much of an SSRI or SNRI at once or when duloxetine is taken along with other drugs that increase the activity of serotonin in the central nervous system. These medications may include MAOIs, triptans (a class of drugs used to treat migraines), tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, and St. John’s Wort. Monitor for symptoms of elevated body temperature, flushing, sweating, abdominal pain, diarrhea, agitation, and a racing heartbeat.
  • Abnormal Bleeding: Tell your provider if you experience any increased or unusual bruising, bleeding, or nose bleed. Duloxetine may increase the risk of bleeding when taken with NSAIDs (such as ibuprofen or naproxen), aspirin, and warfarin. A post-marketing study showed a higher incidence of postpartum hemorrhage in mothers taking duloxetine.
  • Severe Skin Reactions: These skin reactions may need to be treated in a hospital and may be life-threatening. Call your provider right away or get emergency help if you have skin blisters, peeling rash, sores in your mouth, hives, or any other allergic reactions.
  • Activation of Mania/Hypomania: Especially at the beginning of treatment, monitor for changes in behavior such as an unusually elevated mood, feeling unusually irritable, a big increase in energy, being more talkative than usual, racing thoughts, or engaging in risky behaviors. These changes in behavior could be signs of undiagnosed Bipolar Disorder.
  • Eye Effects: In rare instances, antidepressants may cause a certain type of eye problem called acute angle-closure glaucoma. Monitor for eye pain, changes in your vision, or swelling or redness in or around the eye.
  • Low Sodium in the Blood (Hyponatremia): Elderly people may be at greater risk for this condition. Symptoms may include headache, weakness or feeling unsteady, confusion, problems concentrating or thinking, and memory problems.

What are the most common side effects of duloxetine?

  • Nausea, vomiting
  • Dry mouth
  • Change in sleep habits including increased sleepiness or insomnia
  • Constipation, diarrhea
  • Decreased appetite, weight loss
  • Increased sweating
  • Fast heartbeat
  • Agitation
  • Headache
  • Sexual problems including abnormal ejaculation, erectile dysfunction, or decreased sex drive

You are encouraged to report negative side effects of prescription products to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

This information is not comprehensive. Please see the full Prescribing Information for complete safety information.