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At present, in the United States, there is no single, new medicine that has been shown to be useful for all of the symptoms of depression, anxiety, and attention deficit disorder. Interestingly, a few of the older tricyclic antidepressants such as imipramine, desipramine, and nortryptiline are useful in all of these conditions, but they have more side effect problems and greater toxicity than newer antidepressants. These medications all work by increasing the availability of the neurotransmitter norepinephrine, which has a role in depression, anxiety, and attention processes. There are two newer drugs in a class called SNRI’s (selective norepinephrine reuptake inhibitors) called reboxetine and atomoxetine. These drugs make norepinephrine more available without the same side effects or dangers as tricyclic antidepressants. So far, reboxetine, which is not yet on the American market, has shown effectiveness in treating depression and anxiety disorders, and is speculated to have utility in attention deficit disorder. Atomoxetine is marketed in the United States as Strattera, and has shown to be effective for attention deficit disorder. It has not been proven effective as a single agent for depression or anxiety, but will likely be studied as an add-on drug in difficult cases of depression. I have already used it for this purpose in several patients, with good effect.
In addition, there are several “newer” medications for depression and for attention deficit disorder that are worth mentioning. The newest antidepressants on the American market are Lexapro, which is derived from the drug Celexa, and Paxil CR, a longer acting form of Paxil. All of the drugs called SSRI’s (selective serotonin reuptake inhibitors) are equally effective, compared to each other, for depression, panic disorder, social anxiety, obsessive-compulsive disorder, and some of the symptoms of post-traumatic-stress disorder PTSD). They are all more effective for depression, panic disorder, and social anxiety, than for obsessive-compulsive disorder and PTSD, which are harder to treat. There are slight differences in side effects between these drugs, which is how I usually choose between them. I do not think that the newer ones offer substantial advantages over the older ones. These drugs do not work for attention deficit disorder.
Effexor in the XR form is a drug I prescribe quite often, because it is a slightly more powerful antidepressant, at least in people sick enough to be hospitalized, and also measured by the number of people who get better enough so that their depressions can be said to be in remission. It also works for panic disorder, social anxiety, and obsessive-compulsive disorder, and some PTSD symptoms. It has effects on serotonin and also some effect on norepinephrine, which probably accounts for its better antidepressant effect, but has not been well studied for attention deficit disorder, and can’t really be recommended for this. Like the SSRI drugs, it has side effects of nausea, diarrhea, jitteriness, and sexual dysfunction. It can occasionally increase blood pressure.
Other important newer antidepressants are Wellbutrin and Remeron. Wellbutrin increases the neurotransmitters norepinephrine and dopamine, and helps depression and attention deficit disorder, and also decreases nicotine craving. It is marketed as Zyban to help people stop smoking. It does not treat the anxiety disorders effectively, but does decrease anxiety secondary to depression. Remeron is another powerful antidepressant that effects norepinephrine and serotonin, and also several other sites in the brain. In some studies it works better and faster than SSRI’s, at least in hospitalized patients. It decreases nausea and has much less sexual side effects. Its problematic side effects are sedation, due to its antihistamine properties, and weight gain. In my practice, the weight gain side effect makes a lot of people afraid to try it. A new antidepressant that is due out this year is called duloxetine (Cymbalta) and promises to be quite effective and to have a favorable side effect profile.
Newer drugs for attention deficit disorder include Strattera, which I mentioned above, and long-acting forms of methylphenidate (Ritalin) and Adderall. There are several long lasting forms of methylphenidate under different brand names, such as Ritalin SR, Concerta, and Metadate. They are useful for people who find the effect of Ritalin wearing off to be troublesome, since they wear off more gradually. It is unclear whether there are significant differences in efficacy between methylphenidate, dexedrine, and Adderall – however a recent review showed a slight advantage for Adderall over methylphenidate. Strattera will likely see wide use, however, because it lacks abuse potential and because it is not a Schedule II drug, it can be called in to pharmacies and written with refills.
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