Depression: medications and paying cash

Overview

Major depression is a persistent low mood with loss of interest, changes in sleep, appetite, energy and concentration, and sometimes thoughts of death. It is common, often recurrent and very treatable. Psychotherapy and medication are each effective and work best together for moderate and severe episodes.

SSRIs such as sertraline, escitalopram, fluoxetine and citalopram are the usual first prescription because they are effective and well tolerated. SNRIs such as venlafaxine and duloxetine, bupropion (which avoids the sexual side effects and weight gain of SSRIs), and mirtazapine or trazodone (which help sleep) are chosen when the first drug does not suit. Antidepressants take several weeks to work and are continued for at least six months after recovery to prevent relapse.

The class boxed warning about increased suicidal thinking in young people applies to all of them, particularly when starting or changing dose, and anyone with thoughts of self-harm should seek help the same day.

Choosing between the options when you pay cash

Sertraline, escitalopram, fluoxetine, citalopram, bupropion, duloxetine, trazodone and venlafaxine are available as generics, so the clinical choice should lead. Three details are worth checking: venlafaxine extended-release tablets and capsules are different products that cannot be swapped at the counter; bupropion comes as immediate-, sustained- and extended-release products that are not interchangeable; and a prescription that names a brand such as Lexapro, Wellbutrin XL or Pristiq must be filled with that brand unless substitution is allowed.

Newer brand antidepressants exist for people who have not responded to several generics; for those, check insurance coverage and manufacturer programs as well as pharmacy quotes.

Medicines at a glance

How the medicines in this group are supplied and usually taken. Each guide has the full details.

• Sertraline
  Tablets (Zoloft and generic), Oral concentrate (Zoloft oral solution and generic), Capsules (150 and 200 mg)
  Generic: Yes · Once a day
• Escitalopram
  Tablets (Lexapro and generic), Oral solution (generic)
  Generic: Yes · Once a day
• Fluoxetine
  Capsules, Tablets, Oral solution
  Generic: Yes · Once a day
• Bupropion
  Immediate-release tablets (generic), SR tablets (Wellbutrin SR and generic), XL tablets (Wellbutrin XL, Forfivo XL and generic)
  Generic: Yes · Twice a day (SR) or once a day (XL)
• Duloxetine
  Delayed-release capsules (generic), Delayed-release capsules that can be opened (Drizalma Sprinkle), Delayed-release capsules, 80 to 120 mg (Almatica)
  Generic: Yes · Once or twice a day
• Venlafaxine
  Immediate-release tablets (generic), Extended-release capsules (Effexor XR and generic), Extended-release tablets, venlafaxine hydrochloride (generic)
  Generic: Yes · Two or three times a day, or once a day extended-release
• Trazodone
  Tablets (generic), Oral solution (Raldesy)
  Generic: Yes · See the guide
• Citalopram
  Tablets (Celexa and generic), Oral solution (generic), Capsules (30 mg)
  Generic: Yes · Once a day
• Desvenlafaxine
  Extended-release tablets
  Generic: Yes · Once a day
• Vilazodone
  Tablets
  Generic: Yes · Once a day
• Paroxetine
  Tablets (Paxil and generic), Extended-release tablets (Paxil CR and generic), Oral suspension (generic)
  Generic: Yes · Once a day
• Mirtazapine
  Tablets (Remeron and generic), Orally disintegrating tablets (RemeronSolTab and generic)
  Generic: Yes · Once a day
• Amitriptyline
  Tablets (generic)
  Generic: Yes · Once a day
• Nortriptyline
  Capsules, Oral solution
  Generic: Yes · Four times a day
• Doxepin
  Capsules, Oral concentrate, Tablets
  Generic: Yes · Once a day
• Imipramine
  Tablets (imipramine hydrochloride), Capsules (imipramine pamoate)
  Generic: Yes · Once a day

Medications

Which of these is right for a given person is a decision for the prescriber. The guides explain what each drug is, how it is supplied, and why its cash price varies between pharmacies. No page on this site shows a price; prices come from pharmacies responding to your actual prescription.

Questions worth asking

• How long before this should help, and when should we review it?
• Which side effects are common at the start, and which mean I should call?
• Is this form of the drug, capsule or tablet, immediate or extended release, the right one for me?
• How long will I stay on it after I feel better?
• How would it be tapered if I stop?

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