As an individual’s genotype dictates how certain medications are metabolized, testing a patient can help influence which medication to choose. A patient is more likely to experience side effects if he or she does not normally process a compound. The FDA is trying to stay abreast of these rapid changes by implementing labeling changes based on genomic biomarkers, but there is a delay and lack of consistency on where this information is located.5

Testing can be done by a variety of private companies, though the translation of the data from genes to application in the examination room may need to be done by a separate company or genetic counselor. The relative newness and lack of consistency between testing companies means that these tests should be used judiciously.


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Treatment

The vast majority of medications focus on serotonin, norepinephrine, and/or dopamine (Table 2). Because these medications have been on the market in some cases for more than 20 years, their safety has been well established.7

Table 2. Medications used for depression, approved for adults unless otherwise noted

SSRI SNRI NDRI TCA MAOI Other
Citalopram (Celexa) Desvenla-faxine (Pristiq) Bupropion HCL (Wellbutrin, Zyban, Forfivo) Amitriptyline (Elavil) Isocarboxazid (Marplan), for those aged 16 years and older Mirtazapine (Remeron)
Escitalopram (Lexapro), for those aged 12 years and older Duloxetine (Cymbalta) Bupropion HBr (Aplenzin) Clomipramine (Anafranil) Phenelzine (Nardil) Trazodone (Desyrel), for those aged 6 years and older
Fluoxetine (Prozac), for those aged 8 years and older Levomilnacipran (Fetzima) Desipramine (Norpramin) Selegiline (Emsam) Vortioxetine (Brintellix)
Fluvoxamine (Luvox) Venlafaxine (Effexor) Imipramine (Tofranil) Tranylcypromine (Parnate)
Paroxetine (Paxil) Nortriptyline (Pamelor)
Sertaline (Zoloft) Trimipramine (Surmontil)
Vilazodone (Viibryd)

Medications used for bipolar depression or treatment-resistant depression

Anticonvulsant (sometimes referred to as Mood Stabilizers) First Generation/ Typical Antipsychotics Second Generation/ Atypical Antipsychotics
Carbamazepine (Tegretol, Carbatrol) Chlorpromazine (Thorazine), for those aged 6 months and older Aripiprazole (Abilify), for those aged 13 years and older
Gabapentin (Neurontin) *not FDA approved for this use Fluphenazine (Prolixin) Asenapine (Saphris)
Lamotrigine (Lamictal) Haloperidol (Haldol), for those aged 3 years and older Clozapine (Clozaril)
Lithium (Lithobid, Eskalith) Loxapine (Loxitane) Iloperidone (Fanapt)
Oxcarbazepine (Trileptal) *not FDA approved for this use Perphenazine (Trilafon) Lurosidone (Latuda)
Pregabalin (Lyrica) *not FDA approved for this use Prochlorperazine (Compazine), for those aged 2 years and older Olanzapine (Zyprexa), for those aged 10 years and older
Topiramate (Topamax) *not FDA approved for this use Thioridazine (Mellaril) Paliperidone (Invega)
Valproic acid (Depakene, Stavzor); Divalproex sodium (Depakote); Valproate sodium (Depacon) Thiothixene (Navane) Quetiapine (Seroquel), for those aged 10 years and older
Trifluoperazine (Stelazine) Risperidone (Risperdal)
Ziprasidone (Geodon)

This safety profile can be altered by use of multiple psychotropic medications, alcohol consumption, and hepatic and renal dysfunction, but they are still generally well tolerated. Side effects are often transient and experienced with initiation and changes in dose, as well as with abrupt cessation, referred to as “discontinuation syndrome.”8

Side effects may be more noticeable when taking medications with a shorter half-life, such as paroxetine and the serotonin-norepinephrine reuptake inhibitors (SNRIs); thus, a slow, gradual taper or transitioning to a medication with a longer half-life (e.g., fluoxetine) may make withdrawal less noticeable.9 When trying to decide what medication to start with, the STAR*D trial10 and research by Zimmerman and colleagues,11 among others, have shown that it really does not matter what medication is chosen to start with regarding depression for the vast number of people.