Antidepressants change the brain’s chemical makeup to treat mood disorders like depression. Antidepressants aren’t addictive in the same way substances like alcohol and heroin are. The most common forms of antidepressant medication are selective serotonin reuptake inhibitors. Antidepressants are a first-line treatment for many mental health disorders, but there are risks that come with their use. With prescription drug addiction currently . There are several types of antidepressant medications on the market today, and research varies as to the addiction potential of these pharmaceuticals. Different.
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Our literature search of bupropion abuse and misuse yielded a total of 13 articles, two review articles, 38 , 39 and a number of case reports. Bupropion acts via dual inhibition of norepinephrine and dopamine reuptake, thus increasing the intrasynaptic concentrations of these neurotransmitters. While understanding the pharmacology of bupropion offers insight into why it can be misused, the route of administration is also an important factor in abuse potential.
The nasopharynx is a highly vascularized surface area for systemic drug absorption directly into the blood stream, and thus bypassing breakdown by the gastrointestinal tract and first-pass metabolism in the liver.
Intravenous administration or smoking allow for even more rapid concentrations. Baribeau and Araki published the only case report of intravenous bupropion abuse; 43 they describe a year-old woman who was dissolving mg tablets in water and injecting 1, mg daily maximum oral dose recommended by the FDA is mg. Potential consequences of bupropion abuse and misuse have not been studied. However, bupropion is known to have a dose-dependent increased risk of seizures that is also higher with immediate-release as compared with sustained-release.
Concurrent use of alcohol, stimulants, or cocaine also enhances the risk of seizures in those using bupropion. MAOIs were first identified as effective antidepressants in the late s. Phenelzine and tranylcypromine, both nonselective MAOIs, are most cited in the literature. The mechanism of abuse may be associated with the similarity in chemical structure to amphetamine; however, the mechanism of action is different, and thus the pharmacologic basis for potential abuse is unknown.
Delirium and thrombocytopenia have been reported in a number of cases of overdose and withdrawal of tranylcypromine, and may be more pronounced if high doses are used. Tricyclic antidepressants TCAs were the first class of antidepressants to be widely used in depression. Tertiary TCAs are more potent in blocking the serotonin transporter, whereas the secondary TCAs are relatively selective in blocking the norepinephrine transporter.
The first cases of TCA misuse were reported in the s. However, those that do specify, report the medications were taken orally. In unspecified cases, the authors implied that the TCAs were misused orally by defining the use as taking escalating doses of the prescribed medication.
Similar to the policies for bupropion, TCAs have been removed from formularies in some correctional facilities. While the pharmacologic basis for TCA abuse is unknown, it is interesting to note that nearly all of the case reports involve abuse of a tertiary TCA. The anticholinergic and antihistaminergic effects of TCAs can produce confusion and delirium, which are potential consequences of misuse of these medications.
Most concerning is the effect of TCAs on cardiac conduction. Serotonin and norepinephrine reuptake inhibitors SNRIs include venlafaxine, desvenlafaxine, and duloxetine. While TCAs also inhibit serotonin and norepinephrine, the selectivity of the SNRIs for these two reuptake transporters distinguishes the two classes.
At recommended doses, SNRIs do not affect cardiac conduction or lower seizure threshold; however, in overdose they may do both. They also demonstrate that the motivation for abusing an SNRI may be either to achieve an amphetamine-like effect or to experience the dissociative effects of excess serotonin. The selective serotonin reuptake inhibitors SSRIs are the most commonly prescribed antidepressants, and are considered first-line in treatment for major depressive disorder and for most anxiety disorders.
However, it is important to recall that while they are more selective at the serotonin receptor, all the SSRIs impact other neurotransmitter systems, including norepinephrine and dopamine reuptake blockade.
We found a total of six articles, describing seven cases, all involving fluoxetine. It is often classified as a TCA but is pharmacologically distinct. While its mechanism of action is not entirely clear, it is thought to be a serotonin enhancer and thus paradoxically acting in a manner opposite to that of the SSRIs, yet both have efficacy in depression.
Amineptine is another antidepressant classified as a tricyclic but is chemically different due to its 7-aminoheptanoic acid side chain; it has the unique capacity to reduce dopamine uptake selectively in vitro and in vivo. There have been a number of case reports regarding abuse of amineptine, particularly in those with a history of substance abuse, attributed largely to its stimulant effect.
We found no cases in the literature of abuse or misuse of serotonin 2 5-HT2 receptor antagonists trazodone and nefazodone or mirtazapine an alpha-2 adrenergic receptor blocker.
As previously noted, the co-occurrence of mood and substance use disorders is common. The Screening, Brief Intervention, and Referral to Treatment is a comprehensive, integrated, public health approach to the delivery of early intervention for individuals with risky alcohol and drug use, and timely referral for more intensive substance abuse treatment for those who have substance abuse disorders.
A key component of the Screening, Brief Intervention, and Referral to Treatment is linking the screening results with appropriate early intervention services or referral to treatment. Brief interventions focus on motivating clients to change their substance use.
The signs of antidepressant misuse can be difficult to identify. Patients engaged in nonmedical use of a prescribed medication are typically motivated to conceal this behavior from the prescribing physician. However, the presence of aberrant behaviors can alert the clinician to an increased likelihood of prescription medication abuse. Such behaviors may include erratic ability to keep appointments, requests for early refills, a sudden request for dose increase in a patient with a previously stable mood on a lower dose of the antidepressant, an indifference to side effects, and a general decline in functioning.
Clinical research on abuse of another class of abuse medications, namely prescription opioids, has revealed that monitoring for both urine toxicology and aberrant behaviors is more likely to detect patients engaging in prescription misuse than is monitoring either alone. Taking a careful history and risk stratification assessment, including a history of legal, prescribed, and illicit drug abuse, is an important strategy for reducing the likelihood of antidepressant misuse when evaluating a new patient.
However, in some cases, unsuspected antidepressant abuse will be detected once treatment has begun. If misuse of an antidepressant is identified, it is important for the provider to take an open, nonjudgmental approach. The former would warrant treatment by an addiction specialist; the latter likely would not. With respect to available treatment options for the patient who has been discovered to be engaging in antidepressant abuse, the physician may choose to continue treatment using a medication with different pharmacologic properties from the drug which the patient has misused.
When antidepressant misuse is identified, it is also essential to determine how much the individual is using and route of administration ie, oral, intranasal, intravenous, rectal. This information is important to obtain, as it allows for assessment of risk; each of the antidepressants comes with its own profile of side effects, overdose risk, and lethality. Patients should be triaged based upon degree of medical risk and may warrant immediate consultation with a local poison control center, referral to an emergency department or urgent care center, referral to a primary doctor for evaluation, or further medical work-up eg, obtain tricyclic levels, electrocardiography.
It is also important to understand how the patient perceives his or her misuse of the antidepressant eg, the medication provides relief from subjective states of distress that should be a focus of treatment and the potential medical consequences of misuse.
This information will allow for psychoeducation about specific risks, and also provide insight into the degree of motivation to change. There is a paucity of evidence-based research to guide the pharmacologic management of individuals with comorbid mood and substance use disorders, and there are no existing treatment guidelines for the depressed individual who is also misusing antidepressants.
Unlike other substances of abuse, antidepressants are not included in standard drug screen panels. Serum levels of all antidepressants can, however, be tested and potentially used for detection.
However, only tricyclic antidepressant levels are used clinically and have defined reference ranges, limiting the interpretability of the results of the other antidepressant classes. Urine tests of tricyclic antidepressants are often used in emergency departments in cases of suspected overdose, and in the pain literature for pain management compliance testing.
In contrast with the state-run prescription monitoring programs that provide an electronic database to prevent abuse of controlled medications, no such database currently exists for noncontrolled substances. Such efforts may or may not detect misuse in those receiving prescriptions from friends or family, or if filling prescriptions at multiple pharmacies. The majority of patients will not achieve full remission from depression with an initial antidepressant treatment.
Preliminary research suggests that the latter exerts antidepressant activity in the absence of cognitive side effects. For patients with substance use disorders co-occurring with depression, integrated treatment delivered in a group setting has been found to be more effective than treatment as usual. Nonmedical use of prescription drugs is an underrecognized clinical problem and is related to a number of factors, including increased access to medications and a perception that they are safer than illicit substances.
There are, however, a number of potential negative medical and societal consequences of nonmedical use of prescription drugs. Further, while the majority of those using prescription medications nonmedically do not meet criteria for DSM-V substance use disorder, some individuals will develop such a disorder, and early nonmedical prescription drug use may be a predictor of lifetime development of prescription drug abuse or dependence.
The scope of antidepressant misuse is unknown, as antidepressants are currently not included in the large-scale epidemiologic surveys of prescription drug misuse. However, while antidepressants are generally thought to have low abuse liability, there is evidence in the literature of their misuse, abuse, and dependence. The majority of reported cases of antidepressant abuse occur in individuals with comorbid substance use and mood disorders.
While it is important to recognize that the vast majority of individuals prescribed antidepressants do not misuse them, it is also critical for physicians to be aware of the potential for misuse and abuse when prescribing these drugs.
Vulnerable populations include those with a current or past history of substance abuse and those in controlled environments. Even in the absence of such behaviors, physicians should consider including antidepressants when screening for current and past risky prescription medication use. It is important to differentiate the misuse of antidepressants to relieve psychological distress eg, unauthorized dose escalation to reduce anxiety, achieve sleep, or combat fatigue from abuse with the purpose of seeking euphoria.
The former is likely to respond to patient psychoeducation and improved symptom control, whereas the latter may require more intensive clinical interventions, including concurrent substance abuse treatment or referral to an addiction expert.
While it is necessary for prescribers to be aware that antidepressants carry some abuse liability, physicians should not withhold essential pharmacotherapy, even in those with substance dependence. Several classes of antidepressants have demonstrated efficacy in improving depressive symptoms, and these drugs significantly reduce the mortality and morbidity in those suffering from depression.
Additionally, misuse of an antidepressant is not necessarily a reason to withdraw antidepressant treatment. However, when misuse is identified, a thoughtful treatment approach should include patient education, maximizing psychotherapy, considering a different antidepressant class, augmenting with behavioral and alternative strategies eg, exercise , close monitoring, and ongoing consideration of referral to an addiction specialist.
Future research efforts should be directed at collecting epidemiologic data regarding antidepressant misuse to better appreciate the scope of this clinical problem. It will be important to develop better tools for detecting antidepressant misuse, to better characterize risk factors, as well as to gain further insight into specific pharmacologic properties that contribute to abuse liability. Finally, future research should examine the course and consequences of antidepressant misuse, with a focus on improving early detection and developing effective treatment interventions.
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This article has been cited by other articles in PMC. Abstract Background Rates of prescription drug abuse have reached epidemic proportions. Results A small but growing literature on the misuse and abuse of antidepressants consists largely of case reports.
Conclusion The majority of individuals prescribed antidepressants do not misuse the medication. Introduction While prescription drugs have been used effectively and appropriately to treat both medical and psychiatric illness in the vast majority of patients, rates of prescription abuse have escalated and have reached epidemic proportions.
Scope of antidepressant misuse and pharmacology Since most large-scale epidemiologic surveys have not included antidepressant misuse as a category of substance abuse that is specifically measured, it is difficult to fully characterize the prevalence of antidepressant misuse.
Bupropion Bupropion acts via dual inhibition of norepinephrine and dopamine reuptake, thus increasing the intrasynaptic concentrations of these neurotransmitters. Table 1 Abused and misused antidepressants: Open in a separate window. Monoamine oxidase inhibitors MAOIs were first identified as effective antidepressants in the late s.
Tricyclic antidepressants Tricyclic antidepressants TCAs were the first class of antidepressants to be widely used in depression. Serotonin and norepinephrine reuptake inhibitors Serotonin and norepinephrine reuptake inhibitors SNRIs include venlafaxine, desvenlafaxine, and duloxetine.
Selective serotonin reuptake inhibitors The selective serotonin reuptake inhibitors SSRIs are the most commonly prescribed antidepressants, and are considered first-line in treatment for major depressive disorder and for most anxiety disorders. Amineptine Amineptine is another antidepressant classified as a tricyclic but is chemically different due to its 7-aminoheptanoic acid side chain; it has the unique capacity to reduce dopamine uptake selectively in vitro and in vivo.
Table 2 Clinical tools and principles for minimizing risk of antidepressant misuse. Method of ascertainment Example Principle Clinical interviews Obtain history of illicit substance and alcohol abuse Obtain history of antidepressant and other prescription medication misuse Ask about family history of substance abuse Consider motivation for misuse Universal precautions reduce stigma and improve care Objective instruments Screening tools eg, Screening, Brief Intervention, and Referral to Treatment Uniform approach to baseline risk assessment using objective measures Ongoing monitoring Urine toxicology, serum drug levels, frequent appointments, monitor for aberrant behaviors eg, early refill requests, erratic appointment attendance, indifference to side effects Combining objective data with clinical observation is more effective at minimizing risk.
Management of depression in patients misusing antidepressants Taking a careful history and risk stratification assessment, including a history of legal, prescribed, and illicit drug abuse, is an important strategy for reducing the likelihood of antidepressant misuse when evaluating a new patient.
Summary and conclusion Nonmedical use of prescription drugs is an underrecognized clinical problem and is related to a number of factors, including increased access to medications and a perception that they are safer than illicit substances.
Footnotes Disclosure The authors report no conflicts of interest in this work. Centers for Disease Control and Prevention Prescription drug overdoses: Prevalence, correlates, and comorbidity of nonmedical prescription drug use and drug use disorders in the United States: Non-medical use of prescription drugs: The Internet as a source of drugs of abuse. A CASA white paper. Misperceptions of non-medical prescription drug use: Monitoring the future national results on drug use: Pharmaceutical overdose deaths, United States, Does early onset of non-medical use of prescription drugs predict subsequent prescription drug abuse and dependence?
Results from a national study. Societal costs of prescription opioid abuse, dependence, and misuse in the United States. Economic costs of nonmedical use of prescription opioids.
Epidemiology of major depressive disorder: Lifetime and month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication. Baumbacher G, Hansen MS. Abuse of monoamine oxidase inhibitors. Am J Drug Alcohol Abuse. Withdrawal from high-dose tranylcypromine. Clin Toxicol Phila ; Chatterjee A, Tosyali MC. Thrombocytopenia and delirium associated with tranylcypromine overdose.
Tranylcypromine abuse associated with delirium and thrombocytopenia. Mielczarek J, Johnson J. Shopsin B, Kline NS.
Ben-Arie O, George G. A case of tranylcypromine Parnate addiction. Addiction to tranylcypromine Parnate: Tranylcypromine abuse letter Am J Psychiatry. Szeleyni A, Albrecht J. Tranylcypromine abuse associated with an isolated thrombocytopenia.
Vartzopoulos D, Krull F. Dependence on monoamine oxidase inhibitors in high dose. Withdrawal and discontinuation phenomena associated with tranylcypromine: Do antidepressants have any potential to cause addiction?
Abuse of the monoamine oxidase MAOI inhibitors as antidepressive drugs: Bupropion diversion and misuse in the correctional facility. J Correct Health Care. Additional evidence of the abuse potential of bupropion. Yoon G, Westermeyer J. Bupropion perceived as a stimulant by two patients with a previous history of cocaine misuse. Ann Ist Super Sanita. Baribeau D, Araki KF. Recreational bupropion abuse in a teenager. Br J Clin Pharmacol.
Psychotropic medication abuse in correctional facilities. Bay Area Psychopharmacology Newsletter. Kim D, Steinhart B. Seizures induced by recreational abuse of bupropion tablets via nasal insufflation. A case report of seizures induced by bupropion nasal insufflation. Bupropion insufflation in a teenager.
J Child Adolesc Psychopharmacol. Here are a few of the most effective uses:. There are many types of antidepressants, and even without concurrent or previous substance abuse, reactions to these medications can be very individual. It can take time for the medication to work, and it can take more time to switch medications if the first prescription is not effective. A study published on PubMed reviewed comprehensive studies on the efficacy of antidepressants for treatment in specific cases of substance abuse and found that the only clearly effective result came from nicotine addiction treatment involving bupropion.
Alcohol dependence, even with comorbid depression, was not helped by antidepressants; the efficacy of cocaine and opioid dependence treatments was unclear. It is possible that antidepressants may not be an effective substance abuse treatment for many drugs, including for addictions to increasingly popular synthetic cathinones and cannabinoids.
Research indicates that only about 60 percent of people with antidepressant prescriptions experience necessary relief of symptoms. Side effects from antidepressants , including reduced sex drive, weight gain, and fatigue can become more frustrating than the underlying condition, or could, for some people, contribute to increased symptoms of depression due to changes in personal life and appearance. For people who struggle with co-occurring substance abuse, the continuation of symptoms along with brain chemistry changes could lead to relapse.
If a person is taking antidepressants to moderate withdrawal symptoms during detox, it is important to know that antidepressants themselves, including SSRIs, can lead to physical dependence. Although these drugs are less likely to become the target of abuse or addiction, they can still cause withdrawal symptoms when the person stops taking them. If a person struggles with co-occurring substance abuse and mental health problems, these side effects could lead to relapse as they return to old self-medicating patterns to manage the antidepressant withdrawal symptoms.
Although there are potential negatives with use of antidepressants, the benefits most often outweigh the risks. Antidepressants should be used alongside other therapies to overcome both depression and substance abuse. Antidepressants do not cure psychological disorders, including depression or addiction; instead, they are a tool in a full treatment plan to help the person overcome their other conditions.
They can be very effective in the treatment of specific drug issues involving nicotine or methamphetamine. As substance abuse can cause many long-term health issues, it is important to get appropriate help to overcome the abuse. Antidepressants are one aspect of a larger treatment plan to overcome substance abuse for some people; this larger plan involves rehabilitation programs and psychotherapy, not simply detox.
Antidepressants can ease withdrawal symptoms in some people, including cravings and drug-seeking behaviors in people overcoming nicotine or methamphetamine addiction. They can also help people whose underlying depression led to substance abuse or whose substance abuse has induced depression. Detox, rehabilitation, therapy, and social support from family and friends are all necessary parts of the overall treatment plan to overcome addiction. Types of Antidepressants There are six types of antidepressant medications.
Selective serotonin reuptake inhibitors SSRIs: Currently the most popular and effective antidepressant class on the market, SSRIs work by blocking the reuptake of serotonin by neurons. They have fewer side effects than other antidepressants, and they are the frontline prescription choice for depression and some other psychiatric conditions. Serotonin and norepinephrine reuptake inhibitors SNRIs: Like SSRIs, these medications change or reduce absorption of serotonin and also norepinephrine.
This helps elevate and stabilize mood, as there is more of the neurotransmitter available. SSRIs are also one of the first kinds of drugs prescribed to treat depression, as they have fewer side effects than other antidepressants.
Popular brand names include Cymbalta and Effexor. Norepinephrine and dopamine reuptake inhibitors NDRIs: The most famous brand name in this small group is Wellbutrin, which has the generic name bupropion. This antidepressant is now more actively prescribed to help smokers end their addiction to nicotine.
These medications increase the amount of neurotransmitters like serotonin, dopamine, and norepinephrine released in the brain. They have more side effects than newer antidepressants like SSRIs and SNRIs, but they are still occasionally prescribed for people who have tried newer antidepressants and not found them to be effective. Monoamine oxidase inhibitors MAOIs: These medications were among the first antidepressants to be developed, and they are still prescribed on occasion, but they can cause serious side effects.
They also require changes to diet, including the avoidance of certain foods, and they can interact with many other medications, making multimodal treatment difficult. While they are not used as a frontline defense against depression, PTSD, or anxiety, they are still prescribed for people who do not benefit from other antidepressants. This category includes a variety of other medications, including sedatives like Oleptro and Remeron, along with some antipsychotic medications.
Here are a few of the most effective uses: Bupropion and smoking cessation: The generic form of Wellbutrin, called bupropion, helps reduce cravings for tobacco when a person is attempting to quit smoking.
Scientist: Antidepressants cause addiction
Antidepressants are medications prescribed to stabilize moods and treat symptoms Antidepressants pose a lesser risk of addiction and abuse. Antidepressants SSRI abuse signs & withdrawal & side-effects: Get specialised antidepressant rehab programme with antidepressant detox & therapy at Castle. Do antidepressant SSRI drugs cause addiction? Yes, say researchers behind a study from the Nordic Cochrane Centre but their claim is met.