Different Classes of Antidepressant Drugs

Information was found and adopted from the Pharmacology of Education website.

In patients with moderate to severe depression routine antidepressant therapy is effective (as highlighted by Cipriani et al. (2018) following meta-analysis of results from clinical trials of 21 different antidepressants)- and is recommended to be combined with psychological therapy. Drug treatment of mild depression may also be considered in patients with a history of moderate or severe depression. Improvement in sleep is usually the first benefit of antidepressant therapy, with additional beneficial effects on psychomotor and physiological changes such as loss of appetite. The information provided in this section summarises the classes of antidepressants available to the prescriber. For a more critical review of antidepressant therapy see our topic Depression within in the Psychiatric disease module. The major classes of antidepressant drugs include the tricyclic and related antidepressants, selective serotonin re-uptake inhibitors (SSRIs), the selective serotonin and norepinephrine re-uptake inhibitors (SNRIs) and the monoamine oxidase inhibitors (MAOIs). A small number of drugs don’t easily fall into this classification and are listed under Atypical antidepressants below.

There is little to choose between the different classes of antidepressant drugs in terms of efficacy, so choice should be based on the individual patient’s requirements, including the presence of other existing disease and therapy, suicide risk, and previous response to antidepressant therapy. SSRIs are better tolerated and are safer in overdose than other classes of antidepressants and should be considered first-line for treating depression. Notably, sertraline has been shown to be safe in patients who have had a recent myocardial infarction or who have unstable angina. TCAs have similar efficacy to SSRIs, but their more troublesome side-effects leads to patients being more likely to discontinue treatment. TCAs are also more toxic in overdose than SSRIs. MAOIs have dangerous interactions with some foods and drugs, and should be reserved for use by specialists. Anxiolytics or antipsychotic drugs should be used with caution in depression which often presents as anxiety, as they can mask the true diagnosis, but are useful adjuncts in agitated patients. Selective serotonin re-uptake inhibitors (SSRIs) SSRIs are the most commonly prescribed class of antidepressants. They are highly effective and generally well tolerated compared to other types of antidepressants. Side effects of SSRIs may include nausea, vomiting, diarrhoea, sexual dysfunction, headache, weight gain, anxiety, dizziness, dry mouth, and insomnia. Caution should be used when prescribing SSRIs alongside other drugs that increase the risk of bleeding. SSRIs should not be used in patients with poorly controlled epilepsy or in patients entering manic phase. Common shared side-effects (often dose-related) include abdominal pain, constipation, diarrhoea, dyspepsia, nausea and vomiting. An uncommon, but potentially serious side-effect is serotonin syndrome. Citalopram- used to manage depressive illness and panic disorder. Escitalopram (the active enantiomer of citalopram)- used to manage depressive illness, generalised anxiety disorder, obsessive-compulsive disorder, panic disorder and social anxiety disorder. Paroxetine- used to manage major depression, social anxiety disorder, post-traumatic stress disorder (PTSD), generalised anxiety disorder, obsessive-compulsive disorder and panic disorder Fluoxetine (Prozac)- used to treat major depression, bulimia nervosa and obsessive-compulsive disorder. Prescribers should consider the long half-life of when adjusting dosage, especially in regards to overdosage. Fluvoxamine- used to manage depressive illness and obsessive-compulsive disorder. Sertraline- used to manage depressive illness, obsessive-compulsive disorder, panic disorder, social anxiety disorder and PTSD. Failure to respond to initial treatment with an SSRI may require an increase in the dose, or switching to a different SSRI or mirtazapine. Other second-line choices include lofepramine, moclobemide, and reboxetine. Selective serotonin and norepinephrine re-uptake inhibitors (SNRIs) None of these drugs should be prescribed within 14 days of an MAOI and at least 7 days should be allowed between stopping their use and administering a MAOI. Desvenlafaxine (not UK)- indicated for major depressive disorder. Duloxetine- used to manage major depressive disorder, generalised anxiety disorder, diabetic neuropathy and moderate to severe stress urinary incontinence. Use caution when prescribing alongside drugs that increase risk of bleeding. Venlafaxine- indicated for major depression, generalised anxiety disorder and social anxiety disorder. Contra-indicated in patients with conditions associated with high risk of cardiac arrhythmia or uncontrolled hypertension. Milnacipran (not UK)- used to treat the chronic pain caused by fibromyalgia, not used to treat depression. Levomilnacipran (not UK)- used to treat major depressive disorder. Most common side-effects of SNRIs are nausea, dizziness, and sweating. Other side-effects include tiredness, constipation, insomnia, anxiety, headache, and loss of appetite. Duloxetine and milnacipran should not be used in patients with uncontrolled narrow angle or angle-closure glaucoma. Tricyclic antidepressants (TCAs) and related antidepressants TCAs share a similar chemical structure and biological effects. TCAs block the re-uptake of both serotonin and noradrenaline, although to different extents. For example, clomipramine is more selective for serotonin re-uptake, and reboxetine and lofepramine are somewhat more selective for noradrenaline re-uptake. Other TCAs such as nortriptyline, show no such selectivity. Evidence indicates that the secondary amine tricyclic antidepressants, including desipramine HCl, may have greater activity in blocking the re-uptake of norepinephrine. Tertiary amine tricyclic antidepressants, such as amitriptyline, may have greater effect on serotonin re-uptake. Additionally, TCAs block muscarinic M1, histamine H1, and alpha-adrenoceptors. Tricyclic and related antidepressant drugs can be roughly divided into those with additional sedative properties (amitriptyline, clomipramine, dosulepin, doxepin, mianserin, trazodone, and trimipramine) and those that are less sedating (imipramine, lofepramine, and nortriptyline). Agitated and anxious patients tend to respond best to the sedative compounds, whereas withdrawn and apathetic patients will often obtain most benefit from the less sedating ones. TCAs are approved for treating several types of depression, obsessive compulsive disorder, and bedwetting (nocturnal enuresis). Also used for several off-label conditions such as panic disorder, bulimia, chronic pain (for example, migraine, tension headaches, diabetic neuropathy, and post herpetic neuralgia), phantom limb pain, chronic itching, and premenstrual symptoms Although effective, TCAs have largely been replaced by newer antidepressants that generally cause fewer side-effects. Amitriptyline - not recommended for depressive illness because of its toxicity in overdosage- used for migraine prophylaxis, neuropathic pain, abdominal pain or discomfort (in patients who have not responded to laxatives, loperamide, or antispasmodics) Doxepin- used for depressive illness (especially where sedation is required) and pruritus of eczema (topical application). This TCA acts as a selective noradrenaline reuptake inhibitor. Dizziness and drowsiness are very common side-effects, as are agitation, anxiety, confusion, irritability, paraesthesia and sleep disturbance. Lofepramine- used to treat depressive illness. Common side-effects include dizziness, agitation, anxiety, confusion, irritability, paraesthesia, postural hypotension and sleep disturbance Dosulepin hydrochloride- used for depressive illness (especially where sedation is required). Common side-effects include dizziness, agitation, anxiety, confusion, irritability, paraesthesia, postural hypotension and sleep disturbance Desipramine hydrochloride (not UK), is approved in the US to treat symptoms of depression. Use of desipramine in patients being treated with MAOI antidepressants (e.g. linezolid) is contraindicated because of an increased risk of serotonin syndrome. Desipramine may cause exacerbation of psychosis in schizophrenic patients. Concomitant use of tricyclic antidepressants with drugs that can inhibit cytochrome P450 2D6 may require lower doses than usually prescribed for either the tricyclic antidepressant or the other drug. Imipramine hydrochloride – used for depressive illness and nocturnal enuresis. Common side-effects include fatigue, flushing, headache, palpitations and restlessness. Nortriptyline – prescribed for depressive illness and neuropathic pain. Treatment should be stopped if the patient enters a manic phase. Common side-effects include fatigue, hypertension, mydriasis and restlessness Amoxapine (not UK)- used to treat symptoms of depression, anxiety, or agitation. Do not use this medicine within 14 days of taking an MAOI antidepressant. Clomipramine hydrochloride- prescribed for depressive illness, phobic and obsessional states and as an adjunctive treatment of cataplexy associated with narcolepsy. Common side-effects include abdominal pain, aggression, diarrhoea, fatigue, flushing, hypertension, impaired memory, muscle hypertonia, muscle weakness, mydriasis, myoclonus, restlessness and yawning. Maprotiline (not UK)- used to treat major depressive disorder, depressive neurosis, and manic-depression illness. Avoid alcohol as it can increase some of the side-effects of maprotiline. Maprotiline can impair thinking or reactions, so patients are recommended to avoid activities that require alertness (e.g. driving) Trimipramine- used to treat depressive illness (particularly where sedation is required). Side-effects can include agitation, anorexia, anxiety, arrhythmia, blurred vision, confusion, constipation, dizziness and dry mouth. Trimipramine is also a serotonin 5-HT2 receptor antagonist. Protriptyline (not UK)- used to treat symptoms of depression. Do not use this medicine within 14 days of taking an MAOI antidepressant. Common side-effects can include nausea, vomiting, loss of appetite, anxiety, insomnia, dry mouth, little or no urinating and constipation. Monoamine oxidase inhibitor antidepressants (MAOIs) MAOIs block the activity of monoamine oxidase, an enzyme that breaks down norepinephrine, serotonin, and dopamine in the brain and other parts of the body. MAOIs are used much less frequently than tricyclic and related antidepressants, or SSRIs and related antidepressants because of the dangers of dietary and drug interactions. MAOIs exhibit some benefit for phobic patients and depressed patients with atypical, hypochondriacal, or hysterical features, but should only be prescribed by specialists. In general, MAOIs have been replaced by newer antidepressants that are safer and cause fewer side-effects. Common side-effects include postural hypotension, weight gain, and sexual side effects. Isocarboxazid, phenelzine and tranylcypromine are non-selective, irreversible MAOIs, used to manage depressive illness. Rasagiline and selegiline are irreversible MAOB inhibitors used not to treat depression, but to treat Parkinson's disease as a monotherapy or as an adjunct to co-beneldopa or co-careldopa to manage 'end-of-dose' fluctuations. Atypical antidepressants Each drug in this category has a unique molecular mechanism of action, or a chemical structure that excludes them from the classification above. However, like other antidepressants, atypical antidepressants affect the levels or effects of dopamine, serotonin, and norepinephrine in the brain. Bupropion- used to aid smoking cessation in combination with motivational support in nicotine-dependent patients. This drug should not be used in patients with seizure disorders, eating disorders, and within 2 weeks of using MAOI. It generally does not cause weight gain or sexual problems. Mirtazapine- a presynaptic α2-adrenoceptor and serotonin 5-HT2 receptor antagonist which increases central noradrenergic and serotonergic neurotransmission. Used to manage major depression. Nefazodone (not UK)- a serotonin 5-HT2 receptor antagonist also inhibiting serotonin and norepinephrine re-uptake. Used to manage depression, including major depressive disorder. Nefazodone should not be prescribed to patients with active liver disease. Trazodone- principally a serotonin 5-HT2 receptor antagonist, used to manage depressive illness, particularly where sedation is required. Vilazodone (not UK)- a potent serotonin 5-HT1A receptor partial agonist, with combined inhibitory action against serotonin re-uptake. Used to manage major depressive disorder. Vilazodone is not associated with significant weight gain or sexual dysfunction. Vortioxetine (not UK)- a partial agonist of 5-HT1A and 5-HT1B receptors and antagonist of the 5-HT7 receptor used to manage major depressive disorder. May also inhibit re-uptake of serotonin. Side-effect profiles are as unique as their mechanisms of action. Some common side effects include dry mouth, constipation, dizziness, and light headedness. Mirtazapine and trazodone cause drowsiness and are usually taken at bedtime

Note: The drug lists presented here are not exhaustive, but are intended to represent the majority of antidepressants in use in the UK and US. Additional drugs may be approved in other countries.

Definition of Coercive Control via Colorado HB 24-1350 (Kayden's Law)

Here is a link to Colorado Bill 24-1350.

"Be informed and Stay aware."

SECTION 3:

Colorado Revised Statute 14-10-124. Best interests of the child.

a) "COERCIVE CONTROL" MEANS A PATTERN OF THREATENING, HUMILIATING, OR INTIMIDATING ACTIONS, INCLUDING ASSAULTS OR OTHER ABUSE, THAT IS USED TO HARM, PUNISH, OR FRIGHTEN AN INDIVIDUAL. "COERCIVE CONTROL" INCLUDES A PATTERN OF BEHAVIOR THAT TAKES AWAY THE INDIVIDUAL'S LIBERTY OR FREEDOM AND STRIPS AWAY THE INDIVIDUAL'S SENSE OF SELF, INCLUDING THE INDIVIDUAL'S BODILY INTEGRITY AND HUMAN RIGHTS. "COERCIVE CONTROL" INCLUDES ISOLATING THE INDIVIDUAL FROM SUPPORT, EXPLOITING THE INDIVIDUAL, DEPRIVING THE INDIVIDUAL OF INDEPENDENCE, AND REGULATING THE INDIVIDUAL'S EVERYDAY BEHAVIOR. "COERCIVE CONTROL" INCLUDES, BUT IS NOT LIMITED TO, ANY OF THE FOLLOWING: 

(I) ISOLATING THE INDIVIDUAL FROM FRIENDS AND FAMILY; 

(II) MONITORING, SURVEILLING, REGULATING, OR CONTROLLING THE INDIVIDUAL'S, OR THE INDIVIDUAL'S CHILD'S OR RELATIVE'S, FINANCES, ECONOMIC RESOURCES, OR ACCESS TO SERVICES; 

(III) MONITORING, SURVEILLING, REGULATING, OR CONTROLLING THE INDIVIDUAL'S, OR THE INDIVIDUAL'S CHILD'S OR RELATIVE'S, ACTIVITIES, COMMUNICATIONS, OR MOVEMENTS, INCLUDING THROUGH TECHNOLOGY;

(IV) NAME-CALLING, DEGRADING, OR DEMEANING THE INDIVIDUAL, OR THE INDIVIDUAL'S CHILD OR RELATIVE, ON A FREQUENT BASIS; 

(V) THREATENING TO HARM OR KILL THE INDIVIDUAL OR THE INDIVIDUAL'S CHILD OR RELATIVE, INCLUDING WEARING, ACCESSING, DISPLAYING, USING, OR CLEANING A WEAPON IN AN INTIMIDATING OR THREATENING MANNER; 

(VI) THREATENING TO COMMIT SUICIDE OR OTHERWISE HARM ONE'S OWN PERSON, WHEN USED AS A METHOD OF COERCION, CONTROL, PUNISHMENT, INTIMIDATION, OR RETALIATION AGAINST THE PERSON; 

(VII) THREATENING TO HARM OR KILL AN ANIMAL WITH WHICH THE INDIVIDUAL OR THE INDIVIDUAL'S CHILD OR RELATIVE HAS AN EMOTIONAL BOND; 

(VIII) THREATENING TO PUBLISH THE INDIVIDUAL'S, OR THE INDIVIDUAL'S CHILD'S OR RELATIVE'S, SENSITIVE PERSONAL INFORMATION, INCLUDING SEXUALLY EXPLICIT MATERIAL, OR MAKE REPORTS TO THE POLICE OR AUTHORITIES; 

(IX) DAMAGING THE INDIVIDUAL'S, OR THE INDIVIDUAL'S CHILD'S OR RELATIVE'S, PROPERTY OR HOUSEHOLD GOODS; 

(X) THREATENING THE INDIVIDUAL, OR THE INDIVIDUAL'S CHILD OR RELATIVE, WITH DEPORTATION OR CONTACTING AUTHORITIES BASED ON PERCEIVED OR ACTUAL IMMIGRATION STATUS, WITHHOLDING ESSENTIAL DOCUMENTS REQUIRED FOR IMMIGRATION, OR THREATENING TO WITHDRAW OR INTERFERE WITH AN ACTIVE IMMIGRATION APPLICATION OR PROCESS; OR 

(XI) FORCING THE INDIVIDUAL, OR THE INDIVIDUAL'S CHILD OR RELATIVE, TO TAKE PART IN CRIMINAL ACTIVITIES OR CHILD ABUSE.

In Addition to the section above, I included the following information noting required "Coercive Control" training for CFIs:

Section II 

In Colorado Revised Statutes, 14-10-116.5  Appointment in domestic relations cases - child and family investigator - disclosure - background check - definition.

II; B; (b.7)

THE CHILD AND FAMILY INVESTIGATOR SHALL STRIVE TO ENSURE THAT THE WRITTEN REPORT DOES NOT INCLUDE INFORMATION OR RECOMMENDATIONS THAT ARE BIASED, INCLUDING A BIAS REGARDING RELIGION, GENDER, GENDER IDENTITY, GENDER EXPRESSION, SEXUAL ORIENTATION, CULTURE, RACE, ETHNICITY, NATIONAL ORIGIN, OR DISABILITY. 

(f) (I) The court shall not appoint a person from the eligibility registry to be a child and family investigator for a case pursuant to this section unless the court finds that the person is qualified as competent by training and experience in, at a minimum, domestic violence and its effects on children, adults, and families; COERCIVE CONTROL; child abuse; and child sexual abuse in accordance with section 14-10-127.5. The person's training and experience must be provided by recognized sources with expertise in domestic violence, COERCIVE CONTROL, and the traumatic effects of domestic violence in accordance with section 14-10-127.5. Initial and ongoing training must include, at a minimum: 

A) No LESS THAN TWENTY HOURS OF INITIAL TRAINING, REQUIRED PURSUANT TO SECTION 14-10-127.5 (5)(a)(I); AND 

(B) No LESS THAN FIFTEEN HOURS OF ONGOING TRAINING EVERY FIVE YEARS, REQUIRED PURSUANT TO SECTION 14-10-127.5 (5)(a)(I). 

(II) NOTWITHSTANDING SUBSECTION (2)(f)(I) OF THIS SECTION, A CHILD AND FAMILY INVESTIGATOR WHO COMPLETED THE INITIAL TRAINING REQUIRED PURSUANT TO SECTION 14-10-127.5 (5)(a)(I) ON OR BEFORE JANUARY 1,2025, IS NOT REQUIRED TO COMPLETE SUPPLEMENTAL TRAINING OR THE ENTIRE TRAINING AGAIN FOR THE PURPOSE OF COMPLETING INTERVIEWING AND FORENSIC REPORT WRITING TRAINING REQUIRED PURSUANT TO SECTION 14-10-127.5 (5)(b)(IX) AND (5)(b)(X).

"I hope ALL Colorado County CPS departments require their caseworkers to be educated about Coercive Control abuse, and I hope Kayden's Law will be adopted throughout our nation."

Everything Colorado Parents Need to Know About Kayden's Law

Article blog located under Family Law of the JPB Legal website and can be found here.

In May 2023, Colorado became the first state to enact Kayden’s Law, a law designed to protect children from parental abuse by changing the way “parental alienation” and “reunification programs” operate within the family legal system. Kayden’s law was codified as Colorado Revised Statute § 14-10-127.5.

Why was Kayden’s law enacted?

According to the Colorado state legislature, approximately fifteen million children are exposed to domestic violence or child abuse each year. Since 2008, nearly 800 children nationwide have been murdered by a divorcing or separating parent, with more than 100 murders occurring after a court ordered the child into contact with the alleged abusive parent, despite objections from the parent who made the abuse allegations.

A child’s risk of abuse increases when the perpetrator of intimate violence separates from the child’s other parent or caregiver. Additionally, courts regularly discount claims of physical and sexual child abuse during allocation of parental responsibilities cases and are likely to disbelieve the parent making the allegations. Abusive parents frequently claim that the allegations are false and may hire experts who lack expertise in the alleged type of abuse to testify against the abuse allegations on their behalf, often relying upon unproven theories.

The purpose of this statute is to ensure that a child’s safety is the first priority of the court in custody proceedings. By strengthening the ability of the courts to recognize and adjudicate adult and child abuse allegations based on valid, admissible evidence, courts will be able to enter orders that protect and minimize the risk of harm to children involved. Court personnel who receive trauma-informed training on the dynamics, signs, and impacts of abuse and domestic violence will help protect and minimize the risk of harm to children in cases involving abuse allegations.

What is “parental alienation”?

Parental alienation is a term coined to describe when a child refuses to have a relationship with a parent due to manipulation by the other parent. Allegations of parental alienation often arise in allocation of parental responsibilities cases.

Sometimes, a parent who has an allegation or history of abuse or domestic violence will claim that they are being alienated from their child, often hiring experts from reunification programs to testify on their behalf. Courts have a history of weighing parental alienation claims more heavily than allegations of abuse, often resulting in the court ordering reunification therapy programs. Some of these programs have historically taken the child away from their protective parent and placed them with the accused parent, potentially cutting off all contact between the child and their protective parent.

It is important to note that not all parental alienation allegations are malicious attempts to hurt the other party. Parents can become alienated from their children, with or without allegations of abuse, and simply wish to be reintroduced into their children’s lives. Similarly, not all reunification therapies are harmful; in fact, many are scientifically proven to help children maintain strong bonds with both parents after a separation or divorce.

What is the court’s role?

So, what can the court do when parental alienation claims arise during an allocation of parental responsibilities hearing?

First, the court shall consider the admission of expert testimony and evidence only if the expert demonstrates expertise and experience working with victims of domestic violence or child abuse, including child sexual abuse, that is not solely forensic in nature.

The court shall then consider evidence of past sexual or physical abuse committed by the accused party, including:

• Any past or current restraining or protection orders

• Arrests for sexual violence, domestic violence, or child abuse

• Convictions of the crimes above

• Other documentation, including letters from a victim advocate or victim service provider, if the victim has consented, or a letter to a landlord to break a lease

Using these factors in addition to other evidence introduced during the proceeding, the court will decide in the best interest of the child whether to order the family to start reunification therapy, despite the alleged or actual history of abuse.

The statute also places limitations on the court and the actions it can take during an allocation of parental responsibilities proceeding. For instance, the court cannot:

• Remove a child from a protective party solely to improve a deficient relationship with an accused party

• Restrict contact between a child and a protective party solely to improve a deficient relationship with an accused party

• Order reunification treatment, unless the treatment is scientifically proven to be effective and safe, holds therapeutic value, and does not cut off the relationship between the protective party and the child

What if my child doesn’t want to see the accused parent?

According to the statute, if the court orders some type of reunification therapy or program and the child is resistant to spending time with the accused party, the court will not immediately force the child to comply. Instead, before the court will order the protective parent to force their child to spend time with the accused parent, their behavior must be evaluated by a mental health professional.

While it might be difficult to get your child to spend time with the other parent, their refusal does not allow you to ignore the court order. You must take the steps outlined by the court to improve the child’s relationship with the accused parent such as getting them into counseling, and potentially engaging in family therapy geared toward healing the relationship between the child and other parent and thereby reunifying their relationship.