Initial Antidepressant Selection: Let the Client Choose

Last week a middle-aged woman self-referred to me wanting an assessment for depression. Her circumstances in brief are as follows: She is currently going through a very difficult divorce settlement, reports that she awakens repeatedly throughout the night and has lost approximately 12 pounds since the divorce proceedings began. She added that daytime exhaustion is wearing her down – personally, socially and occupationally. She is well-educated and has considerable insight, claiming that what she’s experiencing is temporary and sort of “comes with the territory” given the situation at hand. She reports no prior history of depression. In her current state, she readily meets criteria for Major Depression, or Reactive Dysphoria, at least.

She inquired about antidepressant treatment and whether or not I believed medication might be helpful. I told her I believed an antidepressant trial would be worth a try as she is becoming increasingly vegetative and melancholic. The clincher – for me – pursuant to her trying medication came when she stated that she didn’t expect a drug to solve her problems, but that maybe an antidepressant would help her manage the stressors affecting her during this trying time.

So we discussed possibilities. She was somewhat familiar with the SSRIs and wondered about Lexapro. She mentioned that her sister had taken Lexapro a couple of years ago for a few months and was pleased with the results. We discussed Lexapro’s side effects, particularly possible daytime uneasiness, insomnia at first, weight gain and sexual dysfunction. Then we addressed the initial benefits – possible increased energy, motivation and a “brighter” feeling. She concluded the possible benefits outweighed the risks because she wasn’t sleeping well anyway, could use a few extra pounds and had no interest in sexual activity at this time.

No one antidepressant or antidepressant class consistently outperforms another. So here’s my suggestion: Let the client choose his or her own antidepressant based on acceptable side effects. By acceptable side effects, I mean those that the client is willing to put up with or tolerate.

Prepare your clients for an antidepressant trial by first focusing on drug side effects – not therapeutic effects. Why? Side effects are all but guaranteed to happen; therapeutic effects, who knows, what with the paltry symptom remission rates of antidepressants. Clients should then be encouraged to share their choices with their prescribers, where they aren’t likely to get much if any pushback.

Whenever we have exercisable choices, we feel empowered. The more empowered we feel, the greater the likelihood we’ll be more compliant with our choices.


Joseph Wegmann, R.Ph., LCSW is a licensed clinical pharmacist and a clinical social worker with more than thirty years of experience in the field of psychopharmacology. His diverse professional background in psychopharmacology and counseling affords him a unique perspective on medication management issues. In addition to consulting with numerous psychiatric facilities, he has presented psychopharmacology seminars to thousands of clinicians in 46 states.

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