Who should avoid antidepressants? A Guide to Contraindications and Risks

October 6, 2025 •

4 min read

During 2015–2018, 13.2% of U.S. adults reported using antidepressants in the past 30 days [1.4.2]. While these medications are vital for many, it's crucial to understand who should avoid antidepressants or use them with caution due to specific health risks and conditions.

Quick Summary

Certain individuals, including those with bipolar disorder, pregnant people, youth, and the elderly, require careful consideration before starting antidepressants. This also applies to people with specific medical conditions or those taking interacting medications.

Key Points

Youth Under 25: Face an increased risk of suicidal thoughts and behaviors, requiring close monitoring [1.3.1].
Bipolar Disorder: Antidepressants can trigger mania and are often contraindicated or used with a mood stabilizer [1.2.5].
Pregnancy: Use requires a risk-benefit analysis; some types (e.g., paroxetine) are discouraged due to potential birth defects [1.2.9].
MAOI Interactions: This class of antidepressants requires strict dietary and medication restrictions to avoid life-threatening reactions [1.6.7].
Serotonin Syndrome: Combining multiple serotonergic drugs, including St. John's Wort, can cause this rare but serious condition [1.6.2].
Bleeding Risk: SSRIs and SNRIs can increase bleeding risk, especially when taken with NSAIDs like ibuprofen or aspirin [1.6.2].
Pre-existing Conditions: Individuals with heart, liver, kidney, or seizure disorders need careful medication selection and monitoring [1.3.7, 1.3.8].

Navigating Antidepressant Treatment: Key Considerations and Contraindications

Antidepressants are a cornerstone of treatment for depression and other mental health conditions, with their use increasing nearly 400% between 1988 and 2008 [1.4.1]. While generally considered safe under medical supervision, they are not suitable for everyone [1.3.1]. A thorough evaluation of a patient's health history, existing conditions, and other medications is essential to prevent adverse effects [1.3.1].

Special Populations and Age Groups

Certain demographics must exercise particular caution with antidepressant use.

Children, Teenagers, and Young Adults (Under 25) The U.S. Food and Drug Administration (FDA) requires a "black box warning" on all antidepressants regarding an increased risk of suicidal thoughts and behaviors in individuals under the age of 25, especially during the initial weeks of treatment or after a dose change [1.2.1, 1.3.1]. Close monitoring by healthcare providers and family is critical for this age group [1.3.5, 1.3.7].

Pregnant or Breastfeeding Individuals The decision to use antidepressants during pregnancy involves balancing the risks of the medication against the risks of untreated depression [1.3.1, 1.5.4]. While the overall risk of birth defects is low, some antidepressants like paroxetine have been linked to a slightly higher risk of fetal heart defects, particularly in the first trimester [1.2.9, 1.5.5]. Other options like certain SSRIs (sertraline, citalopram) are often preferred [1.2.9]. Some medications can pass into breast milk, so discussion with a doctor is vital [1.3.2].

Older Adults (Over 65) Older adults may be at increased risk for side effects like falls, fractures, and bone loss [1.2.5]. They can also experience low sodium levels (hyponatremia) [1.2.4]. Liver function can be less efficient in older individuals, increasing the risk of drug interactions [1.2.2]. For these reasons, certain antidepressants, particularly Tricyclic Antidepressants (TCAs), are often not recommended for the elderly due to risks of heart toxicity and falls [1.3.7].

Pre-existing Medical Conditions

Individuals with certain health conditions may need to avoid specific types of antidepressants or be monitored more closely.

Bipolar Disorder: Antidepressants can trigger manic or hypomanic episodes in people with bipolar disorder and may worsen the condition [1.2.1, 1.2.5]. Treatment for bipolar disorder often involves mood stabilizers instead of or in addition to antidepressants [1.6.3].
Seizure Disorders: Some antidepressants, particularly bupropion, can increase the risk of seizures and should not be used by anyone with a seizure disorder [1.3.7].
Heart Conditions: Certain antidepressants, especially older TCAs, can cause heart rhythm problems, palpitations, or increased heart rate [1.2.4, 1.3.8]. Patients with pre-existing heart conditions require careful selection and monitoring, often including an ECG [1.3.8].
Liver or Kidney Disease: Since the liver and kidneys are involved in metabolizing and clearing medications, impaired function can affect drug levels [1.2.2, 1.3.7]. For instance, the antidepressant nefazodone carries a warning for liver failure and should not be used by those with liver disease [1.3.7].
Bleeding Disorders: SSRIs and SNRIs can increase the risk of bleeding, especially gastrointestinal bleeding. This risk is heightened when taken with other medications that affect bleeding, such as NSAIDs (e.g., ibuprofen, aspirin) or blood thinners like warfarin [1.2.2, 1.6.2].
Glaucoma: Tricyclic antidepressants can increase pressure in the eye, which is a concern for individuals with glaucoma [1.2.3, 1.2.6].

Significant Drug Interactions

Combining antidepressants with other substances can lead to dangerous reactions.

Monoamine Oxidase Inhibitors (MAOIs): This older class of antidepressants has severe interactions. They should never be combined with other antidepressants (especially SSRIs), certain pain medications, or the herbal supplement St. John's Wort, as this can cause serotonin syndrome—a potentially fatal condition resulting from excessive serotonin levels [1.2.6, 1.6.3]. MAOIs also require strict dietary restrictions, avoiding tyramine-rich foods like aged cheeses and cured meats, to prevent a hypertensive crisis [1.6.7].
Other Serotonergic Drugs: Combining multiple drugs that increase serotonin (including other antidepressants, St. John's Wort, and some migraine or pain medications) can lead to serotonin syndrome [1.6.2, 1.6.7]. Symptoms include confusion, agitation, high fever, sweating, and rapid heartbeat [1.2.1].
Alcohol: Alcohol is a depressant and can worsen depression symptoms. It can also enhance side effects like drowsiness and dizziness, and make the antidepressant less effective [1.2.4, 1.3.3].
NSAIDs and Blood Thinners: As mentioned, combining SSRIs/SNRIs with NSAIDs or anticoagulants significantly increases the risk of bleeding [1.2.2, 1.6.2].

Comparison of Antidepressant Classes


Class	Key Reasons for Caution/Avoidance	Examples
SSRIs	Risk of serotonin syndrome, bleeding risk (with NSAIDs), discontinuation syndrome, potential for suicidal thoughts in youth [1.2.2, 1.2.7].	Sertraline (Zoloft), Fluoxetine (Prozac) [1.2.9]
SNRIs	Similar risks to SSRIs; may also increase blood pressure or worsen liver problems [1.2.5, 1.2.9].	Duloxetine (Cymbalta), Venlafaxine (Effexor XR) [1.2.9]
TCAs	High risk of overdose, heart rhythm problems, significant side effects (drowsiness, constipation, blurred vision); generally not for elderly or those with heart issues [1.3.7].	Amitriptyline, Nortriptyline (Pamelor) [1.2.9]
MAOIs	Severe drug and food interactions leading to hypertensive crisis or serotonin syndrome; used as a last resort [1.2.6, 1.6.7].	Phenelzine (Nardil), Isocarboxazid (Marplan) [1.6.7]
Atypicals	Varies by drug. Bupropion increases seizure risk; Nefazodone has a liver failure warning [1.3.7].	Bupropion (Wellbutrin), Mirtazapine (Remeron) [1.2.2, 1.3.7]

Conclusion

While antidepressants are transformative for many, they are not a one-size-fits-all solution. A collaborative and transparent relationship with a healthcare provider is the most important factor in safe and effective treatment. Individuals who are young, elderly, pregnant, have bipolar disorder, or suffer from certain heart or liver conditions are among those who should avoid or be extremely cautious with antidepressants. Always disclose your full health history, including all medications, supplements, and alcohol use, to your doctor before starting any new treatment [1.3.1, 1.3.3].

For more information, you can visit the National Institute of Mental Health (NIMH).

Frequently Asked Questions

It is generally not recommended to take antidepressants alone if you have bipolar disorder, as they can trigger manic or hypomanic episodes. Treatment for bipolar depression typically involves mood stabilizers or atypical antipsychotics [1.2.1, 1.2.5].

The decision is based on balancing risks and benefits. While the overall risk of birth defects is low, some antidepressants like paroxetine are often avoided. Sertraline and citalopram are commonly considered safer options. Always consult your doctor [1.2.9, 1.5.4].

Studies have shown that children, teens, and young adults under 25 may have an increased risk of suicidal thoughts and behaviors when starting antidepressants. The FDA requires a 'black box' warning on these medications to highlight this risk [1.2.7, 1.3.1].

Alcohol can worsen depression, increase sedative side effects like drowsiness, and make the medication less effective. For those on MAOIs, drinking certain alcoholic beverages can cause a dangerous spike in blood pressure [1.2.4, 1.6.7].

If you take an SSRI or SNRI, using NSAIDs like ibuprofen or aspirin can increase your risk of gastrointestinal bleeding. It's important to discuss this with your doctor [1.2.2, 1.6.2].

Serotonin syndrome is a rare but serious condition caused by having too much serotonin in your body. It can happen when you combine medications that increase serotonin, like SSRIs and St. John's Wort. Symptoms include agitation, fever, sweating, and rapid heartbeat [1.2.1, 1.6.3].

Most antidepressants do not require dietary restrictions. However, if you are taking a Monoamine Oxidase Inhibitor (MAOI), you must avoid foods high in tyramine, such as aged cheeses, cured meats, and some wines, to prevent a life-threatening hypertensive crisis [1.6.7].