For people living with myasthenia gravis (MG), taking care of mental health is just as important as managing physical symptoms. Depression and anxiety are more common in people with long-term conditions like MG. Left untreated, these mental health challenges can sometimes make MG symptoms worse. Stress is a well-known trigger for MG flares (also called exacerbations), which can lead to increased muscle weakness.

If you’re thinking about taking an antidepressant, it’s important to know that not all medications are safe for people with MG. Some drugs — including certain antidepressants — can worsen muscle weakness in MG, while others are generally considered safer. Before starting any new medication, including antidepressants, always talk to your MG specialist to make sure it’s the right choice for you.

In this article, we’ll go over which antidepressants are usually safer for people with MG and which ones are best to avoid.

How Are Depression and MG Linked?

Before we talk about medications, let’s take a moment to understand why depression and MG often go hand in hand. Living with a condition like MG can be challenging, especially when symptoms make daily tasks harder. Not knowing when flare-ups will happen and managing the condition can lead to frustration, stress, or sadness.

Emotional Toll

Living with an autoimmune disease like MG — where the immune system mistakenly attacks the body’s cells — can be emotionally exhausting. The physical limitations, frequent doctor visits, and uncertainty about the future may contribute to feelings of sadness, anxiety, stress, or hopelessness.

Physical Impact

Depression can also make MG symptoms worse. Studies have shown that emotional distress can trigger MG exacerbations, making muscle weakness and fatigue even harder to manage. This creates a cycle where MG worsens depression, and depression worsens MG.

For example, stress hormones in the nervous system, like cortisol (a hormone that helps the body respond to stress), can affect the immune system and may make autoimmune conditions like MG worse. This connection between stress, the immune system, and MG symptoms makes managing mental health not just a matter of emotional well-being but also a key part of managing the physical symptoms of MG.

Antidepressants To Avoid With Myasthenia Gravis

Before we go over safer options, it’s important to know which antidepressants are usually not recommended for people with MG. Antidepressants come in different types, and each works differently.

Some Tricyclic Antidepressants

Tricyclic antidepressants (TCAs) work by affecting multiple chemicals in the brain, which can lead to more side effects. Medications like amitriptyline (sold under the brand names Elavil and Vanatrip) and imipramine (Tofranil) are known to cause muscle weakness and fatigue, which can make MG symptoms worse. TCAs can cause dry mouth, blurred vision, and constipation, which may be even worse for people with MG who already have these symptoms.

However, some TCAs are less likely to cause these side effects, such as desipramine and nortriptyline. These drugs may be safer to take if your healthcare provider decides you need an antidepressant from this group.

Lithium

Lithium is associated with worsening MG symptoms and should be used with extreme caution or avoided. Lithium carbonate, often used for mood stabilization in bipolar disorder, has been reported to cause new cases of myasthenic symptoms and make MG symptoms worse in people who were already diagnosed.

Antidepressants Generally Considered Safer With MG

Now, let’s look at antidepressants that are typically considered safer for people with MG. Remember, “safer” doesn’t mean risk-free. Always consult your doctor to find the best option for your needs.

1. Fluoxetine

Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI) that helps increase levels of serotonin, a “feel-good” chemical in the brain. It’s commonly prescribed for depression, anxiety, and obsessive-compulsive disorder (OCD), so it may be a good choice for people who need a multipurpose antidepressant.

Although some studies list muscle weakness as a possible side effect, fluoxetine is generally well-tolerated in most people. While one small case-study (with only one person) showed possible effects on MG, another study with a small number of people showed no effect.

2. Bupropion

Bupropion (sold as Wellbutrin and Aplenzin) works differently than SSRIs. It raises levels of norepinephrine (which helps with alertness and energy) and dopamine (a chemical linked to pleasure and motivation) in the brain. It’s used to treat depression and help people quit smoking.

Bupropion is known to slightly increase the risk for seizures, so it should be used cautiously in people with MG. At low doses, however, it’s generally considered safe. In a small study, bupropion was shown to be low-risk for people with MG, and may also help with fatigue and low energy — common MG symptoms.

3. Sertraline

Sertraline (Zoloft) is another SSRI that helps increase levels of serotonin in the brain. SSRIs like sertraline are often the first choice for people with depression because of their lower risk of side effects.

Studies suggest that sertraline is well-tolerated but has been associated with a very small risk of worsening MG symptoms. It can still be, however, considered safer for people with MG than most TCAs and lithium.

Sertraline is also available in a liquid form, which can be helpful for people who have difficulty swallowing due to MG.

4. Citalopram

Citalopram (Celexa) is another SSRI that helps balance serotonin levels in the brain. It’s one of the most commonly prescribed antidepressants due to its effectiveness and relatively mild side effects, and is often prescribed for depression in adults.

Citalopram is generally safe for most people with MG because it doesn’t usually affect muscle function. However, one study found some possible risks, so doctors recommend careful monitoring.

5. Escitalopram

Escitalopram (Lexapro) is an SSRI that boosts serotonin levels to improve mood and reduce anxiety. It’s a newer version of citalopram (Celexa) and is often prescribed because it has fewer side effects. It’s often prescribed for generalized anxiety disorder and major depressive disorder.

A small study reported that escitalopram has a lower risk for people with MG, which provides an additional option for more serious depression and anxiety.

Avoiding Drug Interactions

When managing MG, it’s essential to avoid harmful drug interactions by keeping your healthcare team informed about every prescription and over-the-counter (OTC) product you’re taking. People with MG often take multiple medications, including:

• Corticosteroids (steroids) such as prednisone
• Immunosuppressants like azathioprine (Imuran, Azasan), mycophenolate mofetil (CellCept, Myfortic), or cyclosporine (Gengraf, Neoral, Sandimmune)
• Pyridostigmine (Mestinon)

These medications for the management of myasthenia gravis symptoms can interact with antidepressants, potentially making MG worse or causing other unwanted side effects.

Key Steps for Medication Safety

• Inform your neurologist and pharmacist about every medication you take, including OTC drugs and supplements.
• Be careful with multiple prescriptions, as certain drug combinations can worsen muscle weakness.
• Ask about potential interactions between antidepressants and MG medications before starting a new treatment or changing your medication dosage or schedule.

Safer Choices for You

Managing depression and anxiety is crucial for overall well-being, especially when living with a long-term condition like MG. Although some antidepressants can worsen MG symptoms, others are generally safer and can help improve your quality of life. Remember:

• Always consult your MG neurology team before starting or stopping any medication.
• Keep track of how you feel and report any changes to your healthcare team.
• If you’re struggling with depression or anxiety, don’t hesitate to reach out to a mental health professional.

Finding the right antidepressant may take time and require trial and error. You’re not alone in this process — be patient with yourself and work closely with your healthcare team to find the best solution. With the right support, you can find a treatment plan that helps you feel better both mentally and physically.

Talk With Others Who Understand

On MGteam, the social network for people with myasthenia gravis and their loved ones, members come together to ask questions, give advice, and share their stories with others who understand life with myasthenia gravis.

Have you considered starting treatment for depression? Share your experience in the comments below, or start a conversation by posting on your Activities page.