This article reviews the antidepressant drugs currently available in Europe and/or the United States from the perspectives of their clinical efficacy, pharmacokinetics, pharmacology, structure–activity relationships, metabolism, and mechanisms of action. The older nonselective monoamine oxidase inhibitors (e.g. phenelzine, tranylcypromine) have largely been replaced by agents that selectively inhibit monoamine oxidase A (e.g. moclobemide) or by inhibitors of serotonin/norepinephrine monoamine transporter reuptake mechanisms. The first generation of such drugs, the tricyclic antidepressants, suffered from a number of dangerous and unpleasant adverse side effects caused by their many other pharmacological actions on the heart and on cholinergic and other monoamine receptors in the brain. Most of the current antidepressants are serotonin‐selective reuptake inhibitors or mixed norepinephrine/serotonin reuptake inhibitors that possess a safer side‐effect profile. These drugs have gained widespread use in the treatment of depression and a number of related psychiatric conditions, including phobias and the treatment of generalized anxiety disorder (GAD). Some agents that act as norepinephrine‐selective reuptake inhibitors (e.g. reboxetine) are also clinically effective and there is considerable overlap between noradrenergic and serotonergic mechanisms in the CNS. Monoamine selectivity can also be altered by the formation of active metabolites
in vivo
. All approved antidepressants require several weeks of treatment before the maximum clinical benefit is seen. This, although perhaps somewhat agent‐specific, might be attributable to drug‐induced alterations in the expression of receptors in brain and/or alterations in the expression of neurotrophic factors (e.g. brain‐derived neurotrophic factor, vascular endothelial growth factor) associated with changes in neurogenesis in certain brain regions. New approaches to future antidepressant drug discovery include triple reuptake inhibitors, antagonists for glutamate NMDA receptors, corticotrophin‐releasing factor receptors, or agonists/antagonists for galanin receptors. There is particular interest in ketamine analogs and certain other agents (considered as drugs of abuse) because of their rapid and persistent antidepressant effects, especially in treatment‐resistant depression. Agents with mixed mechanisms also are being pursued.