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Antidepressant Therapy

In the past three decades, antidepressants have become the treatment of choice for people with major depression. Before World War II, these drugs did not exist. In the 1950s two drugs, one an antipsychotic and the other a tuberculosis medication, were accidentally found to elevate the moods of depressed individuals. Since then, a host of new substances has been synthesized, specifically for the treatment of depression. Most recently, medications have been developed that specifically target the particular neural pathways of depression, with less generalized neural impact, and therefore far fewer side effects.

Current theory links the biochemical causes of mood disorders to a deficiency of three of the brain's neurotransmitters-serotonin, norepinephrine and dopamine. Antidepressants don't actually create more serotonin, norepinephrine and dopamine. Instead, they are believed to limit the reabsorption of these chemicals into the brain's nerve cells, thereby increasing the amounts of neurotransmitters available in the space (synapse) between the sending and receiving cells. This in turn causes a better neural transmission from cell to cell, resulting in an elevation of mood.

There are three groups of antidepressants. The first and oldest group is the tricyclics; examples include Imipramine (Tofranil) and Amitriptyline (Elavil). Like the other antidepressants, tricyclics take two to four weeks to begin working, and six to eight weeks to achieve full effectiveness. Their side effects may include dry mouth, blurred vision, sexual dysfunction, fatigue, weight gain, constipation, and abnormalities in the cardiovascular system. Such discomforts can often deter a person from staying on the medication long enough for the beneficial effects to begin to be felt.

The second group of antidepressants is called monoamine oxidase (MAO) inhibitors, or MAOIs for short (examples are Nardil and Parnate). Monoamine oxidase is an enzyme that breaks down neurotransmitters. Hence, by inhibiting the production of MAO, these drugs increase the amount of neurotransmitters retained in the synapses. Unfortunately, the MAOIs have cumbersome dietary restrictions. They cannot be taken with foods that contain the amino acid tyrosine-such as aged cheese, beer, wine, chocolate and liver.

The third and most recently developed class of antidepressants is known as the SSRIs - selective serotonin reuptake inhibitors. This group, which includes Prozac, Zoloft, Celexa and Paxil, is as effective as the tricyclics in treating depression, but generally has fewer and milder side effects. Nonetheless, the SSRIs may be highly agitating for some patients (producing anxiety and insomnia), who thus may require additional sleeping medications.

Finally, there exists a class of "atypical" antidepressants that includes Serzone, Effexor and Wellbutrin. No one class of antidepressant is better than any other. It cannot be overstated that different medications work for different people, depending on the complex interaction between an individual's biochemistry and the drug's pharmacology. This is why finding the right medication is often a matter of trial and error and good medical follow-through.

Antidepressants do not get you "high"; neither are they addictive. They work by reestablishing the right proportion of neurotransmitters in your brain so that nerve impulses can be effectively communicated from cell to cell. In the start-up period of taking antidepressants there may be a trade-off. While waiting for the medication to take effect, you may have to endure side effects which may (or may not) be temporary, before you know if the antidepressant will work for you. Moreover, it may take several trials on different drugs before the right one is found. For those persons who find relief from the hell of depression, enduring the side effects may well be worth the discovery of a medication that lifts one's mood. Moreover, in many instances the side effects are temporary and drop out with continued usage.

It is also important to note that in a small minority of cases, some people experience a recurrence of depression while still on medication, a phenomenon known as "Prozac poop-out." When this occurs, relief may be attained by changing medications or dosages under careful medical supervision.

How long should medication be taken?

The short answer is "as long as you need it." This will depend on how well your body can rebalance its biochemistry on its own. Some people have only one major episode and never need treatment again (just as some individuals suffer just one heart attack or one bout with cancer). Others heal from depression, go off medication and continue to feel well until a later date, when the depression returns. This usually requires going back on medication and/or engaging in other forms of treatment until the episode passes.

Finally, some folks discover that as soon as they stop medication, their symptoms return. These people usually need to take antidepressant medication on a long-term basis in order to correct underlying biochemical imbalances. As I mentioned earlier, if you need to stay on medication to remain well, try not to think of this as a personal weakness. If your body requires assistance to remain in balance, it is no different than having any other illness that requires medication (e.g., insulin for diabetes, antihypertensive drugs for high blood pressure, cholesterol-lowering drugs for heart disease).

Unfortunately, studies show that 70 percent of patients prematurely discontinue their medication-or discontinue their medication abruptly rather than gradually. Such premature or abrupt cessation is associated with a 77 percent increase in the rate of relapse or recurrence of the depressive episode. The moral of the story is do not make any changes in your medication regimen without telling your physician.

Knowing your medication

To increase the likelihood that a medication will work well, patients and families must actively participate with the doctor prescribing it.

Questions you should ask include:

  • What is the name of the medication and what is it supposed to do?
  • When and how often do I take it, and when do I stop taking it, if at all?
  • What, if any, food, drinks, other medications or activities should I avoid while taking the prescribed medication?
  • What are the potential side effects, and what should I do if they occur?
  • What written information is available about the medication?