Depression Meds- Which one? - Q and A
Why is this an important subject?
Depression of the Unipolar variety is very common and often goes undiagnosed, and when it is , it is often not properly treated. Depression is a major cause of distress and impairment often with mostly physical symptoms, again not recognized as having mental health causes, and goes untreated. This is an introduction to using modern anti depressants, some of what I know, and what you should know, so you can be a better informed consumer of mental health services especially of these remarkable medications.
Any warnings before we begin?
Remember first be sure of the diagnosis; using these great medications for the wrong diagnosis may make matters catastrophically worse. Be relatively sure it is not an Unstable Mood Disorder or a problem that is part of the Bipolar Spectrum. MoodAnxietyScreen, Depression which is it, Unipolar or the unstable Bipolar type, Q and A, Unipolar Stable Depressive Disorders Q and A, Unstable Mood Scales Historical Markers, Treatment Scale, Symptom Picutre, Bipolar and Unstable Mood Disorders, Childhood Bipolar and Atypical Mood Disorders Q and A, Warning AntiDepressants, AntiDepressantWorsenSymptoms
Why are you saying modern antidepressants?
Previous to the present medication we use for depression, we used medicines classified as “tricylic anti depressants”, which were effective but not as safe and well tolerated in terms of their side effects, as our modern medications for depression. They are still around variously used in their generic form of Elavil, Tofranil, Pamelor, and others, with the one exception to the un-common usage is Anafranil which is still selectively more useful for depression, anxiety states, and specifically for Panic and OCD, when the modern meds aren’t helpful of helpful enough. The use of Anafranil and the others will be discussed elsewhere.
What were the problems with safety and side effect intolerance, with these older medications?
The problem with safety was that as little as a two week supply if taken in a overdose could be fatal, and their side effects which included tiredness, dry mouth, constipation, problems with memory, concentration and others often caused sufficient problems that people wouldn’t stay on the medications long enough to get good effects. The modern medications we will be discussing work with few of any negative effects and are relatively safe if one took too much in an overdose attempt, therefore they are easier to prescribe, safer, and patients will take them for much longer periods of time, which all helps for better treatment outcomes.
How are the modern antidepressants classified?
These modern medications used to treat depression are classified based on the theoretical mechanism of action, on serotonin, nor-epinephrine, and dopamine. They are labeled after their actions on inhibition of these chemical in parts of the brain, the SSRI’s,[Prozac, Zoloft, Celera, Lexapro, Lenox] are the selective serotonin reuptake inhibitors, SSNRI’s[Effexor, Cymbalta] for both serotonin and nor-epinephrine inhibition, SDRI’s,[Welbutrin] for dopamine, and SNRI’s[Strattera] for only nor-epinephrine. Strattera is used for ADHD, but theoretically should also help anxiety and depression.
Why is it important to know these different chemical types?
No two depressions are the same on the descriptive or biochemical level and thus have differing responses to the antidepressants depending on their chemical mechanism. Some respond more selectively to serotonin, some to dopamine, some to both, some to nor-epinephrine-serotonin types , any combination is possible, including needing all three chemicals to be modified in the brain. In theory the ideal antidepressant would work on all three chemicals; the best one can do until that one is discovered or made is to combine two to get a similar mechanism of action.
Are they equally effective or is one better than another?
They are statistically equal in effectiveness, but for a specific person one may be much better for depression and much better tolerated because of having few or no side effects.
Is there any way to know which medication to pick?
If there is previous history of medication responsiveness in the individual or their family that may be the first choice, otherwise one must depend on the response the patient gets with an individual medication. The individuals unique responsiveness must be the guide, not some expected results made by some theoretical construct, or what the manufacturer, or others say the response should be, nor can we go completely by family history, because even in identical twins who are biochemical clones, medication responses can be vastly different, what helps one may only cause side effects in the other. If there is such variation of response in twins imagine what it may be in less close relatives or in the general public.
Are there some general trends or effects one could expect with the various chemical profiles?
The more purely serotonin ones tend to be better for depression, those with serotonin-norepinephrine effects supposedly help anxiety more, and perhaps are slightly better for concentration, this is supported by the clinical effects of Strattera which is used for concentration problems of ADHD especially with anxious people. Welbutrin the dopamine medication is definitely better for concentration, and seems to help more with drive and motivation, being energizing, but it may make anxiety worse. These are only general guidelines and there are people who don’t get energized by Welbutrin, but sedated and slowed down, especially if they have what I call ADHD brain chemistry, and there are those who become much more anxious with the norepinephrine medication; the variation or responses are vast as the uniqueness of brain chemistry. Many times only multiple clinical trials need to be done to get an optimal and adequate response.
I have heard of people having a hard time getting off these medications, is this because they are addicting or habit forming?
They are not habituating or addicting, but depending on the individuals receptor sensitivity, some people will have more rebound symptoms if they quickly stop the medication, or even if they miss a few doses. I have seen this the most with Paxil and Effexor, but this is only my experience, and have seen it the least with Prozac. It may be this is more of an issue of general brain sensitivity to any substance that changes mood, thinking, behavior, and its ability to fuel physical symptoms associated with panic and its equivalents. The other factor may be how long a medicine stays in ones system called the half life, those with longer half lives, like Prozac leave the brain more slowly, thus is less likely to cause rebound symptoms.
What are the most common mistakes in prescribing these medications?
There are a few I see over and over, doses not being maximized, not staying on the medication long enough, and not fine tuning the treatment balancing negative with positive effects to maximize compliance long enough to get the best effect, and not treating other disorders that may be fueling the depression.
What do you mean maximizing the dose of medication?
This means that the dose is not pushed high enough to get the best results. As long as there are no prohibitive negative effects the dose should be maximized and fine tuned, done by trial and error always based on the individuals unique responses, much like an optometrist will go back and forth until he has the best lens to maximize your vision. The same approach should be taken with medication prescribing. If your are 80% better that may be great, but if you could be closer to 100% by taking higher doses of a medication with no adverse reactions, than that would be in your best interest, and would further protect you from complications and relapses.
How long is long enough on these medications?
Usually it is recommended that one stays relatively symptom free for 9 months to a year, depending on the individual and what may be causing the depression and possible complicating disorders. You want to feel like your old self, or close to it, and then taper off the medication based on individual responses. Most people go off the medications too soon, and then have a partial or full relapse that is not only harder to treat, causes a new problem feeling like a treatment failure, and also fuels more intense and frequent episodes.
Are there other reasons why people stop their medication too soon?
Besides feeling better, though still not their old self, some non dangerous but significant side effects may occur, and the person may feel that are not worth continuing the medication. These may be feeling too mellow, or problems with concentration or memory, increased appetite, being to calm, relaxed or tired, lacking get up and go, a zest for life, not enjoying things as much as you did previously though not feeling depressed anymore , this sometimes showing itself in lack of sexual desire, mild but significant stomach or intestinal upset, headaches, jumpiness, agitation sleep disturbance, too much or too little, to name the most common.
How are these side effect managed?
Most of the time being sensitive to them and adjusting the dose up or down , or when you take the medicine, for example taking it at bedtime rather than in the morning, or spitting the dose, and spreading it out in the day will be sufficient to help. Changing to another similar medicine sometimes will help, or even a dissimilar one, for often the opposite or an expected effect may occur. Sometimes lower the dose but combining the original medication with another one in a low dose will fix the problem, for example Prozac is working great for your depression, but you lack the get up and go you used to have, your concentration is a little off, and your sex drive not like it used to be; a simple and effective fix is to lower the Prozac dose and add a little Welbutrin. Many other possible combinations just in this class can help these nuisance but significant side effects.
Do you ever have to go out of the class to manage these side effects?
There are many reasons to do this, I will go over a few. Say you are doing great on your anti depressant but the stimulating effects are bringing our a slight tremor your always had but now is worse, and though not an impairment is causing some embarrassment. Adding a beta blocker called Inderal or propanalol in small doses can stop this. Another common issue is mild sleep disturbance, here using an older medication like trazadone only at bedtime may help. For residual panic like anxiety or form recurrent muscle contraction headaches a medicine from the class of benzodiazepines, like lorazepam, or Klonopin used as needed may be helpful. There are many other nuisance side effects that may be easily managed, such as the stomach and intestinal upset that is usually temporary and can be managed with a medicine like promethazine, or sometime OTC acid inhibitors such as Pepcid or Zantac.
What about complicating disorders or problems?
This is a discussion in itself, but the important thing is to realize if there is another disorder present if it is not also treated it could not only fuel your present disorder, but result in relapses. Commonly excess anxiety may be present and go unrecognized and all that is required is increasing the present dose of medicine. Untreated unrecognized anxiety is a major cause of relapses and other complications. Equally common but much more dangerous example is using substances of abuse no matter how infrequent and how little, if this is not treated it can only cause problems. The same can be said for environmental stresses, some of which may be seen as pleasurable or harmless , like the youth who play excessive video games, stay up late, over stimulate their brains, become sleep deprived to the point the medications can’t work like they should. Another common problem is inactivity, depression slow you down and make you tired, and a little exercise can combat this as well or better than the medications. Of course ones psychology or mental attitude or mental mechanism may not be the most effective and not responsive to medication and psychotherapy may be indicated. For long term mal adaptive mental attitudes sometime only the techniques for these residual problems that may be fueling symptoms and causing relapses is a combination of specific cognitive behavior therapy and using the techniques and practice of what I call applied clinical mindfulness.