Lesson 3: Antidepressants
Coping with Side Effects and Long Term Treatment
No matter which antidepressant you find yourself on, your drug has a perverse way of making its side effects known almost at once, weeks before its healing power kicks in, when the depression is raging at its fiercest. The side effects tend to diminish over time, but too late for many distressed patients who have given up long before then. Here - and this is tough - you must have faith. Barring some extreme side effect or medical emergency, you need to give your prescription a full six weeks to work.
And another six weeks, should you have to switch medications. And again, another six weeks, if necessary.
The most notorious side effect of the SSRIs is sexual dysfunction (found by one study to be as high as 40 percent, including women, who, incidentally, have no Viagra to turn to). The worst antidepressants in terms of sexual dysfunction, according to one study, were Paxil at 43 percent, Remeron at 41 percent, and Prozac with 37 percent. (Some authorities say that Remeron has no sexual side effects.) The lowest were Wellbutrin (22 percent) and Serzone (28 percent). Falling in between were Zoloft, Effexor, and Celexa. In some people Wellbutrin can act as an aphrodisiac, and is often used in combination with an SSRI to counter the sexual dysfunction side effects.
A University of Texas study of 337 adult depressed patients treated with an SSRI over a year found that 40 percent had at least one side effect on their medical record. The most common were sleep problems, GI/nausea/diarrhea, and fatigue or low mental alertness. Ninety-six patients (28 percent) had 101 medication changes after initial therapy, including 33 additions of medication, 31 switches to another antidepressant, 28 discontinuation of therapy due to adverse events, and nine dose changes.
An article in Medscape cited the Physician's Desk Reference and an article in the New England Journal of Medicine for these side effects and their frequency: increased anxiety (5-8 percent), loss of strength/fatigue (9-15 percent), diarrhea (12 -24 percent), dry mouth (10-18 percent), insomnia (13-28 percent), nausea (21-30 percent), somnolence (13-23 percent), and sexual dysfunction (13-17 percent).
But side effects are no reason for throwing in the towel. Side effects can often be countered by simply lowering the dosage (under the supervision of your doctor). According to an article in the American Family Physician: "Decreasing the dosage of an antidepressant may improve libido while maintaining adequate treatment of depression. In one study, 73 percent of patients whose SSRI dosage was halved reported improved sexual function while antidepressant effectiveness continued."
Combination therapy is a sophisticated way of working with low dosage drugs, typically by combining antidepressants or an antidepressant with lithium or a thyroid drug or another type of drug. The idea is two low dose drugs working together will fly under the side effects radar while boosting the other's therapeutic performance.
Combination therapy can also be used at normal doses, especially for those presently deemed "refractory." A study of Prozac and the antipsychotic drug Zyprexa, for example, found the two worked together best for hard-to-treat depression patients as opposed to each drug alone.
Diet and lifestyle choices also help counter side effects. We will discuss these options in another lesson.
A 1999 survey by the National Depressive and Manic-Depressive Association of 1,370 people with depression found less than a third to be satisfied with their antidepressants. But the alternative can be unthinkable. According to Michael Thase MD of the University of Pittsburgh School of Medicine: Between 50 and 70 percent of those who have experienced one episode of major depression will experience another at some later stage. The risk of subsequent episodes or recurrent depression increases from 50 to 70 to 90 percent across the first three depressive episodes. Chronic minor depressive disorders similarly place the individual at risk of major depression.
Dr Thase then makes this telling point: In a University of Pittsburgh study, an 85 percent recurrence rate was observed within three years after the withdrawal of an antidepressant. By contrast, nearly 80 percent of patients receiving maintenance antidepressant therapy remained well.
Antidepressant therapy is long term, then, possibly for life. You don't get rid of your antidepressants if you're feeling well anymore than a heart patient would throw out his heart pills or a diabetic his insulin (but if you do, the doctor will taper your doses rather than having you go cold turkey).
Beware of Your Doctor
In many cases you may be required to be smarter than your doctor. One study sponsored by a healthcare provider and the drug company Pfizer found that primary care physicians indiscriminately prescribed antidepressants. Even when they made a correct diagnosis, they failed to educate their patients and often prescribed too low a dose for too short a period.
Another study from UCLA-Rand found that only 19 percent of a sample of depressed or anxious people they surveyed received appropriate treatment from their primary care physician. By contrast, 90 percent of those who saw a psychiatrist got proper care.
This potentially lethal combination of incompetent doctors and imperfect medications is one that can only be resolved by you, the patient or the patient's loved one. Depression is a long-term, if not lifetime condition, lasting nine months on average, and usually requiring much longer medications regimes to reduce the likelihood of relapse. If your drugs don't quit on you in that time, your body is almost certainly bound to change, and with it, your ability to respond to your current medication. Consider your brain an organ every bit as important as your heart, together your quality of life, and find a doctor or psychiatrist who feels the same way.
