* If you have a seizure disorder, cheek with your neurologist before taking any antidepressant.
Lithium. In 1949 an Australian psychiatrist, John Cade, observed that lithium, a common salt, caused sedation in guinea pigs. He then gave this agent to a patient with manic symptoms and observed a dramatic calming effect which he then documented in other manic patients. Since that time, lithium has slowly caught on in popularity, although it is still more widely accepted and used in Europe than in the United States. It has two major uses.
1. The reversal of acute manic states;
2. The prevention of manic and depressive mood swings in individuals with the bipolar form of manic-depressive illness.
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"Bipolar" simply means "two poles"—the patient experiences uncontrollable euphoric mood swings in addition to severe depressions. The manic phase is characterized by an extremely elevated, ecstatic mood, inappropriate degrees of self-confidence and grandiosity, constant talking, nonstop hyperactivity (rapid body movements), increased sexual activity, a decreased need for sleep, heightened irritability and aggressiveness, and self-destructive impulsive behavior such as reckless spending binges. This extraordinary disease usually develops into a chronic pattern of uncontrollable highs and lows, so a physician will frequently recommend that you continue to take lithium for the rest of your life.
If you have experienced abnormal mood elevations as well as depression, lithium should be the drug of first choice. The use of lithium in the treatment of recurrent depressions in the absence of manic mood swings is still at the research stage.
Recent findings suggest that if you have a family history of mania, you might benefit from lithium even if you have never been manic yourself.
Like the other drugs used for treating mood disorders, lithium usually requires between two and three weeks to become effective. When taken for a prolonged period of time, its clinical effectiveness seems to increase. Thus, if you take it for a period of years, it will probably help you more and more.
Lithium comes in 300-milligram dosages, and normally three to six pills per day in divided doses are required. Your physician will guide you. The dose must be carefully monitored by frequent blood testing, especially in the early phases of treatment, in order to maintain a proper blood level. If you get too much lithium in your blood, dangerous side effects can develop. In contrast, if your blood level is too low, the drug will not help you. Body size, kidney function, weather conditions, and other factors can influence your dose requirement, so the blood test should be performed on a regular basis when you are on lithium maintenance. Your blood must be drawn eight to twelve hours after your last lithium pill. The best time for the blood test is the first thing in the morning. If you forget and take your lithium pill the morning of the blood test, don't have the test! Try again another day.
Otherwise, the results will be misleading to your doctor.
Prior to treatment, the doctor will evaluate your medical 388
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condition and order a series of blood tests and a urinalysis.
Your thyroid functioning should be tested at yearly intervals while you are taking lithium, and your kidney function must be evaluated with a blood test at four-month intervals because of kidney abnormalities reported in some patients taking this agent.
The side effects of lithium are mildly uncomfortable but are usually not serious. Tiredness and fatigue might be experienced initially but will generally disappear, An upset stomach or diarrhea may occur in the first few days of treatment, but this too will usually disappear. Increased thirst, frequent urination, and a tremor of the hands are often experienced. An antitremor drug called propranalol can be given if the tremor is especially severe and troublesome, but it is my policy to avoid prescribing an additional drug if possible.
Some patients taking lithium complain of substantial weakness and fatigue. This may indicate an excessive lithium level, and a dose reduction may be indicated. Extreme sleepiness with mental confusion, a loss of coordination, or slurred speech suggests a dangerously elevated lithium level. Discontinue the drug and seek immediate medical attention if such symptoms appear.
L-tryptophan. This is the age of ecology. Scientists, like the general public, have wondered whether naturally occurring substances (such as vitamins, etc.) might play any role in the development of mood disorders or in their treatment.
In spite of the hullabaloo about "megavitamins" and other dietary fads, systematic research by top scientists around the world has shown that only one dietary substance has been consistently linked to depression. That substance is L-tryptophan.
L-tryptophan is one of the dietary building blocks that your body tissues use to manufacture proteins. Because your body cannot manufacture its own L-tryptophan, it must be ingested in the food you eat. Hence, it is called an "essential"
amino acid.
L-tryptophan is of great interest to psychiatric researchers because it is used by the brain to manufacture serotonin.
Serotonin is one of those amine transmitters that the nerves In your brain's emotional centers use to send messengers to
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each other, If you do not have an adequate amount of L
tryptophan in your diet, brain serotonin levels fall, which may contribute to your depression.
Of particular interest are the recent findings of Drs. Ronald Fernstorm, Richard Wurtman, and others at the Massachusetts Institute of Technology (M.I.T.). They have proved that the level of serotonin in your brain is directly influenced by the amount of L-tryptophan in your diet. Thus, these scientists have at last confirmed in part what health-food people have been claiming for years—your gut partially controls your brain!
All this is very exciting, and one is tempted to propose a simple solution to clinical depression: Just add large doses of pure powdered L-tryptophan, and your brain would in turn manufacture more chemical messengers. Any presumed chemical "imbalance" should then be corrected, thus reversing your mood disorder. Sounds good! Does it work?
That's precisely what psychiatrists around the world, including our group at the University of Pennsylvania, have been trying to determine for the past several years. The results have been encouraging but inconsistent. While psychiatrists at some centers have reported moderate to marked antidepressant effects from L-tryptophan, in other studies, few if any beneficial effects were noted. Taken in the balance, the results of these studies so far seem to indicate: 1. L-tryptophan does have some antidepressant properties, but clearly only some patients will respond.
2. When it helps, the beneficial effects may be only partial.
Additional drug or psychotherapeutic treatment may be needed to eliminate the depression entirely.
3. L-tryptophan is a moderately effective and probably safe sedative which promotes restful sleep.
Where do you get L-tryptophan? Because it has been clas-sified by the Food and Drug Administration as a food additive and not as a drug, doctors in the United States are not yet allowed to prescribe L-tryptophan, although physicians in England can. If you choose to take it, you must therefore make this decision on your own. You can get it legally through health-food stores (extremely expensive), or through 390
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chemical-supply companies (less costly). If you decide to take it, be sure to get pure L-tryptophan, NOT D-L-trypto-phan The latter is less effective because it does not pass as easily into the brain.
How much should you take? The "correct" dosage has not yet been adequately determined, but research investigators have been giving depressed patients doses in the range of three to fifteen grams per day. That's a lot of L-tryptophan!
A normal diet contains about one gram. It would be wise to consult with your physician about the proper dose if you do decide to take L-tryptophan. Do not take any of it in con-junction with any other medicines, including antidepressants, unless your doctor is aw
are of it.
Is L-tryptophan dangerous? So far, no adverse effects have been reported in humans. In early studies when massive amounts were given to cows or rabbits, some toxic reactions were noted, but it is not felt at the present time that these findings are applicable to humans. In general, there is always some potential risk when any drug or agent is taken in large amounts—even aspirin and vitamins can kill if abused.
Unless the benefits of L-tryptophan or any other antidepressant are obvious and clear-cut, it would not be wise to continue ingesting it.
Other Drugs Your Doctor May Prescirbe. The four categories of antidepressants I have described are the only ones which in my opinion have a clear-cut indication in the treatment of depression. There are several types of drugs which you might want to avoid. Some doctors use minor tranquilizers or sedatives for nervousness and anxiety. I usually do not because they can be addictive, and the sedation they produce might make your depression worse.
Sleeping pills can be dangerous and are easily abused.
They usually begin to lose their effectiveness after only a few days of regular use, and then greater and greater doses may be required to put you to sleep. This can lead to a dangerous pattern of dependency and addiction. These pills disrupt your normal sleep pattern, and since severe insomnia is a withdrawal symptom, every time you try to give them up you will falsely conclude that you need them even more. Thus, they might greatly worsen your sleeping problem. In contrast, some of the more sedative tricyclic antidepressants (see Table 391
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17-1, page 379) enhance sleep without requiring increased doses, and in my opinion represent a superior approach to treating insomnia in depressed individuals. If you feel you need a pill, taking L-tryptophan at bedtime may also be a good alternative, since it produces restful sleep and is not addictive.
How about the "pep pills," such as Ritalin and the amphetamines, which are commonly prescribed for weight loss?
It's true that in some people these drugs produce a temporary stimulation or elation (much like cocaine), but they are dangerously habit-forming. When you come down from the temporary high state, you will tend to crash and experience an even more profound sense of despair. When given chronically, the drugs can produce an aggressive, violent, paranoid reaction resembling schizophrenia. If your doctor or a friend recommends taking such pills, I suggest that you obtain a second opinion from a reliable physician pronto!
What about the so-called "major tranquilizers," such as Thorazine, Mellaril, Stelazine, Haldol, Prolixin, or Navane?
These agents are usually reserved for true schizophrenic reactions or for manic disorders. They do not play a major role in the treatment of most depressed or anxious patients. Only a minority of depressed individuals would benefit from those agents. These are people who are extremely agitated and cannot stop pacing, as well as older depressed patients who are paranoid and delusional. For most depressions the major tranquilizers may cause a worsening of the condition because of their tendency to cause sleepiness and fatigue.
The above review of drug-prescribing practices obviously represents my own approach. Your physician's ideas might differ somewhat. Psychiatry is still a blend of art and science, Perhaps some day the "art" will no longer be a prominent ingredient. If you feel uncertain about your treatment, ask your physician questions and urge him to explain his treat•
ment in simple terms you will understand. After all, you are the boss and he is your employee! It's your brain and body that are at risk, not his. As long as a rational, understandable, mutually acceptable strategy is developed for your therapy.
you will have an excellent chance of benefiting from your doctor's efforts.
Can Anyone Take an Antidepressant? Most people can, 392
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but competent medical supervision is a must. For example, special precautions are indicated if you have a history of epilepsy: heart, liver or kidney diseases; high blood pressure; or certain other disorders. For the very young and elderly, some medications should be avoided, and different dosages may be indicated. If you are taking medicines in addition to an antidepressant, special precautions are sometimes required.
Properly administered, an antidepressant is safe and may be lifesaving. But don't try to regulate it or administer it on your own; medical supervision is a must. Whether a pregnant woman should use an antidepressant requires collaboration between the psychiatrist and the obstetrician. Since fetal abnormalities might conceivably occur, the potential benefit, the severity of the depression, and the stage of pregnancy must all be taken into account. Other treatment approaches should be employed first, and an active self-help program of the type described in this book might entirely eliminate the need for any medication, thus giving optimal protection to the developing child.
Polypharmacy. The question sometimes comes up—why not use more than one psychiatric medication, thus receiving the benefits of several simultaneously? Although there are instances where certain combinations of drugs might be indicated, to take more than one antidepressant medication at a time is generally not advised. Pills that combine an antidepressant with a tranquilizer have been marketed and promoted, but clinical studies have not documented the efficacy of such preparations. In the great majority of cases, a single drug will be sufficient to accelerate your return to a normal mood. If a particular drug doesn't help, stop taking it after three or four weeks and try another. But don't complicate things by taking several medications simultaneously. Multiple drug treatment is confusing and usually unnecessary, and it can be dangerous. The exception would be a depressed patient who has received an adequate trial of several antidepressants one at a time from different chemical classes. In the absence of an adequate therapeutic response, your physician may then try combining antidepressants. An M.A.O. Inhibitor might be combined with a tricyclic or with lithium, or a tricyclic may be combined with lithium. This is an advanced form 393
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of treatment for the specialist to administer, and requires careful teamwork between you and your doctor.
Integrating Cognitive and
Biochemical Theories
By this point you may be wondering why I am writing about drug treatment in a book that stresses self-help and personal growth through a modification of thinking and behavior.
It is true that we have successfully treated hundreds of severely depressed patients in our Mood Clinic with no medication whatsoever. But there are many others who have desired and received simultaneous treatment with drugs and cognitive therapy. They also did well. It may be that for certain types of depression, the addition of the proper antidepressant to help your treatment program might make you more amenable to a rational self-help program and greatly speed up the therapy. I can think of many depressed individuals who seemed to "see the light" with regard to their illogical, twisted negative thoughts more rapidly once they began taking an antidepressant. My own philosophy is: I'm in favor of any reasonably safe tool that will help you!
Our current research studies are designed to provide more information about the combination of drug treatment an:l cognitive self-help therapy. The preliminary data indicate that patients treated with cognitive therapy in addition to an antidepressant respond more favorably than those treated with an antidepressant alone. This confirms that pure "test-tube treatment" with drugs alone is not the total answer for many patients. Thus, there is a definite role for effective psychotherapy even in those individuals who benefit from drugs.
What types of depression are most likely to benefit from an antidepressant drug? Your chance of responding to an appropriate drug is enhanced:
1. If you are functionally impaired and unable to carry c,n with your day-to-day activities because of your depression.
2. If your depression is characterized by the more organiz
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symptoms such as insomnia, agitation, or retardation; a worsening of symptoms i
n the morning; and an inability to feel cheered up by positive events.
3. If your depression is severe.
4. If your depression had a reasonably clear-cut beginning, and if your symptoms are substantially different from the way you normally feel.
5. If you do not have a long history of another psychiatric disorder or hallucinations preceding your depression.
6. If you have a family history of depression.
7. If you have had a beneficial drug response in the past.
8. If you do not have a tendency to complain and to blame others.
9. If you do not have a history of an exaggerated sensitivity to drug side effects, or a history of multiple hypochondriacal complaints.
The above guidelines are of a general nature, and they are not intended to be comprehensive. Many exceptions occur, and our ability to predict a drug response ahead of time is still quite limited. We hope that the use of antidepressant drugs will become more precise and scientific in the future, just as the use of antibiotics has become.
A Cognitive Approach to Drug Therapy. Certain negative attitudes and irrational thoughts can interfere with proper drug treatment. I would like to expose several hurtful myths at this time. I believe that enlightened caution in taking any medication is well advised, but an excessively conservative attitude based on half-truths can be equally destructive.
MYTH NUMBER 1: "If I take this drug, I won't be my true self. I'll act strange and feel unusual." Nothing could be further from the truth. Although these drugs eliminate depression, they do not normally create abnormal mood elevations, and, except in very rare cases, they will not make you feel abnormal, strange, or "high." In fact, most patients report that they feel much more like themselves after they have begun to respond to an antidepressant medication.
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