Overcoming Depression For Dummies

by Smith, Laura L.

  Seeing What Suits: Working with Your Doctor to Find the Correct Medication

  A positive, two-way relationship with your GP or psychiatrist (refer to Chapter 4) may be the most important ingredient for successful treatment of depression. You and your doctor need to discuss openly your particular symptoms of depression, your response to the medication, and any side effects you may experience.

  Unfortunately, it’s unclear which particular antidepressant medication is the most likely to work for any one individual. Research studies show that people opt for taking medication to help them in different areas of their lives and go for psychological therapy in other areas. However, there’s no general agreement on how effective this approach is to treating depression. Some people respond to the first drug prescribed; others may need to try several different ones. The drug your doctor chooses depends on a number of factors:

  Specific depressive symptoms: Your doctor needs to know about all your symptoms before choosing a medication. The doctor may ask the following: Do you sleep too much, or too little? Have you gained or lost weight? Do you have aches and pains? Do you feel anxious as well as depressed? Do you have difficulty concentrating?

  Side effects: For most people, the first choice in medication is the one with the least side effects. But side effects of a drug can sometimes be employed to advantage. For example, people with sleep problems may do better with a medication that has a side effect of sedation. Again, no one can predict the precise degree to which any side effects are going to affect you. Sometimes a change in medication, or a change in the dose, or even the addition of another drug is used to manage side effects.

  History of depression: If you have had previous depressive episodes and been successfully treated with a particular antidepressant, the same one is likely to be the first choice. This time round, though, your doctor may well decide to continue the medication for a much longer period.

  Family response to antidepressant medication: Although there is limited evidence showing that genetics affect how different antidepressant medications work, if a member of your family had a favourable response to a specific antidepressant medication, let your doctor know. Depending on many other factors, that antidepressant may be the best first choice.

  You need to be able to talk freely with your doctor, so that he or she knows how best to help you. Tell your doctor:

  About any other physical conditions you have: Discuss all your current health concerns with your doctor, especially liver disease, hepatitis, diabetes, high blood pressure, or kidney disease.

  If you think you may be pregnant, are trying to get pregnant, or are breastfeeding: Certain medication may not be safe.

  If you want to drink alcohol while on the medication: Generally, you should avoid alcohol when you take antidepressants. Alcohol may interact with some antidepressants, increasing the alcohol’s effect, increasing fatigue, or even blocking the drug’s effects. Drinking too much regularly can also cause depressed mood, and this improves when the drinking stops. However, an occasional drink is probably harmless, depending on which medication you are on, so do discuss this with your doctor.

  About any other medication you’re taking: Antidepressants may interfere with other medications, or vice versa. Be sure to also mention any non-prescription medications in your discussion.

  About any herbal treatments, alternative treatments or supplements you take: Again, there may be interactions with antidepressants. For more about herbs and supplements, see Chapter 16.

  About any and all side effects: Although many troublesome side effects cease within a couple of weeks, don’t suffer in silence. Your doctor may be able to help you manage the side effects by changing your prescription or dosage, or by combining it with another drug. Don’t be embarrassed by the nature of the problems – side effects like decreased sexual pleasure, loss of libido, or inability to achieve orgasm aren’t rare and treatment is available.

  Hang on in there. Antidepressant medication usually takes at least two weeks to begin working and may take up to six weeks for maximum benefit to occur, although many people start to respond more quickly. Sometimes the people around you will notice an improvement before you do. You may well not respond to the first drug. Give your doctor a chance to help you. You may have to go through months of trying different medication to find the one, or combination, that suits. The good news is that after you find which works, it is likely to continue to be effective in easing your depression.

  Research suggests that less than a quarter of people treated with medication for depression get adequate treatment, meaning receiving a reasonable number of psychotherapy sessions with treatments found to be effective for depression (refer to Chapter 4 for an overview of those treatments) or take an adequate dose of medications for a long enough period. About 10 per cent of people with prescriptions for antidepressants start the medication, but then discontinue it within a week! Many more stop the minute they feel a little better. Unfortunately they then quickly slip back to how they felt before the medication started. If you choose to be treated for depression with medication, complete the prescribed course. Otherwise, your risk of relapse increases.

  Understanding How Antidepressants Work: Revising Biology

  Scientists continue to study the relationship between depression and biology. They’ve found some differences when comparing people with and without depression (refer to Chapter 1). However, we also know that the biological aspect of depression isn’t a simple, easily measured and counterbalanced chemical deficiency. If that were the case, an intravenous infusion (directly into the vein) of the precise quantity of a specific antidepressant would be the instant solution. No such luck, unfortunately!

  To understand how antidepressant medication works, you need to know some basic information about your brain and body. We’re going to keep this simple, and don’t worry, there’s no final exam. Promise!

  The brain is made up of nerve cells called neurons. Neurons take in information about the state of the world both outside and inside the body and react to these internal and external happenings. Basically, neurons are the backbone of the nervous system, which controls all actions, thoughts, and emotions (see the nearby ‘Knowing the nervous system’ sidebar). Neurons allow you to walk, talk, and smell the roses, and they give you the ability to love, to remember, to acquire knowledge, and to feel. But to do this, neurons have to communicate between one other. Depression can disrupt neural communication.

  Knowing the nervous system

  The human nervous system senses activity in your body and outside of it. The brain takes in the sensory information and plans a response. The nervous system then responds with action. For example, when you touch a hot cooker with your hand, pain messages surge to your brain. Your brain reacts almost instantly with the information that touching something hot caused the pain. Your brain sends a message to your hand to quickly pull away. Hopefully, your brain will remember the experience so that next time you won’t touch the cooker when it’s hot.

  The nervous system is made up of the central nervous system (CNS) and the peripheral nervous system (PNS). The CNS includes the brain and the spinal cord. The CNS takes in information and using this, then tells the rest of the body what to do. The PNS contains nerves that carry information to and from the CNS. The PNS acts as the go-between with the CNS and skeletal muscles, sense receptors, smooth muscles, cardiac muscles, and glands. Antidepressants primarily affect the CNS.

  So how do the 100 billion or so neurons in your brain talk to each other? They communicate by sending chemical messengers back and forth. Scientists estimate about 100 trillion different lines of communication exist between all those neurons. But to save time, let’s look at just one such neuronal conversation . . .

  Pretend that Nick and Nina are neighbouring neurons (see Figure 15-1). Nina Neuron has an important message to tell Nick, so she sends a jolt of energy down a long tube called an axon. When this burst of energy reaches the end of Nina’s axon, chemical m
essengers, or neurotransmitters, are released into a tiny space, called a synapse, between Nina and Nick, the two next door neurons.

  The neurotransmitters hang around outside both ‘front doors’, that is in the synapse. But then Nina becomes anxious (as all good neurons do) that she’s released so many chemicals, so she starts up a pump that sucks some neurons back in from the synapse. But in the meanwhile, Nick the neighbour welcomes some of the chemical messengers with open arms called dendrites. After they’re inside, these neurotransmitters talk to Nick and may even start telling him what to do. So, the upshot is that some of the neurotransmitters enter the neighbouring neuron and some return to the original cell.

  When depression occurs, the chemical conversations between neurons break down. When neurons can’t communicate well, the mind is unable to use all its resources to deal with events such as stress. This depleted state leads to a communication breakdown, taking the form of depression.

  Competing theories

  Why does antidepressant medication take so long to work? One theory is that when the neurotransmitters are too few, or low in strength, the receiving cells enhance the sensitivity of their receptors. After the antidepressants have increased the number of available neurotransmitters, then the receptors return to their normal level of sensitivity. This process takes about the same amount of time that it takes for a person to feel the beneficial effects of the medication.

  Another theory relates to what kinds of messages the neurotransmitter gives to the receiving cell. Some scientists hold the theory that, despite normal amounts of chemical messengers, the communication between cells and their responses have somehow become defective. With new research, scientists hope to find better ways to predict responses to medication, and find faster routes and drugs with fewer side effects. Watch this space!

  Some experts believe that depression results when there aren’t enough neurotransmitters to get the message out. Others think that depression may stem from neurotransmitter systems that aren’t working properly. Different drugs act on different neurotransmitters in different ways. The bottom line is that no one is entirely certain exactly why antidepressant medications work, other than the fact that they do seem to improve communication among neurons (see the nearby ‘Competing theories’ sidebar).

  Figure 15-1: How Nick and Nina neuron talk.

  Exploring Medication

  Although pharmaceutical companies spend billions of pounds searching for ever improved treatments for depression, there’s still no overall consensus as to how antidepressant medication works. Most experts believe antidepressant medications somehow increase one or more of the neurotransmitters in the brain and that doing so improves communication among neurons and ultimately reduces depression (see ‘Revising Biology’, earlier in this chapter).

  The relationship between the various neurotransmitters and depression isn’t yet completely understood. But the three neurotransmitters that most antidepressants target appear to relate to different symptoms:

  Serotonin: Problems with serotonin are associated with depressed mood, anxiety, insomnia, obsessive compulsive disorder, seasonal affective disorder, and even violence.

  Dopamine: Disruptions in dopamine seem to relate to problems with attention, motivation, alertness, increased apathy, and difficulty in experiencing pleasure.

  Norepinephrine: Disorders in norepinephrine match lack of energy, decreased alertness, and lethargy.

  Your particular symptoms help point your doctor towards what’s likely to be the best first choice of antidepressant for you. However, scientists haven’t yet developed a completely accurate way of predicting which symptoms are best targeted by which medications.

  Antidepressant drugs are classified by how they affect one or more of these neurochemicals. In the following sections, we examine the most commonly prescribed antidepressants and explain their actions, common uses, problems, and side effects. The following discussion can give you practical information about each class of antidepressant drug. And remember that new antidepressants are constantly being developed.

  We believe that knowledge helps you get the best medical care for your depression. The information we give you below is going to help you communicate with your health care provider. Working together, you can find the right medication for you.

  Selecting SSRIs

  Ever since Prozac came on the market in the late 1980s, selective serotonin reuptake inhibitors (SSRIs) have been the most popular antidepressants. One reason for their popularity is that their side effects are less severe than older antidepressants and the consequences of overdose are also less dangerous.

  An SSRI is often the first choice of antidepressant medication. These drugs are used for the treatment of major depressive disorder, dysthymia, and seasonal affective disorder. (For more about these disorders, go to Chapter 2.) SSRIs are commonly used when depression and anxiety are mixed. (They are also used for treating anxiety-related disorders that aren’t accompanied by depression, such as obsessive-compulsive disorder, panic disorder, generalised anxiety disorders, premenstrual syndrome, eating disorders, and some types of chronic pain.)

  SSRIs combat depression by increasing the available levels of serotonin. Remember Nina the neuron from the ‘Revising Biology’ section, earlier in this chapter? Imagine that Nina sends out a burst of serotonin into her synapse. Normally, some of the serotonin she releases is taken in by Nick, the neighbouring neuron, while Nina pumps some of the serotonin back into her cell. An SSRI antidepressant works by clogging Nina’s pump so that she can’t reabsorb her serotonin. There’s therefore more serotonin sitting in the synapse outside Nick’s door, for Nick to invite in!

  SSRIs usually take about one to four weeks to become effective. However, many people notice a slight improvement after a few days, and some people will not experience the full benefit for six weeks or even longer. Side effects may include increased anxiety, fatigue, upset stomach, insomnia, apathy, lack of sexual interest, or inability to obtain orgasm. You might also experience dizziness, sweating, tremors, dry mouth, headache, and weight loss or gain. Side effects are most severe for the first few weeks, and then tend to lessen..

  SSRIs may bring additional complications and problems. Bear in mind:

  If you have bipolar disorder, SSRIs may be dangerous. Occasionally, these drugs induce a manic state, which can involve dangerous or risky behaviours (refer to Chapter 2 for more information about bipolar disorder).

  Abruptly stopping SSRIs (or for that matter, any antidepressant medication) can produce anxiety or flu-like symptoms such as nausea, headache, sweating, fever, and chills. Sudden withdrawal can also cause vivid dreams and problems with sleep. Talk to your doctor if you decide to stop taking SSRIs for advice on how to do so safely.

  The UK Committee on Safety of Medicines banned the treatment of childhood depression (suffered by children under 18) with any SSRI except Prozac in 2003, because evidence exists to suggest a small raised risk of suicide or suicidal thoughts in children taking these drugs

  Taking SSRIs with other classes of antidepressants, especially, but not only, MAO inhibititors (see the later section in this chapter) can cause a life-threatening reaction. Other drugs may also interact negatively. Tell your doctor about all of the medications you are taking.

  Table 15-1 shows you the six SSRIs currently available on the market. We’ve put typical dosage ranges for treatment of depression in the community. Higher doses may be permitted for inpatients or in the treatment of other conditions that may also be present (e.g. OCD/panic/anxiety disorders). However, your doctor will work with you in deciding what’s appropriate for you.

  Untreated depression often lessens sexual interest. SSRIs can also interfere with sexual arousal and pleasure. If you’re in a relationship in which sexual intimacy has already been disrupted, speak to your doctor about your concerns.

  Getting more for your money

  Antidepressant medication probably works by increasing the amount of certain neurotransmit
ters in the brain. SSRIs target serotonin, but some antidepressants increase more than one such chemical messenger or act on the neuron and its neurotransmitters in more than one way.

  In the following list, we take a look at these medications, noting which neurotransmitter system the medication affects and how it acts on them. You don’t need to know the complicated terminology represented by the initials, but we include it in case you come across the terms elsewhere. See Table 15-2 for more information on the following drugs:

  SNRIs (Serotonin/Norepinephrine Reuptake Inhibitor): Boosts both serotonin and norepinephrine

  NDRIs (Norepinephrine/Dopamine Reuptake Inhibitor): Boosts both norepinephrine and dopamine