9. If you have failed to respond to other antidepressants you have been given.
10. If for any reason you have mixed feelings about getting better.
These guidelines are of a general nature and are not intended to be comprehensive or precise. Our ability to predict who will respond best to a medication or to psychotherapy is still extremely limited. Many people with all the positive indicators may fail to respond to antidepressants, and many people with all the negative indicators may respond beautifully to the first drug they receive. In the future, the use of antidepressant drugs will hopefully become more precise and scientific, just as the use of antibiotics has become.
If you have many of the negative indicators, is this bad? I don’t think so. Most patients with all the negative indicators can be treated quite successfully, but it may sometimes take a little longer. In addition, as I have emphasized repeatedly, a combination of medication with good psychotherapy along the lines described in this book is sometimes more effective than treatment with antidepressant drugs alone.
How Fast and How Well Do Antidepressant Drugs Work?
Most studies indicate that approximately 60 percent to 70 percent of depressed patients will respond to an antidepressant medication. Since approximately 30 percent to 50 percent of depressed patients will also respond to a sugar pill (a placebo), these studies indicate that an antidepressant will increase your chances for recovery.
However, remember that the word “respond” is different from the word “recover,” and the improvement from an antidepressant is often only partial. In other words, your score on a mood test like the one in Chapter 2 may improve without going into the range considered truly happy (less than 5). This is why I nearly always combine antidepressant medication treatment with cognitive and behavioral techniques like those described in this book. Most people are not interested in just partial improvement. They want the real McCoy. They want to get up in the morning and say, “Hey, it’s great to be alive!”
As I have emphasized, most of the depressed and anxious people I have treated have problems in their lives such as a marital conflict or a career difficulty, and nearly all of them beat up on themselves with negative thinking patterns. In my experience, medication therapy is usually more effective—and more satisfying—when it is combined with psychotherapy. Many doctors do prescribe medications alone without psychotherapy, but I have not found this approach to be satisfactory.
Which Antidepressants Are the Most Effective?
All of the currently prescribed antidepressant drugs tend to work about equally well, and equally rapidly, for most patients. So far, no new type of antidepressant medication has been shown to be more effective or faster-acting than the older drugs that have been available for several decades. However, there are dramatic differences in the costs of the different types of antidepressants and in the side effects they have. Essentially, the newer medications are much more expensive because they are still on patent. However, they are far more popular because they usually have fewer side effects than the older, cheaper drugs. If you have certain kinds of medical conditions, some antidepressants will be relatively safer for you than others. I will discuss these issues in greater detail in Chapter 20.
Sometimes a patient will respond particularly well to one antidepressant or kind of antidepressant. Unfortunately, we cannot usually predict this ahead of time for the individual, and so most physicians use a trial-and-error approach. There are, however, a few generalizations about the kinds of antidepressants that work best for certain kinds of problems. For example, drugs that have stronger effects on the serotonin systems in the brain are generally considered to be effective for patients who suffer from obsessive-compulsive disorder (called OCD for short). These patients have recurrent illogical thoughts (like a fear that the stove will catch fire and burn the house down) and perform compulsive rituals over and over (such as checking repeatedly to make sure that the stove is turned off). Drugs often prescribed for OCD include several of the tricyclic antidepressants, including clomipramine (Anafranil), one of the SSRIs, such as fluoxetine (Prozac) or fluvoxamine (Luvox), or one of the MAOIs, such as tranylcypromine (Parnate).
If a depressed patient also has symptoms of anxiety, such as panic attacks or social anxiety, the physician might also choose one of the SSRI or MAOI antidepressants, since these often seem to be quite effective. Or the physician might choose one of the more sedative antidepressants, such as trazodone (Desyrel) or doxepin (Sinequan), thinking that the relaxation might help reduce the anxiety.
In my practice, I have treated many patients with a particularly difficult type of chronic and severe depression known as borderline personality disorder (called BPD for short). Patients with this disorder have intense and constantly fluctuating negative moods such as depression, anxiety, and anger. Patients with BPD also experience lots of turbulence in their personal relationships. In my experience, quite a few BPD patients have responded dramatically to the MAOI antidepressants, and so I might be more inclined to choose an MAOI for patients with these features. Of course, some patients with BPD have poor impulse control, and they may do better with one of the newer and safer antidepressants. This is because the MAOIs can be quite dangerous if patients mix these drugs with certain forbidden foods and medications that I will describe in detail in Chapter 20.
There are a number of other guidelines as well, but they should not be taken too literally because there are so many exceptions to them. The bottom line is this: any depressed patient has a reasonably good chance of having a positive response to almost any antidepressant medication if it is prescribed at the correct dose for a reasonable period of time. You can ask your physician if she or he has a reason for recommending a particular antidepressant. However, most physicians will prescribe antidepressants they are familiar with. This is good practice. Few doctors can master the myriad details about all the currently prescribed antidepressants, and so most doctors try to become familiar with the one or two agents they use most frequently. In this way, they will have the greatest expertise about the medication they are recommending for you.
How Can I Tell if My Antidepressant Is Really Working?
My own philosophy is to use a depression test like the one in Chapter 2 as a guide. Take the test once or twice a week during treatment. This is really important. The test will show whether and to what extent you have improved. If you are not getting better, or if you are getting worse, your scores will not improve. If your scores are steadily improving, this indicates the drug is probably helping.
Unfortunately, most doctors do not require their patients to complete a mood test like the one in Chapter 2 between therapy sessions. Instead, they rely on their own clinical judgment to evaluate the effectiveness of the treatment. This is quite unfortunate, because studies have indicated that doctors are often poor judges of how patients feel inside.
How Much Mood Elevation Can I Anticipate?
Your aim should be to reduce the score on the depression test in Chapter 2 until it is in the range considered normal and happy. This is true whether you are being treated with an antidepressant, with psychotherapy, or with a combination of the two. Treatment cannot be considered completely successful if your score remains in the depressed range.
If One Antidepressant Works Somewhat, Will It Be Even Better to Take Two or More Antidepressants at the Same Time?
As a general rule, it is usually not necessary (or even beneficial) to take two or more different antidepressant drugs simultaneously. The two drugs may interact in ways that are unpredictable, and the side effects may increase substantially. There are exceptions to this, of course. For example, if you are restless and having trouble sleeping, your doctor may sometimes add a small dose of a second, more sedating antidepressant at night to help you get a good night’s sleep. Or your doctor may add a small dose of a second antidepressant to try to increase the effectiveness of the first antidepressant This is called an “augmentation” strategy, and I will discuss this app
roach in greater detail in Chapter 20. But on the average, one drug at a time usually works best.
How Long Will It Take Before I Can Expect to Feel Better?
It typically requires a minimum of two or three weeks before an antidepressant medicine begins to improve your mood. Some drugs may take even longer. For example, Prozac may not become effective for five to eight weeks. It is not known why antidepressants have this delayed reaction (and whoever discovers the reason will probably be a good candidate for a Nobel prize). Many patients have the impulse to discontinue their antidepressants before three weeks have passed because they feel hopeless and believe the medicine is not working. This is illogical, since it is unusual for these agents to become effective right away.
What Can I Do if My Antidepressant Doesn’t Work?
I have seen many patients who failed to respond adequately to one or many antidepressants. In fact, at my clinic in Philadelphia, most of the patients were referred to me after unsuccessful treatments with a variety of antidepressant drugs and therapy as well. Most of the time we were eventually able to get an excellent antidepressant effect, often through a combination of cognitive therapy and another medication that the patient had not yet tried. The important thing is to keep persisting in your efforts until you recover. Sometimes this requires enormous dedication and faith. Patients often feel like giving up, but persistence nearly always pays off.
I have stated earlier that the feelings of hopelessness are probably the worst aspect of depression. These feelings sometimes lead to suicide attempts because patients feel so convinced that things will never get any better. They think that things have always been this way and that their feelings of worthlessness and despair will go on forever. In addition, there is a kind of genius about depression. Patients can be so incredibly persuasive about their hopelessness that even their doctors and families may start believing them after a while. Early in my career I grappled with this and often felt tempted to give up on particularly difficult patients. But a trusted colleague urged me never to give in to the belief that any patient was hopeless. Throughout my career, this policy has paid off. No matter what type of treatment you receive, faith and persistence can be the keys to success. I cannot emphasize this enough.
How Long Should I Take an Antidepressant if It Doesn’t Seem to Be Working?
Of course, you should always check with your physician before making any changes in your medication, but on average, a trial of four or five weeks should be adequate. If you do not have a clear-cut and fairly dramatic improvement in your mood, then a switch to another drug is probably indicated. It is important, however, that the dose be adjusted correctly during this time, since doses that are too high or too low may not be effective. Sometimes your doctor may order a blood test to make sure the dose you are taking is adequate for you.
One of the commonest errors your doctor may make is to keep you on a particular antidepressant for many months (or even years) when there is no clear-cut evidence that you have improved. This makes absolutely no sense to me! However, I have seen many severely depressed individuals who reported that they had been treated continuously with the same antidepressant for many years but were not aware of any beneficial effects from the medication. Their scores on the mood test in Chapter 2 usually indicated they were still severely depressed. When I asked them why they were taking the drug for such a long time, they usually said that theirs doctors told them that they needed it, or that it was necessary because of their “chemical imbalance.” If your mood has not improved, it seems clear that the drug has not worked, so why keep taking it? If a drug does not have fairly substantial beneficial effects, as indicated by a clear and continuing improvement in your score on a depression test like the one in Chapter 2, then it is usually appropriate to switch to another antidepressant medication.
How Long Should I Continue to Take the Antidepressant if It Does Help Me?
You and your doctor will have to make this decision together. If this is your first episode of depression, you can probably go off the medicine after six to twelve months and continue to feel undepressed. In some cases, I have discontinued antidepressants after only three months with good results, and rarely found that treatment for more than six months was necessary. But different doctors have different opinions about this.
One of the strongest predictors of relapse in research studies is the degree of improvement at the end of treatment. In other words, if you are happy and completely free of depression, and this is documented by a score below 5 on the depression test in Chapter 2, the likelihood of a prolonged depression-free period is high. On the other hand, if you are partially improved but your depression score is still somewhat elevated, the likelihood is much greater that the depression will worsen or return in the future, whether or not you continue to take an antidepressant medication.
This is another reason why I like to combine antidepressant medications with cognitive behavioral therapy. The patients usually have a much better response, and very few patients in my private practice appeared to relapse and return for additional treatment following recovery.
What if My Doctor Tells Me I Have to Stay on the Antidepressant Indefinitely?
Patients with certain kinds of depressions will almost definitely need to take medications on a long-term basis. For example, if a patient has bipolar (manic-depressive) illness with uncontrollable highs as well as lows, long-term treatment with a mood-stabilizing medication such as lithium, valproic acid, or carbamazepine may be necessary.
If you have had many years of unremitting depression or if you have been prone to many recurrent attacks of depression, you might want to consider maintenance therapy for a longer period of time. Since doctors are becoming more aware of the relapsing nature of mood disorders, the use of antidepressants on a long-term or prophylactic basis is gaining greater favor.
Some doctors routinely recommend therapy with antidepressants indefinitely, in much the same way they might insist that patients with diabetes must take daily insulin to regulate their blood sugar. Several research studies suggest that such maintenance therapy can reduce the incidence of depressive relapses. However, research studies also indicate that treatment with the cognitive therapy techniques described in this book can also reduce depressive relapses. In addition, these studies suggest that the preventive effect of cognitive therapy may be greater than the preventive effect of antidepressant medications. One important advantage of cognitive behavioral therapy is that you learn new skills to minimize or prevent future depressions. For example, the simple exercise of writing down and challenging your own negative thoughts when you are under stress can be invaluable.
In my private practice, the vast majority of the depressed patients I have treated have not had to stay on antidepressant drugs indefinitely following recovery. Most of them did extremely well with no medications simply by using the cognitive therapy skills they learned whenever they became upset again in the future. This is very encouraging, and it shows there is quite a bit you can do not only to treat your own depression, but also to minimize the probability of severe and prolonged depressions in the future. It also suggests that if you are taking an antidepressant, it might be very helpful for you to study and practice the methods in this book.
Once you discover how to change your own negative thinking patterns using the techniques I describe, you may find that you will be able to remain undepressed without any medications. But certainly, you will want to discuss this with your physician. It is never smart to go off a medicine or to change the dose of a medication unless you talk this over with your doctor first.
What if I Start Getting More Depressed When I Taper Off the Medication?
This is actually pretty common, and I will tell you how I have handled it in my own practice. First, I make sure the patient continues to take the depression test in Chapter 2 at least once or twice a week while she or he is tapering off the medication. Then we develop a plan for slowly reducing the dose of the antidepressant. I tel
l patients that if they start to feel depressed again while tapering off the drug, and this is reflected by an increased score on the depression test, then they should temporarily raise the dose slightly for a week or two. This usually leads to an improvement in mood again. Then they can slowly continue to taper off the drug again. This approach is reassuring because it puts the patient in control. After a couple tries like this, most patients have been able to taper off their antidepressants without becoming depressed again.
What Should I Do if the Depression Comes Back in the Future?
If your depression returns, the chances are excellent that you will again respond to the same drug that helped you the first time. It may be the proper biological “key” for you. So you can probably use that drug again for any future episode of depression. If any blood relative of yours develops a depression, this drug might also be a good choice for them because a person’s response to antidepressants, like the depression itself, appears to be influenced by genetic factors.
The same reasoning applies to the psychotherapy techniques. I have found that for most people, the same kinds of events (for example, being criticized by an authority figure) tend to trigger depression, and the same kinds of cognitive therapy technique usually reverse the depression for a particular patient. In most cases patients have been able to reverse a new episode of depression fairly rapidly without having to take the medication again. I encourage my patients to come in for a little “tune-up” if they become depressed again in the future. Often these “tune-ups” consisted of only one or two therapy sessions, since we were usually able to reapply the same technique that had helped them so much the first time I treated them.
Feeling Good: The New Mood Therapy Page 42