There are several types of antidepressant medications used to treat depressive
disorders. These include newer medications—chiefly the selective serotonin reuptake
inhibitors (SSRIs)—the tricyclics, and the monoamine oxidase inhibitors (MAOIs).
The SSRIs—and other newer medications that affect neurotransmitters such as
dopamine or norepinephrine—generally have fewer side effects than tricyclics.
Sometimes the doctor will try a variety of antidepressants before finding the
most effective medication or combination of medications. Sometimes the dosage
must be increased to be effective. Although some improvements may be seen in
the first few weeks, antidepressant medications must be taken regularly for
3 to 4 weeks (in some cases, as many as 8 weeks) before the full therapeutic
effect occurs.
Patients often are tempted to stop medication too soon. They may feel better
and think they no longer need the medication. Or they may think the medication
isn't helping at all. It is important to keep taking medication until it has
a chance to work, though side effects (see section on Side Effects on page 13)
may appear before antidepressant activity does. Once the individual is feeling
better, it is important to continue the medication for at least 4 to 9 months
to prevent a recurrence of the depression. Some medications must be stopped
gradually to give the body time to adjust. Never stop taking an antidepressant
without consulting the doctor for instructions on how to safely discontinue
the medication. For individuals with bipolar disorder or chronic major depression,
medication may have to be maintained indefinitely.
Antidepressant drugs are not habit-forming. However, as is the case with any
type of medication prescribed for more than a few days, antidepressants have
to be carefully monitored to see if the correct dosage is being given. The doctor
will check the dosage and its effectiveness regularly.
For the small number of people for whom MAO inhibitors are the best treatment,
it is necessary to avoid certain foods that contain high levels of tyramine,
such as many cheeses, wines, and pickles, as well as medications such as decongestants.
The interaction of tyramine with MAOIs can bring on a hypertensive crisis, a
sharp increase in blood pressure that can lead to a stroke. The doctor should
furnish a complete list of prohibited foods that the patient should carry at
all times. Other forms of antidepressants require no food restrictions.
Medications of any kind—prescribed, over-the counter, or borrowed—should never
be mixed without consulting the doctor. Other health professionals who may prescribe
a drug—such as a dentist or other medical specialist—should be told of the medications
the patient is taking. Some drugs, although safe when taken alone can, if taken
with others, cause severe and dangerous side effects. Some drugs, like alcohol
or street drugs, may reduce the effectiveness of antidepressants and should
be avoided. This includes wine, beer, and hard liquor. Some people who have
not had a problem with alcohol use may be permitted by their doctor to use a
modest amount of alcohol while taking one of the newer antidepressants.
Antianxiety drugs or sedatives are not antidepressants. They are sometimes
prescribed along with antidepressants; however, they are not effective when
taken alone for a depressive disorder. Stimulants, such as amphetamines, are
not effective antidepressants, but they are used occasionally under close supervision
in medically ill depressed patients.
Questions about any antidepressant prescribed, or problems that may be related
to the medication, should be discussed with the doctor.
Lithium has for many years been the treatment of choice for bipolar disorder,
as it can be effective in smoothing out the mood swings common to this disorder.
Its use must be carefully monitored, as the range between an effective dose
and a toxic one is small. If a person has preexisting thyroid, kidney, or heart
disorders or epilepsy, lithium may not be recommended. Fortunately, other medications
have been found to be of benefit in controlling mood swings. Among these are
two mood-stabilizing anticonvulsants, carbamazepine (Tegretol®) and valproate
(Depakote®). Both of these medications have gained wide acceptance in clinical
practice, and valproate has been approved by the Food and Drug Administration
for first-line treatment of acute mania. Other anticonvulsants that are being
used now include lamotrigine (Lamictal®) and gabapentin (Neurontin®):
their role in the treatment hierarchy of bipolar disorder remains under study.
Most people who have bipolar disorder take more than one medication including,
along with lithium and/or an anticonvulsant, a medication for accompanying agitation,
anxiety, depression, or insomnia. Finding the best possible combination of these
medications is of utmost importance to the patient and requires close monitoring
by the physician.
Side Effects
Antidepressants may cause mild and, usually, temporary side effects (sometimes
referred to as adverse effects) in some people. Typically these are annoying,
but not serious. However, any unusual reactions or side effects or those that
interfere with functioning should be reported to the doctor immediately. The
most common side effects of tricyclic antidepressants, and ways to deal with
them, are:
Dry mouth—it is helpful to drink sips of water; chew sugarless gum; clean
teeth daily.
Constipation—bran cereals, prunes, fruit, and vegetables should be in the
diet.
Bladder problems—emptying the bladder may be troublesome, and the urine
stream may not be as strong as usual; the doctor should be notified if there
is marked difficulty or pain.
Sexual problems—sexual functioning may change; if worrisome, it should be
discussed with the doctor.
Blurred vision—this will pass soon and will not usually necessitate new
glasses.
Dizziness—rising from the bed or chair slowly is helpful.
Drowsiness as a daytime problem—this usually passes soon. A person feeling
drowsy or sedated should not drive or operate heavy equipment. The more sedating
antidepressants are generally taken at bedtime to help sleep and minimize
daytime drowsiness.
The newer antidepressants have different types of side effects:
Headache—this will usually go away.
Nausea—this is also temporary, but even when it occurs, it is transient
after each dose.
Nervousness and insomnia (trouble falling asleep or waking often during
the night)—these may occur during the first few weeks; dosage reductions or
time will usually resolve them.
Agitation (feeling jittery)—if this happens for the first time after the
drug is taken and is more than transient, the doctor should be notified.
Sexual problems—the doctor should be consulted if the problem is persistent
or worrisome.
Herbal Therapy
In the past few years, much interest has risen in the use of herbs in the treatment
of both depression and anxiety. St. John's wort (Hypericum perforatum), an herb
used extensively in the treatment of mild to moderate depression in Europe,
has recently aroused interest in the United States. St. John's wort, an attractive
bushy, low-growing plant covered with yellow flowers in summer, has been used
for centuries in many folk and herbal remedies. Today in Germany, Hypericum
is used in the treatment of depression more than any other antidepressant. However,
the scientific studies that have been conducted on its use have been short-term
and have used several different doses.
Because of the widespread interest in St. John's wort, the National Institutes
of Health (NIH) conducted a 3-year study, sponsored by three NIH components—the
National Institute of Mental Health, the National Center for Complementary and
Alternative Medicine, and the Office of Dietary Supplements. The study was designed
to include 336 patients with major depression of moderate severity, randomly
assigned to an 8-week trial with one-third of patients receiving a uniform dose
of St. John's wort, another third sertraline, a selective serotonin reuptake
inhibitor (SSRI) commonly prescribed for depression, and the final third a placebo
(a pill that looks exactly like the SSRI and the St. John's wort, but has no
active ingredients). The study participants who responded positively were followed
for an additional 18 weeks. At the end of the first phase of the study, participants
were measured on two scales, one for depression and one for overall functioning.
There was no significant difference in rate of response for depression, but
the scale for overall functioning was better for the antidepressant than for
either St. John's wort or placebo. While this study did not support the use
of St. John's wort in the treatment of major depression, ongoing NIH-supported
research is examining a possible role for St. John's wort in the treatment of
milder forms of depression.
The Food and Drug Administration issued a Public Health Advisory on February
10, 2000. It stated that St. John's wort appears to affect an important metabolic
pathway that is used by many drugs prescribed to treat conditions such as AIDS,
heart disease, depression, seizures, certain cancers, and rejection of transplants.
Therefore, health care providers should alert their patients about these potential
drug interactions.
Some other herbal supplements frequently used that have not been evaluated
in large-scale clinical trials are ephedra, gingko biloba, echinacea, and ginseng.
Any herbal supplement should be taken only after consultation with the doctor
or other health care provider.
An alternative to drugs in the treatment of depression is psychotherapy. Find
out more here
