Medication Strategies for Depression

Medication Strategies for Depression

A case of the blues?

Most everyone can say they’ve had a case of the blues.  In fact, it’s normal for people to feel sad every now and then or to experience mood swings.  Sometimes, these moods can be easily explained by certain life events:  The death of a loved one, a divorce, or the loss of a job.  So what is the difference between “normal” mood swings and the feelings caused by clinical depression?

This booklet will answer that question and others related to clinical depression.   It was written to help you understand that there are a variety of treatments for clinical depression that may make coping with the illness easier.

Reading this booklet will help you become a more informed consumer and allow you to better manage your illness.  You’ll learn how to assess different medication strategies and how to develop the most beneficial relationship with your physician.   You’ll also learn more about the stigma associated with taking medication for clinical depression.

What is depression?

Clinical depression is a treatable medical illness marked by extreme changes in mood, energy and behavior.  That’s why doctors call depression a mood disorder.  In this booklet, the term “depression” is used to refer to clinical depression.

Depression is not a character flaw or a sign of personal weakness.  You can’t develop depression from listening to too many blues musicians or reading too many sad stories.  And you can’t catch depression from someone else, although it can run in families.

While it’s normal for people to experience ups and downs during their lives, those who have depression experience drastic lows that make it difficult for them to function at work, at school, and in relationships. 

Is there more than one type of depression?

Yes.  In this booklet, major depressive disorder will be discussed.  However, there is another type of depression called dysthymia.  Dysthymia is a type of chronic, moderate depression.  The Diagnostic Statistical Manual of Mental Disorders (DSM-IV) describes dysthymia as a “chronically depressed mood that occurs most of the days more days than not, for at least two years.”  To raise awareness of the signs, symptoms and treatments for dysthymia.

Major depressive disorder and dysthymia are considered types of clinical depression because they are biologically-based illnesses triggered by chemicals in the brain.   Situational or reactive depression, on the other hand, is triggered by distressing life events such as the death of a loved one, rather than by biological causes.   However, if situational or reactive depression increases in intensity or lasts for more than two weeks, it can evolve into clinical depression.

What causes depression?

Research has shown depression is the sign of an imbalance in the brain chemicals called neurotransmitters.  Although the direct cause of the illness is unclear, it is known that body chemistry can bring on a depressive disorder, due to the presence of another illness, altered health habits, substance abuse, or hormonal changes.  In addition, studies have shown the illness often is passed genetically through families, and that stressful life experiences can trigger some symptoms.  However, there is no evidence that stressful life experiences or a troubled childhood can actually cause depression.

Who develops depression?

People of all ages, races, ethnic groups, and social classes have the illness. Many people with depression are very well known.  Some have won Academy Awards™.   Others have created literary and fine-art masterpieces, or led their nations in critical times of history.

More than 17 million Americans suffer from a depressive disorder annually.   Chances are that at some point, you or someone you know will become affected.   If you are a woman, you are twice as likely as a man to experience depression.   In fact, one in four women will experience clinical depression in her lifetime.

How can you tell the difference between depression and a bad mood?

Everyone goes through times when they feel down.  However, the severity of depressive moods, also called depressive episodes, and the way they disrupt normal activities, distinguish them from the ordinary lows that are normal part of life.

When the episodes are charted over time, daily, weekly, and/or seasonal patterns become evident.  Major depressive episodes last at least two weeks.  Many people have several episodes of depression a single year.  Others live for years without a new episode.

Symptoms of depression:

  • Prolonged sadness or unexplained crying spells
  • Significant changes in appetite and sleep patterns
  • Irritability, anger, worry, agitation, anxiety
  • Pessimism, indifference
  • Loss of energy, persistent lethargy
  • Feelings of guilt, worthlessness
  • Inability to concentrate, indecisiveness
  • Inability to take pleasure in former interests, social withdrawal
  • Unexplained aches and pains
  • Excessive consumption of alcohol or use of chemical substances
  • Recurring thoughts of death or suicide

It is important to inform your physician or health care provider of any depressive episodes, past or present, so a correct diagnosis can be made.   Anyone experiencing four or more symptoms should seek help from a medical professional if symptoms persist for longer than two weeks.  Do not try to diagnose yourself . . . only a health care professional can determine if you have depression.   If you have thoughts of death or suicide, contact a medical professional, clergy member, loved one or friend immediately.

Could I have bipolar disorder?

Bipolar disorder (also called manic depression) differs significantly from clinical depression.  In manic-depressive illness, a person’s mood alternates between mania and depression.  A mood swing can last for days, weeks or months.  It is important to inform your medical professional of all mood swings — the highs and the lows — so that a correct diagnosis can be made.

Is there a cure for depression?

Depression is similar to other lifelong illnesses–such as arthritis or diabetes–in that it cannot be “cured.” It can, however, be managed successfully through proper treatment, which allows most patients to return to productive lives.  If given proper care, at least 80% of  patients with depression can lead significantly improved , productive lives.

Treatments for depression

There are many safe, effective treatments.  People with depression usually benefit from a combination of medication, counseling, and support from a local Healthlinerx to help them control their illness.  Talking with friends and family isn’t enough to treat depression, although their moral support is very beneficial.

It’s important to see a doctor who can make a diagnosis and make certain that other illnesses are not causing your depression.  The purpose of this brochure is to provide information about the different medication strategies available today and in the near future.  It is not intended to take the place of a visit to your mental health professional.

The importance of an open mind

Despite the progress that’s been made there is still great resistance to pursuing treatment for depressive disorders.  So many people think their problem is “just in their head.”  Chances are, it’s not.  Depression is a serious, potentially fatal, illness.  In fact, people with severe depression who don’t seek proper help have a suicide rate as high as 15%.

Many people are ashamed of their symptoms of depression.  They feel that some how this is all their fault, and that they should “pull themselves up by their bootstraps.”  The shame people feel is a turning inward of the stigma society places on depression.

Some believe that people experiencing depression don’t need medication.  Instead, they need to learn how to deal with life’s disappointments, need to develop self-discipline, or perhaps gain more insight, faith, or receive more love.  Some may feel that the use of medication is a sign of moral weakness, a “cop out,” or an unrealistic expectation that a “magic pill” will solve their problems.

Be aware and don’t lose hope.  Don’t perpetuate the secrecy and shame society often associates with depression.  Talk about your symptoms, research all your treatment options and keep trying until you find the one that significantly improves your life.

Medication strategies for depression

The past 30 years has witnessed great progress in the treatment of clinical depression.   The development of new, safer and easier to use medications has brightened the outlook for people with depressive illnesses.  Today, at least 80% of people with depression find successful treatment.  With neuroscience research increasing and many new medications in development, there is promise of even more effective and easier to use treatments on the horizon.

There is a role for learning new skills to better cope with life, such as ways to increase self esteem, cope with stresses, deal with interpersonal relationships.   These skills can be learned through various types of talking and interaction therapies, if an individual is able to respond to these therapies.

Evidence exists that more severe depressions respond more reliably and positively to medications.  Many people who don’t respond to “talk” therapies will improve with the correct medication therapy, sometimes combined with psychotherapy.

What should you expect if you take medication?

You don’t have to experience all the symptoms listed above to have depression.  One person may have no energy/motivation and sleep all the time while gaining weight, while another may be anxious, sleepless, with poor concentration no appetite.  Work with your doctor to choose a medication strategy that is most likely to help alleviate your particular symptoms.

Your symptoms of depression should lessen, and ideally disappear, with a course of medication.  You should feel relief within two to eight weeks, although a full response sometimes may take 12-16 weeks.  Sometimes it’s necessary to try more than one medication to achieve a good result.

Some people’s depression improves while problems still remain, such as harmful relationships or unsuccessful living styles.  Psychotherapy may be necessary in these cases, since medications benefit a patient by reducing or removing symptoms of a depression, not by changing negative life situations.  However, a person feeling better after taking medication will find coping with life’s adversities easier.

It is very important that antidepressant medications continue to be taken long after they relieve depressive symptoms, which will occur if they are topped too soon or without a gradual tapering of the dose.  generally, taking medication for three to six months is considered necessary to give initial relief from symptoms. 

After this initial phase, medication is usually continued for six months.  Antidepressant medications are not habit forming or mind altering.  Depending on the duration of the depressive episode and the number and severity of prior episodes, you may be advised to continue medication for one to several years, and perhaps indefinitely.  Remember, depression is often a recurring condition.

How is the best medication for an individual chosen?

The most important principle to keep in mind is that no two people will respond the same way to medication.  While one individual with depression may have a total improvement with medication “X”, another patient with similar symptoms may not benefit at all or have too many side effects.  That patient may do well on medication “Y.”

Sometimes several different medication trials or a combination of medications may be necessary to achieve sufficient improvement.  Prior experience with medications is a good predictor of what medications to try or avoid.  Keeping your own records of treatment, including the medication, dosages used, the length of time taken, and your positive or negative experiences, can be very important to your doctor in deciding what medications to try or avoid.

More than 20 antidepressant medications are now available.  Some, including SSRI medications (serotonin reuptake inhibitors) and the newer dual action medications, are safer in terms of overdose toxicity, or in having no effect on a diseased hear compared with the older TCAs (tricyclic antidepressants.)  In addition, they are considered easier to use in terms of side effects for most patients.

Most antidepressant medications currently available act to increase the effect on a neurotransmitter, serotonin, in the brain.  Some medications have effects on other neurotransmitters such as norepinphrine.  Some have the capacity to block one or more serotionin receptors, which may reduce anxiety or sexual side effects in some patients.

More effective medications with less side effects are being developed as we learn more about the brain chemistry of a person with depression.  While different medications have different results and side effects, a particular person’s response is not predictable since different individuals respond quite differently to the same medication.

Sometimes when it is difficult to attain a good response to treatment, adding a medication or combining certain medications may help.

Finding the right medication strategy for you can take time.  don’t lose hope!   Many options are available today.  The following chart should help you understand the differences between “classes” of antidepressant medications.  

Medications are classified by the way they work in the brain.  Even within a class, the medications may affect you differently.  While it is frustrating and often painful to wait for results, you will find relief if you patiently work with your doctor to find the medication that works for you.  If one doesn’t work, remember antidepressant medications do not all work the same way in all people.

Medications for Depression

Medication ClassMedications
(Trade Names)
How It Works
In the Brain
Possible Side
Effects
Other Uses
SSRI
selective
serotonin
reuptake
inhibitors
Celexa®
Luvox®
Paxil®
Prozac®
Zoloft®
+serotonin



Nausea
Insomnia
Sleepiness
Agitation
Sexual dysfunction
Panic Disorder
OCD
Bulimia

Aminoketone
Wellbutrin®
+norepinephrine
+dopamine
Agitation
Insomnia
Anxiety

Smoking cessation

SSNRI
selective
serotonin
norepinephrine
reuptake
inhibitors
Effexor®


+serotonin
+norepinephrine


Agitation
Nausea
Dizziness
Sleepiness
Sexual dysfunction

SSRIB
selective
serotonin
reuptake
inhibitor & blocker
Deseryl®
Serzone®


+serotonin


Nausea
Dizziness
Sleepiness

TETRACYCLICRemeron®+serotonin
+norepinephrine
Sleepiness
Weight gain
Dizziness
TCA
Tetracyclic-
Heterocyclic


Anafranil®
Elavil®
Norpramin®
Pamelor®
Surmontil®
Tofranil®
Vivactil®
+serotonin
+norepinephrine
(depending on medication)


Sleepiness
Nervousness
Dizziness
Dry mouth
Constipation
High overdose
toxicity
Panic Disorder




MAOI
monoamine
oxidase
inhibitors
Nardil®
Parnate®
+serotonin
+norepinephrine
+dopamine
Fatal interaction with
all above
Dizziness
Interaction with some foods
Panic Disorder


MOOD STABILIZER
(used to augment antidepressants)
Eskalith®
Lithobid®
Lithonate®
+serotoninTremor
High overdose toxicity
Dry Mouth
Nausea
Bipolar Disorder

SNRI
selective
norepinephrine
reuptake
inhibitors
Reboxetine
(new class available
by the end of 1999)
+norepinephrine


Dry mouth
Constipation
Increase sweating
Insomnia

What are the common side effects of antidepressants?

The occurrence and severity of of side effects from antidepressant medications are difficult to predict in an individual.  However, it is possible to estimate which side effects are more likely to occur.  Side effects are not usually serious but may reduce the quality of your life to a greater or lesser extent.

The older TCA medications cause more severe side effects than the newer medications, such as the SSRIs.  Possible side effects from the older medications included:   tiredness, drowsiness, dry mouth, constipation, light headedness, low blood pressure after standing, sweats, and palpitations, and possible dose related recent memory loss.

The newer antidepressants may also cause tiredness or drowsiness.  They may cause nervousness initially in some patients, sometimes temporary nausea, and mild constipation or loose stools.  Inhibition of sexual orgasm, desire, and sometimes partial impotence can be related to some antidepressants.

Within a medication class, different medications have different side effects.  In fact, two people taking the same medication may experience very different side effects.

It is difficult sometimes to separate side effects from the symptoms of the depression.   It is clear that side effects are a factor if they only occurred after beginning medication or after a dose increase.  Side effects usually occur early in treatment; rarely do they begin after weeks of treatment without side effects.  Many of the newer antidepressants are likely to produce only one or two of these side effects.   Usually time and dosage adjustments made can minimize any side effects encountered.

Do I need to see a psychiatrist for antidepressant medication?

While many primary care physicians have the training and experience to diagnose depression and prescribe antidepressant medications, others do not have the training or interest in making a diagnosis and treating a patient for depression.  A psychiatrist   should be consulted if symptoms mentioned above are persistent, and either undiagnosed or unresponsive to two attempts of medication, or if suicidal thoughts are present.  The skillful use of antidepressant medications in the treatment of depression can reclaim, even save, a life.

What about St. John’s wort?

The dietary supplement St. John’s wort has been heralded by the media as a safe and effective treatment for depression.  However, recent studies on St. John’s wort highlight potential dangers for people with depression.  for example, the good Housekeeping Institute conducted a study that revealed a “startling lack of consistency in the quantity of the suspected active ingredients”  among 10 different brands.

This inconsistency between brands leaves consumers vulnerable because they can never be sure of what they are taking.  Natural is not always synonymous with safe.   Although small studies in Europe in patients with mild to shown promise, no clinically significant U.S. medical data supports the claim that St. John’s wort is effective or safe. 

The National Institute of Mental Health and Office of Alternative and Complementary Medicine have commissioned duke University to study St. John’s wort.   However, until more studies are completed, there is limited evidence about how the herb works, its effectiveness, the potential for dangerous interactions with prescription drugs, ling-term effects, or even a guarantee that what is on the label is actually in the bottle.

Talking with your health care provider

It’s important you feel confident in your doctor’s knowledge, skill, and interest in helping you.  You should never feel intimidated or feel as if you’re wasting your doctor’s time.

We use the term “doctor,” even though your mental health care provider may be a therapist.  social worker or registered nurse.  If you and your provider decide medication is the best course of treatment, only a medical doctor can prescribe it for you.

It’s important to share information your doctor needs to help you, such as medications, “natural” treatments, alcohol and other substances you are using.  A complete medical history, including medication reactions, allergies, and prior experiences with medication is important to know.

A skilled and interested doctor will address most of your concerns, but there may be questions left unanswered.  Don’t leave the doctor’s office until all your questions are answered.

Do you understand . . .

  • What dosage of medication is to be taken, at what time of day, and how to increase your dosage if this is to be done before your next visit?  (Take notes if this is complicated.)
  • What are the possible side effects of your medication(s) and what should you do if you experience a side effect?
  • How can you reach your doctor if you experience any severe side effect or worsening of your condition?  (Be sure you leave the appointment with an emergency phone number to reach your doctor.)
  • How long will it take to feel improvement and what type of improvement should you expect?
  • Are there risks associated with this treatment and, if so, how can you recognize them?  If you have any concerns, share them.
  • How long will you need to take medication?
  • If the medication needs to be stopped for any reason, how should this be done?
  • How often will you need to see your doctor?  How long will your appointments take?
  • Is psychotherapy recommended as part of treatment?  If so, what type?
  • What can you do to improve your response to treatment?
  • If this medication isn’t helpful, are there alternative treatments?
  • If someone questions why your doctor prescribed medication, or raises doubts about possible dangers of taking medication, how should you respond?
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