Anti-depressant Drugs
The kind of depression that will most likely benefit from treatment with medications is more than just "the blues." It's a condition that's prolonged, lasting 2 weeks or more, and interferes with a person's ability to carry on daily tasks and to enjoy activities that previously brought pleasure. The depressed person will seem sad, or "down," or may show a lack of interest in his surroundings. He may have trouble eating and lose weight (although some people eat more and gain weight when depressed). He may sleep too much or too little, have difficulty going to sleep, sleep restlessly, or awaken very early in the morning. He may speak of feeling guilty, worthless, or hopeless. He may complain that his thinking is slowed down. He may lack energy, feeling "everything's too much," or he might be agitated and jumpy. A person who is depressed may cry. He may think and talk about killing himself and may even make a suicide attempt. Some people who are depressed have psychotic symptoms, such as delusions (false ideas) that are related to their depression. For instance, a psychotically depressed person might imagine that he is already dead, or "in hell," being punished. Not everyone who is depressed has all these symptoms, but everyone who is depressed has at least some of them.
A depression can range in intensity from mild to severe. Antidepressants are used most widely for serious depressions, but they can also be helpful for some milder depressions. Antidepressants, although they are not "uppers" or stimulants, take away or reduce the symptoms of depression and help the depressed person feel the way he did before he became depressed. Antidepressants are also used for disorders characterized principally by anxiety. They can block the symptoms of panic, including rapid heartbeat, terror, dizziness, chest pains, nausea, and breathing problems. They can also be used to treat some phobias.
The physician chooses the particular antidepressant to prescribe based on the individual patient's symptoms. When someone begins taking an antidepressant, improvement generally will not begin to show immediately. With most of these medications, it will take from 1 to 3 weeks before changes begin to occur. Some symptoms diminish early in treatment; others, later. For instance, a person's energy level or sleeping or eating patterns may improve before his depressed mood lifts. If there is little or no change in symptoms after 5 to 6 weeks, a different medication may be tried.
Some people will respond better to one than another. Since there is no certain way of determining beforehand which medication will be effective, the doctor may have to prescribe first one, then another, until an effective one is found. Treatment is continued for a minimum of several months and may last up to a year or more. While some people have one episode of depression and then never have another, or remain symptom-free for years, others have more frequent episodes or very long-lasting depressions that may go on for years. Some people find that their depressions become more frequent and severe as they get older. For these people, continuing (maintenance) treatment with antidepressants can be an effective way of reducing the frequency and severity of depressions. Those that are commonly used have no known long-term side effects and may be continued indefinitely.
The prescribed dosage of the medication may be lowered if side effects become troublesome. Lithium can also be used for maintenance treatment of repeated depressions whether or not there is evidence of a manic or manic-like episode in the past. Dosage of antidepressants varies, depending on the type of drug, the person's body chemistry, age, and, sometimes, body weight. Dosages are generally started low and raised gradually over time until the desired effect is reached without the appearance of troublesome side effects.
There are a number of antidepressant medications available. They differ in their side effects and, to some extent, in their level of effectiveness. Tricyclic antidepressants (named for their chemical structure) are more commonly used for treatment of major depressions than are monoamine oxidase inhibitors (MAOIs); but MAOIs are often helpful in so-called "atypical" depressions in which there are symptoms like oversleeping, anxiety, panic attacks, and phobias.
The last few years have seen the introduction of a number of new antidepressants. Several of them are called "selective serotonin reuptake inhibitors" (SSRIs). Those available at the present time in the United States are fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft). (Luvox has been approved for obsessive-compulsive disorder , and Paxil has been approved for panic disorder.) Though structurally different from each other, all the SSRIs' antidepressant effects are due to their action on one specific neurotransmitter, serotonin. Two other antidepressants that affect two neurotransmitters serotonin and norepinephrine have also been approved by the FDA. They are venlafaxine (Effexor) and nefazodone (Serzone). All of these newer antidepressants seem to have less bothersome side effects than the older tricyclic antidepressants. The tricyclic antidepressant clomipramine (Anafranil) affects serotonin but is not as selective as the SSRIs. It was the first medication specifically approved for use in the treatment of obsessive compulsive disorder (OCD). Prozac and Luvox have now been approved for use with OCD. Another of the newer antidepressants, bupropion (Wellbutrin), is chemically unrelated to the other antidepressants. It has more effect on norepinephrine and dopamine than on serotonin. Wellbutrin has not been associated with weight gain or sexual dysfunction. It is contraindicated for individuals with, or at risk for, a seizure disorder or who have been diagnosed with bulimia or anorexia nervosa.
Side Effects of Antidepressant Medications
1. Tricyclic Antidepressants
There are a number of possible side effects with tricyclic antidepressants that vary, depending on the medication. For example, amitriptyline (Elavil) may make people feel drowsy, while protriptyline (Vivactil) hardly does this at all and, in some people, may have an opposite effect, producing feelings of anxiety and restlessness. Because of this kind of variation in side effects, one antidepressant might be highly desirable for one person and not recommended for another. Tricyclics on occasion may complicate specific heart problems, and for this reason the physician should be aware of all such difficulties. Other side effects with tricyclics may include blurred vision, dry mouth, constipation, weight gain, dizziness when changing position, increased sweating, difficulty urinating, changes in sexual desire, decrease in sexual ability, muscle twitches, fatigue, and weakness. Not all these medications produce all side effects, and not everybody gets them. Some will disappear quickly, while others may remain for the length of treatment. Some side effects are similar to symptoms of depression (for instance, fatigue and constipation). For this reason, the patient or family should discuss all symptoms with the doctor, who may change the medication or dosage. Tricyclics also may interact with thyroid hormone, antihypertensive medications, oral contraceptives, some blood coagulants, some sleeping medications, antipsychotic medications, diuretics, antihistamines, aspirin, bicarbonate of soda, vitamin C, alcohol, andtobacco. An overdose of antidepressants is serious and potentially lethal. It requires immediate medical attention. Symptoms of an overdose of tricyclic antidepressant medication develop within an hour and may start with rapid heartbeat, dilated pupils, flushed face, and agitation, and progress to confusion, loss of consciousness, seizures, irregular heart beats, cardiorespiratory collapse, and death.
2. The Newer Antidepressants
The most common side effects of these antidepressants are gastrointestinal problems and headache. Others are insomnia, anxiety, and agitation. Because of potentially serious interaction between these medications and monoamine oxidase inhibitors, it is advisable to stop taking one medication from 2 to 4 or 5 weeks before starting the other, depending on the specific medications involved. In addition, some SSRIs have been found to affect metabolism of certain other medications in the liver, creating possible drug interactions.
3. Monoamine Oxidase Inhibitors (MAOIs)
MAOIs may cause some side effects similar to those of the other antidepressants. Dizziness when changing position and rapid heartbeat are common. MAOIs also react with certain foods and alcoholic beverages (such as aged cheeses, foods containing monosodium glutamate (MSG), Chianti and other red wines), and other medications (such as over-the-counter cold and allergy preparations, local anesthetics, amphetamines, insulin, some narcotics, and antiparkinsonian medications). These reactions often do not appear for several hours. Signs may include severe high blood pressure, headache, nausea, vomiting, rapid heartbeat, possible confusion, psychotic symptoms, seizures, stroke, and coma. For this reason, people taking MAOIs must stay away from restricted foods, drinks, and medications. They should be sure that they are furnished, by their doctor or pharmacist, a list of all foods, beverages, and other medications that should be avoided. Precautions to be observed when taking Antidepressants When taking antidepressants, it is important to tell all doctors (and dentists) being seen not just the one who is treating the depression about all medications being used, including over-the-counter preparations and alcohol. Antidepressants should be taken only in the amount prescribed and should be kept in a secure place away from children. When used with proper care, following doctors' instructions, antidepressants are extremely useful medications that can reverse the misery of a depression and help a person feel like himself again.
