Sunday, 4 October 2009

Antidepressants: 10 Things You Need To Know

1. What Antidepressants Are
Antidepressants are drugs which are used to treat clinical depression, although many of them are approved for use in other conditions as well. There are five main types:
  1. Tricyclic Antidepressants (TCAs)
  2. Selective Serotonin Re-uptake Inhibitors (SSRIs)
  3. Noradenaline Re-uptake Inhibitors (NRIs)
  4. Multiple Re-uptake Inhibitors
  5. Monoamine Oxidase Inhibitors (MAOIs)
There are also miscellaneous antidepressants which don't fit into any of those categories. Apart from depression, antidepressants may be used for severe anxiety disorders and panic attacks, obsessive-compulsive disorder, eating disorders, post-traumatic stress and chronic pain.

2. How We Think They Work
It's not known for certain how antidepressants work, but most of them are thought to work by inhibiting the reabsorption of certain chemicals in the brain. For those of you who know nothing about the brain, let me run you through a couple of basics. The brain is made up of about 10 billion brain cells, or 'neurons'. Each one connects to about 10,000 others, but they don't actually touch one another. They are separated by small gaps called synapses. This is my fantastic diagram of two brain cells:

Brain cells communicate with each other by releasing chemicals called neurotransmitters, which other brain cells respond to. These chemicals are then either broken down or re-absorbed, because otherwise your neurons would be soaking in chemicals all the time, and they wouldn't be able to respond to other neurons any more. The most common antidepressants slow down the reabsorption of certain neurotransmitters, so that your neurons get longer to respond to them. That is why they are called 're-uptake inhibitors'. The three main neurotransmitters involved in depression are thought to be serotonin, noradrenaline and dopamine. SSRI's work on serotonin, NRI's work on noradrenaline, Multiple Reuptake Inhibitors work on two or more of the three and Tricyclics work on all three.

MAOI's work a bit differently; they slow down a chemical called Monoamine Oxidase, which breaks down neurotransmitters. The effect, however, is the same. Your brain cells get to soak in the right chemicals for longer.

3. Not Everyone Needs Medication
Antidepressants should not be used for treating mild depression for two reasons:
  1. Recent research shows that if you're not severely depressed, antidepressants don't work any better than placebos.
  2. While the placebo effect can be useful, antidepressants have risks and side-effects, so for those with mild to moderate depression, the risks basically outweigh any potential benefits.
Here's the deal. Most people with mild or moderate depression can be treated with therapy, regular exercise, a good diet and a support group. Some people ask for medication straight away because they're looking for a quick fix, which is a dumb idea because antidepressants are not happy pills. You still need to do all those other things even if you are on medication. But there are those who do all the right things and don't feel any better. In that case, medication may be a valid option.

Severe depression is different. If you're so depressed that you spend hours lying in bed trying to get up the strength to get up and make a cup of tea, it's pretty pointless for somebody to tell you that you need to get some exercise. That's the kind of depression where you need medication straight away.

4. They Don't Work Straight Away
Some people respond almost immediately to antidepressants, but others may not notice any difference for up to a month after they start taking, or six weeks for fluoxetine (Prozac). If there's still no response after about six to eight weeks, that's when it's time to try a different drug.

5. Side-Effects
Common side-effects when you start an antidepressant are: dry mouth, nausea, headaches, sleepiness or insomnia, weight gain and constipation or diarrhoea. These effects are usually temporary and they should pass in a few weeks. SSRI's can make you anxious at first and they can sometimes cause longer-term problems with weight gain and with your sex drive. Tricyclics can affect your blood pressure, and MAOI's can have serious and potentially fatal interactions with certain types of foods. If you are prescribed an MAOI, your doctor will tell you which foods to avoid. Always read the patient information leaflet for the full list of side-effects before you take an antidepressant.

6. Suicide Risk
All antidepressants carry an increased risk of suicide. Therefore it's very important that anybody who is starting an antidepressant is carefully monitored by a doctor, and that they report any suicidal thoughts immediately. It's a good idea to keep a list of phone numbers you can call in a crisis, and this should include your doctor or therapist or a crisis team. The risk of suicide associated with antidepressants is a lot higher in children and teenagers.

7. Alcohol
Generally speaking, it's best to avoid alcohol if you're taking an antidepressant. A few drinks here and there or a glass of wine with your meal is usually okay, but some combinations should not be mixed with alcohol at all. Ever. So ask your doctor first. Large amounts of alcohol also tend to make you more depressed, which can further increase your risk of suicide in the first few weeks of treatment.

8. Physical Dependency
When you've been taking an antidepressant for a while, your brain gets used to the chemical changes the meds cause. Although antidepressants aren't addictive in the true sense of the word, some people experience withdrawal symptoms when they stop taking their medication especially if it's an SSRI, and even more so if you stop taking them abruptly. Withdrawal from reuptake inhibitors can cause severe fatigue, headaches, nausea, vomiting, chills, dizziness, shaking or tremors, insomnia, electric-shock like sensations, vertigo, confusion and suicidal thoughts, plus "brain shivers". These symptoms are collectively known as SSRI Discontinuation Syndrome, but multiple reuptake inhibitors which affect serotonin can also cause this. Don't try to come off your medication on your own. You need to gradually reduce your dose over time to avoid withdrawal effects. Also, some drugs leave the body very quickly so even if you only miss one dose you can experience withdrawal symptoms. It's important to take your meds at the same time every day (or however often your psychiatrist or pharmacist told you to). Getting a pill organiser is a good idea.

9. Sometimes They Stop Working
SSRI's and other reuptake inhibitors can work really well at first and then suddenly stop working. It's known as the 'poop-out' effect. I kid you not, that's what doctors call it. It usually just means you need to switch to another medication in the same class, so don't panic if you find your medication suddenly stops working. Luckily, if you take a break from an antidepressant then start taking it again, it will often work as well as it did when you took it the first time. So if you find two SSRI's that work well for you, but they tend to quit working after a while, you can cycle between the two of them for as long as you need to.

10. Antidepressants Are Not A Cure
For people with severe depression, medication can be a very important part of treatment. It can be the difference between being completely incapacitated, and being able to engage in therapy, being able to go for a walk etc. But antidepressants aren't a magic cure. They don't suddenly make everything okay. Severe mental illness can't be fixed overnight. It usually takes months or even years of treatment to reach some sort of stability where you can get back to your life as it was before you became ill. And non-drug treatments are just as important for people who take medication as they are for those who don't. Doctors, patients, friends, family etc often expect medication to make the problem go away straight away. Some people will even wonder why you can't just "snap out of it" already. It doesn't work like that. Recovering from a serious depressive illness is like recovering from major surgery. It takes time, and the right treatment.

Just a reminder: I'm not a doctor and this is not a replacement for proper medical advice. You should always consult the patient information leaflet for a medication before taking it.


james said...

Thanks a lot for a bunch of good tips. I look forward to reading more on the topic in the future. Keep up the good work! This blog is going to be great resource. Love reading it.

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Anonymous said...

Just wanted to point out that when returning to a previously tried med, they RARELY work as well as they did the first time around.

I don't know why this happens, but a lot of people seem to experience this (me included).

Informative blog!

Sarah said...

Dear anonymous,

It depends on the person and the medication. It is true that cycling between different medications can mean that each one works less well each time, or for less long, but for some people, it works well enough to get them through the worst part of their depression.

For others, yeah you can just end up burning out two decent meds which might have worked better without the cycling. It varies.

Anonymous said...

My meds literally worked within hours - incredible and that was with moderate depression. I think it's important to blog from a personal perspective. No amount of excercise or self help could have found the person I had lost - The meds are and have done that. Keep your fingers crossed for me.

Anonymous said...

Antidepressants work only for certain people. The problem is, many doctors receive a kick-back from every prescription they write, so they hand these things out like candy. They even prescribe them for chronic pain now. They tried that crap with me, and I said no thank you, walked out of that office and never returned. If a doctor tries to prescribe these things to you, and you are not severely depressed, it's time to find a new doctor!

Dave M. said...

I loved this post. For my family we have found an alternative to prescription drugs. They all come with side effects and they are thought to work by causing inflammation (the mother of all disease).

brooke said...

thanku so much for breaking brain activity down for me

Alex Neil said...

Not very many people in my life know that I was also once on antidepressants but I found them helpful for just getting me into a better place to get on with things and to manage the longer term things I needed to put in place to look after my mental health for the rest of my life.