Should I take antidepressants ?

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This is a question I am frequently asked.

Just as someone might wonder if they should take a paracetamol (Tylenol) for a headache, people appear to have the same thoughts about depression. There seems to be a clear divide: Those who would do absolutely anything to relieve themselves of the discomfort of a headache, swallowing painkillers as if they were Jelly beans, and those stoic individuals who would not let a pill pass their lips.

Whilst broadly speaking, the same can be said for antidepressants, the difference is often not confined to mere choice and the factors are often more complex. Choosing whether or not to take a painkiller (Analgesic) is often shaped by one’s outlook. In my experience people who don’t take painkillers, probably have grown up with the mindset that all medication is to be avoided if possible. They recognise that rest, fresh air and quiet may be all they need and they will willingly endure the pain until it passes. Depression however, is different.

Whilst a headache may simply pass with rest, sadly the same cannot be said of depression. Mild depression often responds very well to interventions like Counselling and CBT and these should be seen as the mainstay of treatment. Taking antidepressants should not be viewed as the first course of action for mild depression. Rest, taking time out from work, increasing exercise, reducing stress and external demands will all help.

With regard to moderate/severe depression. Yes, it may spontaneously lift, after, say, eighteen months, but that’s an awful long time to endure a condition that leaves you feeling truly rotten. Furthermore, the way depression chips away at confidence, self-esteem and impacts on outlook cannot be underestimated. The risk of suicide is ever present and the impact on those around you cannot be ignored. According to the organisation NICE (National Institute for Clinical Excellence), talking therapies such as CBT should be used alongside antidepressant medication. In cases of severe  depression, however, it may well be that medication has to begin to work and lift the mood and reduce negative thoughts before talking therapies can be truly effective. The exception is supportive counselling or psychotherapy.

What is it that puts people off taking antidepressant medication? Well, a number of things. The stigma for one. People often view themselves as weak, or having failed. So different from taking painkillers! The notion that depression is something that happens to someone else, or somehow suggests a character flaw, perhaps to be associated with films such as, “One flew over the cuckoos nest.”  Such negative perceptions are so damaging and probably contribute to more misery and stereotyping of mental health problems than anything else.

Another factor that cannot be ignored is the failure of the medical establishment to give people an adequate explanation as to how medication works and what side effects to expect. Time after time,  people come to me after their GP has prescribed antidepressant medication, only to tell me how alarmed they were when they saw the list of side effects in the leaflet issued with the medication. I then have to take time to explain that pharmaceutical manufacturers are duty bound to list every “known” side-effect. I explain how the list is compiled. I point out that they may experience common side effects such as dry mouth, nausea and sometimes raised anxiety for the first week or thereabouts. By this time they may have wasted a week or two with the pills sitting on a shelf at home.

Another factor to note, again as a result of lack of information, is that when they start taking the medication and experience anxiety, it provokes fear and they stop, often, wrongly assuming they are getting worse. If you are at all concerned about side effects or even want to ask some questions about them, consult a healthcare professional such a pharmacist if you do not want to return to the prescribing doctor or nurse.

Probably one of the chief reasons for not taking anti-depressant medication is the fear of drug addiction or dependence. I explain to people that many years ago before the advent of modern antidepressants, the only medicines available were tranquillisers and sedatives (often benzodiazepines) and these were addictive. However, nowadays, modern antidepressants are not addictive and they are not “tranquillisers.” After all, why would your doctor prescribe you with something that would treat one condition (depression) and create another (addiction!)

Antidepressant medication is very effective for treating moderate to severe depression. As well as effectively targeting mood related symptoms, they target physiological symptoms such as loss of appetite and poor sleep. In fact, improvement to sleep is usually one of the first benefits when taking antidepressants and can often happen within the first few days.

It is important to understand that antidepressants usually take up to two weeks and sometimes longer to bring about significant change to mood and disposition. Improvements usually continue up to four or five weeks before they are working at there optimum. Unlike other drugs that act on the brain, one would generally take a single dose of antidepressant medication each day (The daily amount might be taken in smaller divided doses). Other drugs, antibiotics, analgesics,etc, might need to be taken several times per day. Even our humble cup of tea (or coffee) has to be taken several times per day, as the positive effects, while fast acting, are short lived.

Because antidepressants build up slowly in the body, one benefit is that if a dose is missed it will not be the end of the world, as most have a reasonably long half life. (The term “half life” refers to the amount of time it takes for the drug in the body to lower to half it’s potency).

It is important to take the full dose prescribed, because taking a dosage lower than a certain threshold will serve no useful therapeutic purpose, except perhaps give you side effects alone. Likewise, doses in excess of the prescribed amount will not bring about any more benefits or work any quicker. Doses in excess of the prescribed amount should be avoided in any case, due to risk of overdose. Whilst nowadays modern antidepressants are much safer, some can be fatal in even small amounts. Sticking to the prescribe dose is both safe and beneficial.

What about taking antidepressants if your not depressed to give you a lift or promote a sense of calmness? Well, I am sorry to disappoint you. Unfortunately, they do not seem to make people who are not depressed feel calmer or more relaxed, neither do they leave you skipping down the street with a grin on your face. They only seem to “anti-depress” people who are depressed and that’s the bottom line.

Antidepressants do work and you should take them because they are extremely effective in treating depression.

Sometimes, people may need to try a different one in the event the first one they try is not bringing about the desired uplift in mood. This is frustrating, but par for the course. Mostly they are prescribed very effectively, targeting key symptoms unique to you. For example, you might be prescribed a more “sedative” type antidepressant if you are sleeping poorly. Alternatively, you might be prescribed one with a more “stimulating” effect if you are slowed down, sleeping excessively and particularly lethargic. You will know whether any medication you are taking is stimulant or sedative due to the time of day you take it. A stimulant antidepressant is generally taken in the morning, while a sedative antidepressant is taken in the evening.

Sometimes antidepressants are prescribed for a number of other reasons than simply depression. For example, anxiety. So often, anxiety accompanies depression. A number of antidepressants have very good anti-anxiety properties. Other antidepressants are good when somebody is suffering from aches and pains. They may also be prescribed for the treatment of eating disorders, such as bulimia and for panic disorder, social anxiety and obsessive compulsive disorder and post-traumatic stress disorder.

Another very important consideration is that they should ideally be taken for three to six months once the person is well. This is recommended by the World Health Organisation and the rationale is that if the person has a major stressful life event or similar, it will not set them back. It is not unknown for people to stop taking antidepressants once they feel well, but this is not to be recommended. I think of it in the same way as antibiotics, once the “wound” has healed you must still finish the course of treatment.

A word or two about coming off medication. Firstly, do not come off your medication without consulting the person who prescribed it in the first instance or your family doctor. Secondly, it is a good idea when stopping to do so gradually. While just stopping abruptly can be done, it is not recommended as some people experience a rebound effect on the cholinergic system ( Cholinergic generally refers to a chemical known as acetylcholine, a neurotransmitter responsible for sending messages throughout the nervous system) and may be a source of increased dreaming, sleep disturbance and marked nausea. Reducing the dose gradually over a couple of weeks or longer is ideal.

Finally, a little about the different types of antidepressants:

Tricyclics – these were the first truly effective and oldest antidepressants. They are more toxic in overdose and may have slightly more side effects than others. One valuable side effect is that fact that they may have a marked sedative effect. For this reason I have on occasion recommended  a prescriber consider using them as an alternative to sleeping tablets for they are not addictive and do not cause depression as some sleeping tablets can.

MAOIs  (Monoamine oxidase inhibitors) – These are usually used when other antidepressants have not been helpful. They can be very effective, however one big drawback is that they can interact with certain foods such as cheese, certain wines and yeast extract which contains a protein called tyramine, as these may bring about a severe rise in blood pressure. However modern cheeses when taken in moderation should not cause reactions (Dr P Ken Gillman V, 2013). They are usually prescribed first thing in the morning rather than last thing at night as they can interfere with sleep and are mildly stimulant.

SSRIs (Selective Serotonin Reuptake Inhibitors) – These are the most popular antidepressants prescribed today. Probably the best known are Fluoxetine (Prozac), Citalopram ( Cipramil), Sertraline (Lustral), and Paroxetine (Seroxat).

SNRIs (Serotonin and Noradrenaline Reuptake Inhibitors) – These are also commonly prescribed and tend to work really well for some people when SSRIs are not effective, however, for some people SSRIs work better. Probably the best known are Venlafaxine (Effexor) and Duloxetine ( Cymbalta and Yentreve).

Others –  Include herbal antidepressants such as:

Hypericum ( Evening Primrose Oil)

NASSA ( Noradrenergic and Specific Serotonergic Antidepressant). Probably the best known are Mirtazepine ( Remeron, Avanza and Zispin).

(SNDRI) Serotonin–Norepinephrine–Dopamine Re-uptake Inhibitor.

(TRI)  Triple Re-uptake Inhibitor.

Until next time, Steve Clifford, Cognitive Behavioural Psychotherapist

www.steveclifford.com

www.facebook.com/yourmentalhealthmatters

References:

National Institute for Clinical Excellence – www.nice.org.uk

World Health Organisation – www.who.int‎

One Flew Over the Cuckoo’s Nest: is a 1975 American drama film directed by Miloš Forman, based on the 1962 novel One Flew Over the Cuckoo’s Nest by Ken Kesey, and starring Jack NicholsonLouise Fletcher, and William Redfield. The supporting cast features Will SampsonBrad DourifDanny DeVitoChristopher Lloyd, and Scatman Crothers. [Source Wikipedia – Accessed 31/10/13]

Monoamine Oxidase Inhibitors (MAOI), Dietary Restrictions, Tyramine, Cheese and Drug interactions (abbreviated). Dr P Ken Gillman V. abbrev. 2.3.2 March 2013http://www.psychotropical.com/index.php/anti-depressants/209-maoi-diet [Accessed 31/10/13]

Image ref: http://commons.wikimedia.org/wiki/File%3ADatos_Pegados_ff93.jpg

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