Over at Health Central, I’ve put up a post called My 20 Meds. It’s about the trial and error process I went through to find a medication for depression that gave me more help than harm. The interesting thing is that none of the newer antidepressants worked for very long. The most effective have belonged to older classes of drugs.
The first one I used was Elavil (amitritypline) back in the 1960s. It worked perfectly to get me through a two-month crisis. After that brief use, I took no medications until the 1990s – primarily because the psychiatrists I worked with, especially in the 60s and 70s, prescribed medication only when depression reached crisis proportions.
I wrote about that practice in this 2007 post. Depression, according to Peter Kramer, was considered a useful tool for motivating a patient to dig deep into the past to identify the “real” problems buried in the unconscious. The question of medication never came up, and I didn’t even think to ask about it.
When the 90s brought in the widespread use of the newer generation of drugs, psychiatrists started making up for all the time lost in my medication history. I wrote about my experience with the side effects of the SSRI antidepressants and their close cousins in Feeling Fine on Prozac.
Prozac was the first SSRI I tried, and I felt an immediate turnaround. Energy, focus, upbeat attitude – all returned – for just about three months. Then I went through a long period with the drug declining in effectiveness as the symptoms of depression grew worse. I moved on from Prozac to Effexor, Paxil, Zoloft, Lexapro – each for at least two years – and many others, 20 in all, for briefer periods.
Each one gave me the same experience. At first there would be a slight improvement in mood. Then, as that wore off, the dosage would be increased and often another medication added. Eventually, it became clear that the drug wasn’t doing anything, so it was on to another. I’ve never had a psychiatrist who suggested stopping medication altogether, and I never wanted to stop for fear that I’d fall into an abyss without antidepressants.
The medication that finally worked for a sustained period was selegiline, the antidepressant in Emsam. It’s a member of one of the oldest groups, the MAOIs (monoamine oxidase inhibitors). The innovation of Emsam is its transdermal delivery system that uses a patch to put the chemical directly into the bloodstream. Bypassing the gastrointestinal tract greatly reduces the danger of interaction with a substance found in most foods, an interaction that can cause a stroke-inducing spike in blood pressure.
The effect of Emsam, however, also started to wear off, and so Lamictal (lamotrigine) was combined with it. That combination has held up for several years and has given me the energy I needed to make dramatic progress in recovery. Lamictal, though, is not an antidepressant but rather an anticonvulsant originally used for epilepsy. It turned out to be effective in treating bipolar, and quite recently has been prescribed as an adjunct treatment for major depressive disorder.
So all the promises of the “designer” drugs of the last 20 years have fallen through, at least in my experience. What they did most of the time was drain all feeling out of my system. I felt disconnected from everyone, and that wasn’t due to depression itself, even though loss of the ability to feel emotion is a common symptom. The success I’ve had with Emsam and Lamictal hasn’t dulled me down but rather energized me, showing that an effective medication doesn’t necessarily force you to pay a high price by intensifying some aspects of depression while mitigating others – if they offer any help at all.
Everyone has a different experience with medication, and I know that side-effects are likely to develop the longer I stay on the combination I’m now using. But they’ve served their purpose as a tool to help me do the hard part of recovery – finding out who I am, rebuilding a life, restoring relationships, and all the other human things that drugs can never reach.
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John,
This is a timely essay for me as I stopped taking Wellbutrin XL a few days ago due to the development of hypertension. I will remain in Effexor. About 1 yr ago I had a severe 5 month relapse, my first in 6 yrs. My dose of Effexor was eventually doubled and Wellbutrin was added.
The trial & error process with meds for depression is not only frustrating but scary, especially if one is experiencing suicidal thoughts. Then there are the variations in onset of action, the waiting period for improvement (or none), adverse effects, and drug interactions.
My med history = imipramine (no improvement, just adverse effects), fluoxetine (magical transformation for me after 3 wks, but it pooped out after several years, citalopram, augmentation with a thyroid hormone (no help), augmentation with buspirone (no help), venlafaxine (which I remain on) and finally bupropion was added on.
So now I will see what happens as bupropion washes out of my body. I fear the emergence of depression and suicidal thoughts. If that occurs then a decision must be made about which med to try next—aripiprazole vs lithium?
I will continue with psychotherapy, vigorous exercise, omega-3 fatty acids, vitamin D3, friendships, self-talk, etc.
Thanks for sharing, John.
Hi, Margaret –
Thanks for describing some of your history with antidepressants. I agree that the trial and error process is scary – since there’s no telling which particular side effects may become a problem or whether the drug will work on the basic depressed mood at all. I’ve often had your experience of initial success with a drug and then a gradual wearing off of its effectiveness. Then come ever higher doses which may work for a time until my system somehow adapts to those levels as well. I haven’t found much by way of explanation for this wearing off problem, but I have the impression that it’s extremely widespread.
Does the need to add another drug mean that the high dose of Effexor isn’t working? As for adding an antipsychotic, mood stabilizer or something else in combination, that’s also trial and error. But I found that the side effects with these powerful drugs can be even more severe – lithium, for example, felt like it was shutting down half the cognitive area of my brain. As consumers of these meds we need as much information about potential problems as we can get ahead of time. I’ve found, though, that psychiatrists rarely volunteer the information – perhaps they fear the power of suggestion – but it’s essential to know what you’re getting into.
I hope you can find the right medication soon.
John
Medications for me has been, as usual, trial and error. I find that a combination of medications and psychotherapy work best for me. I’ve actually come to a point that no other medication combinations will work with me. My symptoms are situational and complicated and need to be dealt with in therapy. Thank you for sharing your journey through medications.
Take care,
CC
Hi, CC –
I think I’ve come to that same point of feeling that the combination of meds I now take is the only one that will work. While therapy has been beneficial, the many insights I took from it never really got at the depression itself, at least not in a lasting way. Both meds and therapy, though, have helped me get to this point where I feel I’ve taken over the part of recovery that gets at healing the whole person, as Remen and Lerner put it. Sherwin Nuland said something similar when he talked about his treatment (electroconvulsive was the only thing that worked) got the symptoms under enough control that he could take over and “by an act of will” bring himself back to life.. It’s so different for everybody! Depression is only a general term covering a great variety of conditions and symptoms – and I believe brain chemistry and effects on different areas of the brain as well.
John