After about 18 years of non-stop, mostly ineffective antidepressant treatment, I’ve brought this long experiment to an end. I had been wearing Emsam patches for the past six years, but I’ve been fairly sure for some time that they had stopped working.
It seems I was right. Getting off the drug has made no difference at all in how I feel. It’s been a non-event. I haven’t had a relapse, despite all the warnings you hear when you consider stopping antidepressants. I was preparing myself for one because I thought it might be hard for my brain, so long conditioned to these drugs, to adapt to the change. But so far, so good.
Stopping antidepressant treatment is always a tricky thing. When you feel better, or completely recovered, as I do, a psychiatrist might tell you that the medication is the reason for improvement. That could well be the explanation, and you might be setting yourself up for a bad recurrence if you stop taking it.
In my case, I kept track for three years after I first sensed that the drug had stopped working. During that time, it failed to prevent the customary cycle of ups and downs of the “hangover” symptoms of depression I’ve had since recovery began. Only after this period of observation did I decide to stop.
I’m still taking lamotrigine (Lamictal) which was added to Emsam after the antidepressant stopped working on its own. Lamotrigine is one of the major mood stabilizers used to treat bipolar disorder. In recent years it’s also been approved as an added treatment to boost the effect of an antidepressant.
Now that I’m done with Emsam, I’ll be planning with my doctor the best way to withdraw from lamotrigine. I’m confident that I’ll have the same result – no change at all – but only time will tell.
What Do We Know about Antidepressants?
As I’ve read more about antidepressants, I’ve become concerned about how little is known about the effects of long-term use. Now that I’ve stopped using Emsam, I’m trying to bring myself up to date on recent research.
I soon found a December blog post by Thomas Insel, head of the National Institute of Mental Health. He provided an overview of antidepressants that gives me a start in getting answers. What he says about treatment with medications emphasizes how complicated depression is and how far we have to go to find better treatments.
1. How Many Take Them:
The Center for Disease Control says that 1 in 10 Americans are now taking antidepressants. The growth in their use has been enormous, but it hasn’t been due to psychiatrists. About 80% of the 250 million or so prescriptions written each year (at a cost of $10 billion) come from non-psychiatrist physicians. A great many of those prescriptions are not based on a depression assessment or diagnosis, nor are they written to treat depression.
2. What They’re Used For:
Psychiatrists routinely prescribe these medications not only for depression but also for the fear-related disorders, as they’re known in the official diagnostic manual. They include obsessive-compulsive disorder, post-traumatic stress disorder, general anxiety disorder and various phobias. Primary care doctors prescribe them for numerous problems: back pain, migraine headaches, fibromyalgia, menstrual symptoms and fatigue, among others.
3. How Well They Work:
Insel reviews several problems with antidepressant research that limit what the studies tell us about long-term effectiveness of these drugs. To begin with, most studies in the past only looked at short-term effects over a few months. Researchers have used different criteria for effectiveness. Some consider any level of response as the measure, while others require elimination of all symptoms. All the studies use standard lists of symptoms to measure effectiveness, but these leave out the ability to function well socially and mentally as well as the patient’s main concern about feeling better overall.
The studies that have tried to measure long-term effectiveness have shown mixed results. They do establish that your likelihood of having a recurrence of depression is much less with antidepressant treatment than without it. However, people with mild depression tend to benefit very little, while those with severe symptoms tend to benefit a great deal.
Here’s his overall conclusion. “The bottom line is that these medications appear to have a relatively small effect in patients broadly classified as having depression. In some patients, perhaps those with more severe clinical conditions, they appear to be essential for remission. Clearly we need to know more about who will and will not benefit.”
4. What We Know about Depression:
Part of the reason that antidepressants aren’t more effective is that depression isn’t a single condition. Given the pick-and-choose clinical criteria for a diagnosis, Insel points out, two people sharing only one of the nine criteria for depression could receive the same diagnosis. That’s a pretty stretchable diagnosis, but the clinical criteria are only one set of differences.
At the biological level, “depression likely comprises scores of different disorders.” (My emphasis.) When you add in the individual differences in the length of depressive episodes, the frequency of recurrence, family history, the presence of other illness or any of a dozen other factors, it’s no surprise that antidepressants don’t work for everyone.
5. The NIMH Research Agenda
Like every thoughtful observer, Insel emphasizes that treating depression is more art than science and that none of the methods we now use should be ruled out. However, when he turns to the new NIMH research direction, it’s all about biology.
There’s a program to identify biological signatures for depression that would make it possible to personalize treatment. Another program will figure out how to link the present clinical criteria for depression to neuroscience and gene research. A third focuses on developing more rapidly acting antidepressants.
That’s all fine, but funding for psychotherapy research never comes up. I have a hard time understanding why this approach to treatment – proven to be at least as effective as medication – doesn’t rate when it comes to financial support. I know that most research money comes from pharmaceutical companies and that they have no interest in psychotherapy or other non-drug treatments. Still, you would think that government funding could be spread around more evenly.
There’s a lot of concern about the high rates of relapse after initial success with antidepressants as well as concern about the many people who get little or no benefit at all from medication. Despite this mixed record, the push is always for newer, better, faster drugs, and there is always a promising new medication in the works.
I doubt this situation will change anytime soon. All the more reason for those of us who get no help from antidepressants to keep trying other methods. They may not be considered evidence-based, but that’s partly because researchers don’t spend time or money trying to figure out how effective they are – or how to improve them.
I hope you’ve had better luck than I have with antidepressants. Have they worked for you? Do you consider them the mainstay of your treatment?