Trying to get a balanced view of antidepressants is becoming harder by the day. Supporters of antidepressant use shoot down the statements of those activists who reject the use of psychiatric medications. Those activists, in turn, debunk the simplistic claims that depression is caused by a chemical imbalance in the brain, describe the drugs as useless or worse and go after the pervasive influence of the pharmaceutical companies.
Those who’ve used medications for years are taking sides as well. If your life has either been saved or shattered by these medications, you’ll talk and write passionately about your experience. You want others to get the information that’s guided you, but misinformation is everywhere.
Most of us with depression, however, aren’t activists. We want to know how to get better and want the best information so that we can find the treatment we need. If you have depression, you can’t afford to wait until there’s general agreement – that day will never come. You have to choose who you’re going to believe and which treatments to rely on.
I’ve been asking a lot of questions about antidepressants. I’ve wondered if these medications could possibly have caused me more harm than good. I don’t have answers yet, and so I keep revisiting the basics.
That’s why I’ve come up with a personal 10-point guide for understanding why and how I might use antidepressants.
We all have to make choices about what to do on the basis of the incomplete and much fought-over information that we have. The list is my attempt to make sense of conflicting opinions, evolving research and my own experience.
It’s the best I can do so far to get a balanced view of antidepressants and the role they might play in treatment.
Multiple Causes. Research points to many potential causes and influences on the overall course of depression. Most books and online health information sites take you through a list that will likely include genetics, family environment, trauma, stress, personality traits and several aspects of brain chemistry, structure and neuron growth. You’ll find this type of overview at the Mayo Clinic site, WebMD, and MentalHelp.Net, among many others.
Chemical Imbalance. Depression can’t be explained simply as the result of deficient levels of neurotransmitters. As Ronald Pies helpfully explains in a recent post, even the originators of the idea that neurotransmitters could play a role in depression never claimed that mood disorders were caused by an imbalance of brain chemicals. They were careful to review the same array of factors that are discussed today.
Public Information. However, even sources of public information that describe multiple causes will then emphasize that antidepressants control symptoms by correcting an “imbalance” of neurotransmitters. Have a look at the Stanford Depression Center site, National Institute of Mental Health and the New York Times comprehensive overview of depression – among many others.
Right to Know. Antidepressants are the first-line, often the only treatment offered but frequently with little discussion about side effects and alternatives. Yet we have a right to good information about treatment options before we begin to use them. We should ask plenty of questions if the physicians and psychiatrists don’t provide the background we need.
Treatment Choice. People have a better chance of recovering if they participate in decisions about treatment. One of the little-discussed features of the important STAR*D study on antidepressants was the participation of patients in the choice of treatment after the initial stage. The options were limited, but I think this aspect of the study comes from the recognition that patient involvement in decisions is important.
Benefit. Antidepressants work for most of the people who take them. The level of improvement varies from response, or limited reduction in symptoms, to remission, or complete elimination of them. Under proper care, most patients should be able to get rid of all their symptoms if they stay with treatment long enough. But …
Relapse. Antidepressants do not prevent relapse for most of the people who take them. The beneficial effects of antidepressants often last no more than a year – and as little as a few months.
Treatment Resistance. As many as a third of the people who take antidepressants are said to be treatment resistant. They do not respond even after multiple rounds of different medications. Yet the recommended response to treatment resistance is medication and/or electroconvulsive therapy. I believe that lack of response to repeated meds should prompt a return to square one. Redo the assessment and diagnosis, and give patients the choice of stopping medication altogether and considering a wide range of other treatment options.
No Treatment. People whose depression goes untreated do far worse than those who receive treatment, and most of the time that treatment consists of antidepressants.
Psychotherapy. Psychotherapy should be offered at the same time or even prior to the use of antidepressants, and the options should go well beyond cognitive behavioral therapy. This is already the preferred approach, but often not observed in practice.
These are my guiding ideas about antidepressant use thus far. What are your thoughts about these medications?
Image by psyberartist at Flickr
Hi not sure when you wrote the above list and view, but I think its a good guide. I agree that not treating can be worse than treatment, even if that treatment is not perfect. I just tried taking an antidepressant called mirtazapine as I have issues sleeping. The starting does was too high I feel and it made me comatose and I slept all night but still got woken as often but I felt so groggy in the morning when I had to go to work and it felt lke someone had smashed my temporal lobes on both sides with a sledge hammer. However I have taken other antidepressants in the past and they worked well. So although I do not feel they are the ideal therapy they can and do help…albeit with side effects.
Hey.I’m a 100% non synthetically-medicated pyishotcc kid. Diagnosed schizophrenic and have very serious positive symptoms and equally horrible negative symptoms. Here is what I do to keep on top of the depression that is one of my negative symptoms.1) Omega 3 Fish Oil. You may have to buy a brand manufactured for kids because adult brands don’t tend to be filtered for mercury and you DEFINITELY want a mercury-free product. 2) Multi-vitamins. Take something with a very high iron, vitamin D and magnesium.3) Exercise. If you’re overweight, a healthier bodyweight will help you out. If you’re not, exercise will still release endorphins. Personally when I’m at my worst I do yoga from flashcards, (this is when I cannot leave the house) boxing, and jumping jacks while a music channel (usually rock but I figure anything with a good beat that you like listening to when you’re happy will work) is on. I also go running, when I’m not as bad, usually in a forest on warm days or at a beach on cold days, somewhere where I’ll be alone with nature and my ipod. 4) Music. I mentioned the music channel & ipod above, but I also blare Queen, Bowling for Soup, Blink-182 and the All-American Rejects (aka nobody who sings about death, depression, suicide, sadness, or has a downbeat – less than 4/4 – track) and I HATE IT. It makes me MAD and MAD is better than depressed. It is more productive. ;]5) I force myself to do things I enjoy when I’m happy. I take a shower with the nice smelling soap and warm my towels on the radiator, I watch the funny episodes of Firefly and my favourite films and read magazines and This Book Will Save Your Life (A.M Homes – it’s my favourite book). And if that sucks, I do the laundry and hoover. For me what works is just keeping moving. Then even if my whole day sucks and I can’t bear it, the next day I can wake up to something good I’ve done and maybe feel better for it – or I have fond memories of my favourite movie etc.6) My favourite one – I read a book I’ve written. It’s a big old book that I bought ages ago and when I’m happy, I write things I like in the book. Stupid stuff like, Xander from Buffy, and the sound from line arrays, and Diamond 4’s, and sherbert lemons, and Harry Potter 1, and Gandhi quotes, things that have no consequence. If I’m only mildly down, it can get me back up.7) Meditation. Just sit quietly and concentrate on not concentrating on anything. If that makes sense. Don’t allow yourself to have thoughts. Let your only thought be the thought that stops you thinking about anything. It sounds complex but you probably get my meaning. I like to meditate either in the dark in my room but the sunlight is good for depression so I force myself to sit in the middle of the living room with all the shades open in the sunlight. Therapy. Not from a councillor – from a psychologist, in particular a psychologist who is a qualified Cognitive Behavioural Therapist – these people are like GOLDDUST. They will teach you how to get through your worst moments and help you tailor your recovery techniques to your own personality. Plus, they’re also usually really cool not-up-themselves people. Interview a few different psych’s if you can, and if they’re in an office and wearing a suit, don’t bother. Find someone who wears jeans and listens to the music you like and likes the TV shows you like, so you geniunely like their company and that way, you’ll get a lot more out of your time with them – it’ll be more friendly and less clinical. And that in itself will lift your mood.Please bear in mind that the most important thing to have to get over depression without meds is psychological resilience. You need to be the type of depressed person who says, this sucks, but I WILL GET THROUGH THIS. I WILL NOT GIVE UP.. I WILL FORCE MYSELF THROUGH THIS. If you’re prone to giving up (I am not saying this is something to be ashamed of, it’s just something to be honest about – I understand fully that being a can’t-be-f*cking-bothered/don’t-want-to-can’t-make-me depressive is horrific and not something the depressive can help) you may have to come to terms with the fact that you may need a low dosage of meds (Citalopram is good in low doses) to get you through, and you may have to rely more heavily on therapy. Either way, get a CBT and remember you are not alone, and you should never give up on yourself.’When all you’ve got to keep is strong, move along. And even when your hope is gone, move along.’Good luck. Was this answer helpful?
Dear John: Went to see a phsychiatrist; after a few questions, he says I am depressed. Like I didn’t know that…Major depression- so he prescribed Fluoxetine 20 mg; clonazepam .5 mg. Didn’t care for the doctor’s refusal to answer simple questions. He encouraged me to stop reading and don’t drive myself crazy doing research. I took with me a copy of a book I have been reading for a few months, “Getting unstuck:unraveling the knot of depression, attention, and trauma.” by Dr. Don Kenson. I also had a list of all the possible antidepresants and their side effects and wanted to discuss them. We obviously didn’t; he wrote the prescriptions; said he wanted to seem me in one week, collected his co payment and rushed me off. After I picked my the prescriptions from the pharmacy, it become very anxious and sad about having to take medication. I felt like a failure. I don’t have the strength, the will power to just snap out this state of mind and get with it. I know I must try these medications since time off from work exercise, writing, sleeping are not suficient. So hard to admit and accept that I left myself hit bottom, almost, and that I know must depend on some medications. I feel shame, disappointment in myself, although I know this is the right thing to do. I took the pills for the first time today: a little dizzy, space out. Praying and hoping…
Dear John: I am planning to go with psychotheraphy, exercise, writing, change of job asap, and protect myself as much as possible from damaging relationships and other stressors. And of course, use this great website as an informational resource and source of inspiration and courage. I am starting with step 10 and then take it from there. The brief experiences I have had with antidepressants have been negative: insomnia, anxiety, more distress, and then more pills to counteract the side effects.
Excellent advise! But it has to be the right kind of therapist and theraphy. That’s what I am trying to figure out now. I need someone to help me put the pieces together and to help me heal.
“10) Psychotherapy. Psychotherapy should be offered at the same time or even prior to the use of antidepressants, and the options should go well beyond cognitive behavioral therapy. This is already the preferred approach, but often not observed in practice.”
My depression was so pervasive and severe that I eagerly sought any treatment that might help. Medication, therapy, ECT, exercise, nutrition, supplements, self-help books, etc. Of course, I didn’t know in 1995 what I know now. And I’m not sure I would have changed my course of action even with more information. Lately, I have felt very confused about the medication controversy. I no longer feel like I have a firm grasp on the subject; I no longer have strong convictions about the use of antidepressants. I was taught early-on by my PCP and psychiatrist that antidepressants were the best course of treatment — for multiple reasons. And the sooner the better. I don’t know how many of them were thrown at me with no discussion of side effects, long term complications, the possibility of becoming manic; and no one told me that once on them, I would probably be on them for life. I might have thought twice about taking them had I known. But then again, maybe not. I was desperate.
I did become manic for the first time not long after I took my first antidepressant in 1974. And I stayed in an uncomfortable hypomanic state for 4 years while the depression continued to get worse. And I’ve had two such episodes in the years since. Would I have become manic even without antidepressant use? There’s no way of knowing, but from what I have read the last month, it’s not uncommon. And despite switching medications often, none of them worked for years. I’m beginning to wonder if I wouldn’t have recovered anyway, as the years passed. Time can be a great healer. Was there a chance I never would have recovered w/o the antidepressants? Of course. But I don’t want to keep taking them the rest of my life. So far I have weaned myself of the anti-anxiety med Klonopin after taking it for several years. And I have almost completely stopped taking Zoloft after taking it for many years. I would like to get rid of the Wellbutrin, trazodone, and the antipsychotic Latuda, also. But I’m taking my time. I don’t want to push it and end up relapsing now that I’m feeling so good.
John Folk-Williams says
Hi, Donna –
I think so many of us have gone through a similar experience. We’ve taken medications for years on faith that they’d keep working but were never told what to expect, how long we’d have to stay on them, what their effects might be in the long run. Part of it could be ignorance, certainly on the part of primary care doctors but even with some psychiatrists. I do believe that many are guilty of relying more on pharma reps for information than on the latest research. Others aren’t used to answering questions and never encourage them or take time to explain things. I’m doing what you are – taking a long time to wean myself off meds that no longer do much instead of jumping to the next round. I’m hoping to avoid whatever bad effects stopping might produce.