Antidepressants - 5 Things You Need to Know
You will be much happier with the results if you expect very little.
Antidepressants and depression. There are occasions when antidepressants are appropriate, and that occasion is when you're desperate and willing to try anything. Make no mistake - too many people do not survive their depressions. Many many more have to endure miserable half-lives, day in, day out. Trust me, I've been there. In these situations, an antidepressant is a sensible choice, but you need to keep your expectations realistic.
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First Thing You Need to Know About Your Antidepressant
You can get more out of your antidepressant if you don't ask too much of it. Antidepressants are not magic bullets. They are certainly not going to get you 100 percent better. They may not get you even 10 percent better. But even a slight improvement is better than no improvement.
A slight improvement may be all that is required in shifting your critical mass to the next phase of recovery: From not being able to get up out of bed to getting up out of bed, from not wanting to get out the door to getting out the door, from not doing things to help yourself to doing things to help yourself.
Keep in mind, recovery is a game of inches. Gaining one inch gives you a vital toe-hold to gain additional inches. Often, the modest improvement from an antidepressant represents that crucial first inch. That first inch is obviously not where you want to be, but don't estimate the value in simply getting there from where you were before.
The Second Thing You Need to Know About Your Antidepressant
Don't expect an antidepressant to make your miserable life bearable. If the underlying cause of your depression is a toxic relationship or abusive working situation or something similar, at best an antidepressant will perk you up enough to help you resolve it. Doing nothing invites depression back in.
No one should have to endure depression one second longer than necessary. But our psychic pain is often part of the healing process - as part of channeling our grief, acknowledging reality, reaching acceptance, and making tough choices. Often, depressions will resolve themselves when we face life issues head on, but this generally involves feeling worse before we feel better.
An antidepressant may prove extremely useful in keeping us from falling apart when we least need it. But it serves no useful purpose in masking the very thoughts and feelings - however unpleasant - that we so desperately need to experience. Having the wisdom to distinguish the first from the second is vital.
The Third Thing You Need to Know About Your Antidepressant
Your antidepressant will work much better if you put in the work. Mental health advocates stress that mental illness, including depression, is biologically based and therefore no-fault. This may be true, but if you interpret this to mean that all you have to do is sit back and wait for your pill to kick in, you will be sorely disappointed.
To use a medical analogy, statins don't work well for people on high-fat diets. Insulin doesn't work well for people on high-sugar diets.
"Moral character" implies that you are lacking in it if your depression persists. People who have never been depressed have no clue that snapping out of it is virtually impossible when your brain is not working. But then there comes a stage where personal virtue (namely moral character) enters the picture. There is no sugar-coating this: depression is not for wimps.
The Fourth Thing You Need to Know About Your Antidepressant
Doctors (including psychiatrists) are not necessarily your best advisers. Far too many have fallen in love with the idea that a pill will solve all of your problems. They often fail to see the whole picture - that you are a person and not just a diagnosis, and that your medication plays but a small role in your recovery. They don't see their job as working with you in devising a strategy to integrate your meds with other important aspects of your recovery.
Virtually all psychiatrists have swallowed Pharma propaganda wholesale. You cannot sit in a waiting room for more than ten minutes without a Pharm rep walking in the door. Pens and coffee mugs and notepads and literature with drug logos are everywhere. The impression is being in the branch office of Eli Lilly or Bristol-Myers Squibb rather than in the clinic of a professional who has taken an oath to do you no harm.
Adequate monitoring and follow-up is nonexistent. If your psychiatrist doesn't come across as a front man for the drug companies, he or she will almost certainly give you the impression of being a paid insurance industry hack (which is exactly their status). Thus ten-minute meds checks rather than thorough evaluations. Mindless rounds of pill roulette rather than the actual practice of medicine. As for actually listening to you - no time for that.
Last but not least, far too many psychiatrists lack the wisdom to make the recommendation that you may be better off not on an antidepressant.
In the final analysis, you are your own best judge. A good working relationship with your psychiatrist is strongly advised, but you need to be the lead partner. Your psychiatrist is there to serve you in getting well and staying well, and you can best help out by turning yourself into an "expert patient" who is not afraid to speak out. Give your psychiatrist the third degree. If you are not satisfied with the answers, find another psychiatrist.
The Fifth Thing You Need to Know About Your Antidepressant
The scientific/medical evidence base for antidepressant treatment is nonexistent, or at best highly suspect. Virtually all treatment studies regard all depressions as the same, with one-size-fits-all remedies, which means there are no studies in support of what works best for you.
Nearly all short term antidepressant trials (about six weeks) are conducted by drug companies to serve their own interests (an FDA indication to market to the widest possible audience) rather than your own interest (namely, what works best to get you well and keep you well).
As for the long-term, it simply doesn't exist. No one does five-year studies. Studies lasting a year or more are extremely rare and are marred by extremely high drop-out rates and methodological glitches too numerous to mention.
Finally, prominent academic researchers have been bought out by Pharma. "Findings" that support drug company marketing objectives rather than dispassionate scientific enquiry are the rule rather than the exception. Clinical trials are replete with various tricks of the trade to improve the performance of the test med, from weeding out beforehand likely nonresponders to cooking data to spinning results.
The one authoritative proposition that comes out of this is the surprising amount of studies that fail, despite every effort made by the drug companies to optimize a good result.
In 1999, GSK published a study showing that Lamictal was effective for treating bipolar depression in its acute (initial) phase. The finding was at best ambiguous, as the study failed on its primary endpoint.
GSK spent the next six years working to come up with a study that would impress the FDA. (The FDA looks for at least two successful trials.) In all, GSK sponsored seven more acute phase trials testing Lamictal for unipolar and bipolar depression. In each of these studies, Lamictal failed to beat the placebo. Predictably, none of these studies was published.
But GSK did come up lucky in two long-term studies showing that, compared to lithium, Lamictal worked better at delaying relapses into bipolar depression. These studies had a major flaw in that the long-term phase only included patients who had responded to lithium or Lamictal during the initial phase of the study. In other words, "nonresponders" likely to fail had been weeded out.
Another point: Virtually all the patients in the study relapsed anyway. It just took the Lamictal patients a bit longer, so the two studies basically proved nothing.
Nevertheless, on the strength of these two studies, in 2003 Lamictal received an FDA indication for "bipolar maintenance." This amounted to a green-light for GSK to aggressively market Lamictal for bipolar depression.
Chances are you have heard your doctor sing praises to Lamictal as the magic bullet for treating bipolar depression, even though there is absolutely no scientific evidence to support this. But wait. Here comes the first twist:
In late 2003, Eli Lilly received a true FDA indication for its combo Prozac-Zyprexa pill, Symbyax, to treat bipolar depression. Confident its own med would crush the competition, Eli Lilly sponsored a head-to-head trial (with no placebo group) pitting Symbyax against Lamictal under conditions that gave its own drug considerable home field advantage.
But - surprise - Lamictal and Symbyax ended up in a virtual dead heat. Not only that, those on Lamictal had way fewer side effects.
Here's how Eli Lilly spun the study (published in 2006):
[Symbyax]-treated patients had significantly greater improvement than l[Lamictal]-treated patients in change from baseline across the 7-week treatment period on the Clinical Global Impressions-Severity of Illness scale ...
The best way to explain the spin is this: If Eli Lilly were AIG (which went belly up in 2008 in one of the biggest financial scandals in history), they would be reporting record profits.
Ironically, then, the one unambiguous finding in favor of GSK's Lamictal came from the competition.
But here's the second twist: Clinical observation indicates that Lamictal really does work well for bipolar depression. The trouble is, as Hagop Akiskal of UCSD explained to me, that GSK did not know how to measure for bipolar. (Obviously, Eli Lilly did.)
Either way you look at it - overhype based on flimsy evidence or a good med undercut by bad evidence - there is little in the way of hard science to support antidepressant treatment. A good clinician knows this and will work with you in figuring out your best options. A bad clinician (and there are many) will pass industry hype on to you as medical advice. Caveat emptor.
Wrapping Up Antidepressants
When we use a fork to do a spoon's job, we tend to be unhappy with the results. Just ask anyone who has ever stuck a fork into a bowl of soup.
It is far worse with antidepressants. Not only are we asking a fork to do the job of a spoon, we are asking it to do the job of a knife, a screwdriver, a hammer, a shovel, the tires on your car.
People who use their forks (and antidepressants) wisely, tend to be pleased with the results. Doctors need to exercise far greater selectivity in their prescriptions. Patients need to recognize that antidepressants can only accomplish so much.
Be wise, live well ...
Final article in this series: Antidepressant Treatment Strategies
This article completely replaces earlier articles on antidepressants, Jan 8, 2011
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