Treatment

You and Your Antidepressant

Success may require being smarter than your doctor.

Perhaps we should start with the bad news about antidepressants: First, the success rate for antidepressants in clinical trials is 50 percent of patients getting 50 percent better - the type of result neither you nor I would find tolerable. In addition, SSRIs poop out on as many as fifty percent of their users, bringing on perhaps their second major depressive episode in the space of a year - a situation about as acceptable as two by-pass operations in twelve months.

Also, 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.

Antidepressant Side Effects

Then there are the side effects. Far from operating with laser precision deep inside the brain as many of us were initially led to believe, SSRIs have a bit more in common with the massive sledge-hammers of those earlier generations of medications than perhaps the pharmaceutical companies would like to let on. The most notorious side effect of the SSRIs is sexual dysfunction (found by one study to be as high as 40 percent, including women).

The worst antidepressants in terms of sexual dysfunction, according to one study, were Paxil at 43 percent, Remeron at 41 percent, and Prozac with 37 percent. (Other authorities say Remeron has no sexual side effects.) The lowest were Wellbutrin (22 percent) and Serzone (28 percent). Falling in between were Zoloft, Effexor, and Celexa. In some people Wellbutrin can act as an aphrodisiac, and is often used in combination with an SSRI to counter the sexual dysfunction side effects.

A University of Texas study of 337 adult depressed patients treated with an SSRI over a year found that 40 percent had at least one side effect on their medical record. The most common were sleep problems, GI/nausea/diarrhea, and fatigue or low mental alertness. Ninety-six patients (28 percent) had 101 medication changes after initial therapy, including 33 additions of medication, 31 switches to another antidepressant, 28 discontinuation of therapy due to adverse events, and nine dose changes.

The article cited the PDR and an article in the New England Journal of Medicine for these side effects and their frequency: increased anxiety (5-8 percent), loss of strength/fatigue (9-15 percent), diarrhea (12 -24 percent), dry mouth (10-18 percent), insomnia (13-28 percent), nausea (21-30 percent), somnolence (13-23 percent), and sexual dysfunction (13-17 percent).

Side effects can be reduced by lowering the dose, but patients on lower doses face a greater risk of relapse.

In the meantime, we simply do not know the long-term effects of many of these drugs. Trials are typically conducted amongst rather small population groups for periods that tend to range from six to eight weeks. Year-long trials are an extreme rarity, and 10-year data of the newer antidepressants is simply not available.

To make matters worse, your doctor is largely reliant on his or her information from the pharmaceutical companies. Moreover, according to a survey conducted by the Depression and Bipolar Support Alliance, he or she is unlikely to inform you of the side effects or make adjustments should you bring these up. According to an article in Medscape, as many as 70 percent of patients on antidepressants may be noncompliant, and according to another article in Medscape 50 percent of patients quit on their antidepressants before 30 days.

Not Quitting on Your Antidepressant

An earlier survey by the Depression and Bipolar Support Alliance in 1999 of 1,370 people with depression found less than a third to be satisfied with their antidepressants. But the alternative can be unthinkable. According to Michael Thase MD of the University of Pittsburgh: Between 50 and 70 percent of those who have experienced one episode of major depression will experience another at some later stage. The risk of subsequent episodes or recurrent depression increases from 50 to 70 to 90 percent across the first three depressive episodes. Chronic minor depressive disorders similarly place the individual at risk of major depression.

Dr Thase then makes this telling point: In a University of Pittsburgh study, an 85 percent recurrence rate was observed within three years after the withdrawal of an antidepressant. By contrast, nearly 80 percent of patients receiving maintenance antidepressant therapy remained well.

Antidepressant therapy is long term, then, possibly for life. You don't get rid of your antidepressants if you're feeling well anymore than a heart patient would throw out his heart pills or a diabetic his insulin.

Even if all goes well, there are bound to be adjustments along the way. For example, soon after your system has adapted to its medications, your doctor is likely to increase your dose to maintenance levels, and should you need to switch medications or go off them entirely, the doctor will "taper off" your doses rather than having you go cold turkey.

In many cases you may be required to be smarter than your doctor. One study sponsored by a healthcare provider and the drug company Pfizer found that primary care physicians indiscriminately prescribed antidepressants. Even when they made a correct diagnosis, they failed to educate their patients and often prescribed too low a dose for too short a period.

Another study from UCLA-Rand found that only 19 percent of a sample of depressed or anxious people they surveyed received appropriate treatment from their primary care physician. By contrast, 90 percent of those who saw a psychiatrist got proper care.

This potentially lethal combination of incompetent doctors and imperfect medications is one that can only be resolved by you, the patient or the patient’s loved one. Depression is a long-term, if not lifetime condition, lasting nine months on average, and usually requiring much longer medications regimes to reduce the likelihood of relapse. If your drugs don't quit on you in that time, your body is almost certainly bound to change, and with it, your ability to respond to your current medication. Consider your brain an organ every bit as important as your heart, together with a quality of life free from permanent side effects, and find a doctor or psychiatrist who feels the same way.

Treating to Remission

"This is the outcome that should be targeted," Michael Thase MD of the University of Pittsburgh told a sympsium at the 2002 APA annual meeting, which meant "no symptoms" and a "return to functional self," corresponding to a Hamilton-17 Depression score of 7 or lower. Dr Thase cited a UK study that showed a 70 percent relapse over 15 months for those who merely responded on antidepressants (ie a partial improvement in symptoms). In contrast, there was only a 20 percent relapse among the remitters on meds, a difference of 3.5 times.

The response/remission figures played out with patients in talking therapy, according to a study he was involved in. There, the relapse rate for remitted patients was 10 percent over one year vs a 50 percent relapse rate for the responders, a five times difference.

Over 10 years, 30 percent of remitters stayed well, compared to 13 percent for responders. "Partial remission," Dr Thase emphasized, "is a very very high indicator of relapse."

Dr Thase observed that depression needs to be vigorously treated at high doses for adequate duration. Doctors need to ensure patient adherence, as two-thirds to three-quarters of patients do not take their antidepressants, he said. Doctors also have to measure patient outcomes, as "a simple finding of a symptom or two determines if a patient is in the response zone or the remission zone."

Significantly, Dr Thase said that remission needs to be the goal of the acute (initial) phase of treatment.

In the same symposium, Andrew Nierenberg MD of Harvard and Associate Director of the Mood Disorders Program at Mass General, polled the audience for how many measured depression in their patients in practice, and found about 10 percent. "I [began measuring] a few years ago," he told his audience, and the patients turned out to be "sicker than I thought." "I urge you to measure," he emphasized. "It will change your practice."

Nearly all antidepressant trials test for response (50 percent reduction in symptoms) rather than remission.

Dr Thase and others recommend high antidepressant doses. For instance, Paxil on 40 mg/day runs the risk of a 23 percent recurrence while 20 mg/day of the same drug puts patients at more than double the risk at 51 percent (keeping in mind that lower doses are likely to reduce side effects and raise compliance). The optimal length of continuation therapy should be four to six months, and indefinitely for greater risk patients, he said. Unfortunately, by week 10, 50 percent of patients stop taking antidepressants, either because of the side effects, or they feel they don’t need the medication, or they feel better, or they feel the meds aren’t working, or they forget to take them.

Antidepressant Do's and Don'ts

If early in your treatment you begin to feel agitated hyper, or anxious, notify your physician at once. The anxiety usually goes away in a few days, but if you are an undiagnosed manic depressive, an antidepressant without a mood stabilizer can send you into orbit. Others who do not have manic depression can have these reactions as well. Check out the article, Prozac Mania.

The flip side of agitation is the drowsy feeling many users experience, particularly in the early phases of taking the drug, when the body has not yet adjusted. All antidepressants come with the warning to be careful about operating heavy machinery, and this includes your car.

Other things to be watch out for include:

Other substances that affect your mood, be it alcohol, legal or illegal drugs, caffeine, or foods rich in sugars or carbohydrates. Alcohol and recreational drugs should be regarded as taboo, caffeine should be taken advisedly, and junk foods should be only an occasional indulgence.

Different names, same drug. Sarafem, which is prescribed for premenstrual dysphoric disorder, is a new trade name for Prozac. Let your doctor know if you are on one or the other. More worrying is the fact that the FDA has allowed Glaxo-SmithKline to market its antidepressant drug Wellbutrin as an anti-smoking drug under the name Zyban. Wellbutrin should not be prescribed for people who are at risk of having seizures. An unwitting patient could find him or herself in double jeopardy.

Antidepressants and other drugs. Let your doctor know what other drugs you are taking, as some drugs affect the metabolism of the other. This includes herbal supplements, as well.

Access to Antidepressants

Lack of disposable income should not prevent you from seeking antidepressant therapy. True, each pill retails in the neighborhood of $2.00 in the US, but few individuals wind up paying the full price. Private health plans and state welfare usually pick up the tab or most of the tab, and for those who otherwise do not qualify, the best-kept secret in America is that pharmaceutical companies have patient assistance programs that give away drugs to those in need.

You need to work through your prescribing physician to take advantage of these programs. The drug companies have 1-800 numbers for your physician’s office manager to call. Once the paperwork is completed, you will be able to pick up your medications at your doctor’s office.

Finally

By now we know better than to expect the equivalent of a cure for polio. The mind is simply too complex to allow that to happen. But we all possess the wisdom to work with what is available to us. And we are getting smarter every day

Updated Feb 10, 2008