When is an antidepressant needed?

When an antidepressant medication is indicated:

When I am asked to place a patient on an antidepressant, there are three steps. First, the patient and I have to agree that there is a problem that an antidepressant can help with. Second, I have to choose an antidepressant that I feel is appropriate for that specific problem. And third, the patient has to accept the plan and follow through with it. For if a patient doesn't believe that the medication is needed, it is often ineffective. To help understand how this process of deciding on a specific medication works, let me map out how my thought process goes.

The first indication for antidepressant treatment is Major Depression or Biologic Depression. Everyone gets depressed from time to time, but ongoing depression is different- it requires that one have ongoing and daily impairment. To be considered Major Depression there need to be five or more of the following elements:

  • Changes in Sleep Pattern (typically early morning awakening and being unable to return to   sleep, but sleeping too much can be a symptom)
  • Change is in eating pattern (too much or too little)
  • A loss of energy, feeling hopeless or helpless, down-in-the-dumps or blue
  • A loss of interest in things that were previously enjoyable
  • A loss of ability to concentrate, or thoughts of death or of dying.

In treating Major Depression, if it has never been treated before, all antidepressant seem equally effective. A recent study showed of all the SSRI's (Selective Serotonergic Reuptake Inhibitors) were equally effective. The most common of these being Prozac, Paxil, Zoloft and Lexapro. So, if as a first line medication, all are effective, why choose one over the other.

Often this choice is based on the side-effects of the medication or the other disorders that a medication can treat. Often ( about 40-60 percent of the time) a person with depression has a second psychiatric diagnosis- one that the antidepressant can treat. In the area of side-effects and other areas of effectiveness, not all antidepressants are the same.

All SSRI's can cause some nausea, headache and diarrhea. These of often mild and transient, but can lead to one stopping the medication. They all can cause sexual dysfunction, especially problems in reaching Climax. Prozac and Lexapro may have slightly less of those problems, but I don't believe anyone has proved that.

Weight gain is another common problem with all the SSRI's except Prozac. Prozac also stays in your system longer then any of the others, so if you miss a dose, you don't have as many problems. They in fact have a one a week dose. The rest of the SSRI's have a potential withdraw syndrome, if you stop the medication abruptly after taking it for a while. This can include an increase in irritability, trouble with sleep and possibly a feeling of needles and pins (or small electric shocks). In a few cases, this can be quite distressing. So if you have been on the medication for more then a few months and your doctor advises you to stop it, it is best to reduce the dosage slowly over a few days.

SSRI's also are being used as the first line drug in the treatment of Anxiety Disorders, either as a single illness or co-existing with depression. These disorders are Generalized Anxiety, Obsessive Compulsive, Post-traumatic Stress, and Panic. In the past, the first line drug was the Benzodiazepines, such as Valium, Librium, Xanax, or Klonipin, and while these medications may help in the short term, the SSRI's are more effective in the long term treatment. Effexor, an antidepressant that shares some traits with the SSRI's is also effective with Anxiety disorders and is helpful in treatment resistant depression.

The other medication that I commonly prescribe is WelbutrinSR. It is also sold as Zyban as an aid for smoking cessation. It has the benefits of a less severe side-effect profile. It doesn't cause weight gain (and may actually help you lose weight, by helping you stick to your diet), nor does it cause sexual dysfunction, withdraw syndrome, or nausea. It also specifically improves concentration, such that it is helpful in treating Attention Deficit Disorder. It can transiently decrease appetite and impair sleep though because it has a mild stimulant effect. It is not indicated if one has Bulemia or a Seizure disorder. The down side is that it doesn't have the same anxiety fighting effect that the SSRI's have, and with the high frequency of co-existing anxiety, it is not prescribed as often as the SSRI's. Once started, it may take two to six weeks to see the full effectiveness of the medication. If effective, the medication needs to be continued for at 6 least months. There are other antidepressants, but because of one problem or another, they are not prescribed as often as a first line drug. Again in closing, this is not an exhaustive guide to medication, nor should it be a substitute for discussing your illness and its treatment with your doctor.