Goals of Antidepressant Treatment
The goal of treatment with an antidepressant is to restore a balance of emotions, relieving the symptoms of depression and restoring the individual to their previous quality of life in terms of thoughts, functioning, and general outlook on life. Antidepressants are not meant to achieve a perpetual “high” or to eliminate all low or sad moments in a person’s life; this state would be just as unnatural as having the perpetual feelings of depression that the treatment is intended to relieve. Further, the antidepressant that best suits the individual is one that not only relieves the signs and symptoms of depression and restores pre-depression functioning, but also works at a dose that has a minimum of side effects and prevents the return of depressive symptoms.
A Treatment Plan for Depression
If it is determined that you will benefit from antidepressant treatment, your physician should work out a treatment plan with you. The objective, as stated earlier, is to achieve and maintain symptom remission.
Depression symptoms can be quite different from person to person. Similarly, different treatments can be completely effective, somewhat effective, or not at all effective, depending on the individual. Because no one treatment works for everyone, a wide range of treatments have been developed. The focus of research is to refine current approaches and to develop new ones. This applies to medications, psychological treatments and new approaches to brain stimulation. Treatment typically consists of two stages: Acute treatment lasts up to 3 months, and is aimed at relieving the depressive symptoms. Medication can actually take a few weeks to start working, so it is important to keep taking it as scheduled. Very often, your appetite, energy and sleep will improve before your mood, and others may notice the change in you before you do. Psychotherapy can take longer to be effective.
Maintenance treatment should continue for at least one year to prevent the return of symptoms, or relapse. In some people, depressive episodes occur regularly; the return of a depressive episode is called recurrence. Maintenance treatment is aimed at preventing recurrence of symptoms and may be required for several years or even lifelong.
Taking Medication for Depression
Compliance with treatment – that is, taking the correct dose of medication at the correct time, for as long as the physician has indicated – is one of the major keys – or stumbling blocks – to effective treatment of a mood or anxiety disorder. Your doctor should review the commonest side effects associated with the drug you are prescribed and explain why you should do everything you can to take the correct doses.
Some people still have trouble seeing depression as a serious illness. Taking antidepressant medication should not be seen as a sign of weakness – more a case of using a tool to help you work through your depression and return to a normal life. A good analogy is that of wearing eyeglasses; your eyesight, through no fault of your own, simply is not good enough to go without wearing them. Whether you like wearing glasses or not, they are necessary for everyday functioning (reading, driving, etc.), and an eyecare professional has prescribed the strength that is appropriate to your needs.
Anxiety, depression and poor eyesight all have a biological basis. Following a prescription to improve these conditions is intended improve your day to day quality of life.
If depression were only a matter of “pulling up your socks” or “just doing it” as certain sports manufacturers suggest, antidepressant medication which alters the chemistry of the brain wouldn’t work. In fact, antidepressant medications don’t work in people who are not depressed. These medications are not – and never will be “happy” pills, and they do not make depressed people feel better immediately. What they will do for the majority of people is gradually bring back into balance certain brain chemicals associated with depression, mania or anxiety.
If you are not responding to the initial choice of medication after three to four weeks of therapy, the dose of the medication may be adjusted and “optimized”, a different medication may be added to “augment” therapeutic benefit, or the initial medication may be switched altogether. Provided the optimal dose is used, and treatment continues for long enough, about 2 out of 3 people treated with antidepressant medication do well. Certain types of psychotherapy including cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) may also be successful, especially in mild to moderate depression. These therapies not only treat acute symptoms, but may help prevent relapse of depression.
The Role of Psychotherapy
Psychotherapy provides an opportunity to express and discuss feelings with a therapist, either one-on-one or in a group. The objective is to work on resolving life issues that may be related to your depression, and developing more positive attitudes and ways of dealing with things. Depending on the individual, psychotherapy can be helpful on its own, or in combination with medication.
How do Therapies Work?
In a basic way, we can think of the brain as a marvelous system of interconnected wiring made up of brain cells or neurons. In order for each of these neurons to “talk” to each other, electrical signals from one brain cell are transmitted via chemical messengers to the next brain cell across a tiny, fluid-filled gap called a “synapse”. In depression, mania and anxiety (among other disorders), it’s now felt that certain abnormalities in either the amount or the activity of these chemical “neurotransmitters” trigger a cascade of effects in the brain that produce symptoms.
Antidepressant medications affect the level of specific brain chemicals within the synapse in a number of ways. Some of them do it by causing more of the needed chemicals to be released into the synapse. Others do it by inhibiting a reuptake pump that normally regulates the level of chemicals in the synapse. Once inhibited, the reuptake pump can not take chemicals back into the transmitting cell so that more of the chemicals remain in the synapse and can be picked up by the receiving cell.
Some of the older antidepressants don’t allow a specific enzyme, monoamine oxidase, inside brain cells to break down serotonin and other “neurotransmitters”, allowing a build-up of desirable brain chemicals which can then be transmitted to the receiving cell. Some antidepressants might do a little bit of both – block the reuptake pump so that chemicals in the synapse can’t get back into the transmitting cell, and block receiving cells so that they selectively pick up certain chemicals and send them on down through the nervous system. These various actions may directly affect only one brain chemical at a time, as is the case with the selective serotonin reuptake inhibitors (SSRIs) such as Prozac (fluoxetine) and cipralex (escitalopram), which directly affect only serotonin. Other antidepressants including Effexor (venlafaxine), Cymbalta (duloxetine) and Pristiq (desvenlafaxine), monoamine oxidase inhibitors (MAOIs) and reversible inhibitors of monoamine oxidase (RIMAs) affect a number of brain chemicals either directly or indirectly. In general, the newer classes of antidepressant medications are as effective as the older medications, but they tend to be more selective and have fewer unwanted side effects.
Treatment is usually continued for at least six months once a good response has been achieved, and can last much longer if a person has had more than one depressive episode. People taking an antidepressant should also know that antidepressant medications generally take several weeks to produce a favorable effect, although different symptoms may improve at different rates. For example, sleep and appetite may normalize before mood or energy. Unfortunately, there is no way doctors can tell beforehand how a person is going to respond to the medication they prescribe.
“Sleep the sleep that knows not breaking, Morn of toil nor night of waking.”
The Lady of the Lake
– Sir Walter Scott 1771-1832
Antidepressant medications currently available in Canada include:
Adapted from the CANMAT Clinical guidelines for the management of major depressive disorder in adults.
- Tricyclic Antidepressants (TCAs)
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- Monoamine Oxidase Inhibitors (MAOIs)
- Reversible Inhibitors of Monoamine Oxidase (RIMAs)