The American Psychiatric Association estimates that 80 to 90 percent of all Depression can be treated. The first step is an accurate diagnosis. Along with a physical and lab tests to rule out causes such as reduced thyroid activity, a complete psychiatric history should be taken.
And because Depression and other major psychiatric problems are side effects of many medications, a good work-up will also include a review of the patient’s medications and any illicit drug use.
Once a diagnosis is made, the basic medications used for Depression today are:
- Tricyclic antidepressants such as Elavil, Tofranil, and Pamelor are prescribed for patients who are in despair, feeling helpless, and unable to feel pleasure.
- Serotonin uptake inhibitors such as Prozac, Paxil, and Effexor, all prescribed for uncomplicated depression.
- Monoamine Oxidase (mao) Inhibitors like Nardil and Parnate: These medications are usually used when depressive symptoms are accompanied by symptoms of an Anxiety disorder.
- Lithium: This is the most effective drug for manic depression. However, it can also be used to prevent recurring episodes of depression.
When one of these medications is prescribed, follow-up and continued medical supervision are critical. Blood tests and other metabolic studies are often performed on a regular basis to determine the effect of the drug on the patient. This can be a drawn-out process, because most drugs for depression don’t relieve symptoms instantly. Often it takes four to six weeks for a medication to become effective.
Other forms of therapy for depression include interpersonal psychotherapy to help broken relationships, cognitive behavioral therapy to help reverse the patient’s negative view of himself and the world, and traditional psychoanalysis. Electroconvulsive therapy-known as ECT or shock therapy-has been used effectively in patients who cannot tolerate the side effects of today’s medications, who cannot wait for the medications to work, or who are unable to take drugs for other reasons. While controversial, ECT has proved to be a good treatment option.
Anti depressant Medications
There are several types of antidepressant medications used to treat depressive disorders. These include newer medications-chiefly the Selective Serotonin Reuptake Inhibitors (SSRIs)-the tricyclics, and the monoamine oxidase inhibitors (MAOIs). The SSRIs-and other newer medications that affect neurotransmitters such as dopamine or norepinephrine-generally have fewer side effects than tricyclics. Sometimes the doctor will try a variety of antidepressants before finding the most effective medication or combination of medications. Sometimes the dosage must be increased to be effective. Although some improvements may be seen in the first few weeks, antidepressant medications must be taken regularly for 3 to 4 weeks (in some cases, as many as 8 weeks) before the full therapeutic effect occurs.
Patients often are tempted to stop medication too soon. They may feel better and think they no longer need the medication. Or they may think the medication isn’t helping at all. It is important to keep taking medication until it has a chance to work, though side effects may appear before antidepressant activity does. Once the individual is feeling better, it is important to continue the medication for 4 to 9 months to prevent a recurrence of the depression. Some medications must be stopped gradually to give the body time to adjust, and many can produce withdrawal symptoms if discontinued abruptly. For individuals with bipolar disorder and those with chronic or recurrent major depression, medication may have to be maintained indefinitely.
Antidepressant drugs are not habit-forming. However, as is the case with any type of medication prescribed for more than a few days, antidepressants have to be carefully monitored to see if the correct dosage is being given. The doctor will check the dosage and its effectiveness regularly.
For the small number of people for whom MAO inhibitors are the best treatment, it is necessary to avoid certain foods that contain high levels of tyramine, such as many cheeses, wines, and pickles, as well as medications such as decongestants. The interaction of tyramine with MAOIs can bring on a hypertensive crisis, a sharp increase in blood pressure that can lead to a stroke. The doctor should furnish a complete list of prohibited foods that the patient should carry at all times. Other forms of antidepressants require no food restrictions.
Medications of any kind - prescribed, over-the counter, or borrowed - should never be mixed without consulting the doctor. Other health professionals who may prescribe a drug-such as a dentist or other medical specialist-should be told of the medications the patient is taking. Some drugs, although safe when taken alone can, if taken with others, cause severe and dangerous side effects. Some drugs, like alcohol or street drugs, may reduce the effectiveness of antidepressants and should be avoided. This includes wine, beer, and hard liquor. Some people who have not had a problem with alcohol use may be permitted by their doctor to use a modest amount of alcohol while taking one of the newer antidepressants.
Antianxiety drugs or sedatives are not antidepressants. They are sometimes prescribed along with antidepressants; however, they are not effective when taken alone for a depressive disorder. Stimulants, such as amphetamines, are not effective antidepressants, but they are used occasionally under close supervision in medically ill depressed patients.
Questions about any antidepressant prescribed, or problems that may be related to the medication, should be discussed with the doctor.
Lithium has for many years been the treatment of choice for bipolar disorder, as it can be effective in smoothing out the mood swings common to this disorder. Its use must be carefully monitored, as the range between an effective dose and a toxic one is small. If a person has preexisting thyroid, kidney, or heart disorders or epilepsy, lithium may not be recommended. Fortunately, other medications have been found to be of benefit in controlling mood swings. Among these are two mood-stabilizing anticonvulsants, carbamazepine (Tegretol�) and valproate (Depakote�). Both of these medications have gained wide acceptance in clinical practice, and valproate has been approved by the Food and Drug Administration for first-line treatment of acute mania. Other anticonvulsants that are being used now include lamotrigine (Lamictal�) and gabapentin (Neurontin�): their role in the treatment hierarchy of bipolar disorder remains under study.
Most people who have bipolar disorder take more than one medication including, along with lithium and/or an anticonvulsant, a medication for accompanying agitation, anxiety, depression, or insomnia. Finding the best possible combination of these medications is of utmost importance to the patient and requires close monitoring by the physician.
Revision date: July 6, 2011
Last revised: by Sebastian Scheller, MD, ScD