Exploring the world of Anti-Depressant Medication

Do I really need anti-depressants?

Are anti-depressants effective?

Which is the best anti-depressant?

What other options do I have?

When it comes to the topic of anti-depressants, there are many questions and viewpoints that tend to come out. As a psychologist I am unable to prescribe “psychotropics” (medication for mental health issues), however many of my clients are either current, past or potential future takers of psychotropics. So, I’m often talking to my clients about this very topic, and exploring this world with the facts on hand helps individuals make the best decision for them in any given time of their life.

Last week I attended a professional development seminar run by the Australian Psychological Society (APS) on psychotropics. The guest speaker was Chris Alderman, who is a senior lecturer at the University of South Australia and editor for a pharmacology journal; a very knowledgeable man who’s PhD was on pharmacological treatment of PTSD in war veterans. The information I’m sharing in this article is a combination of the key learnings I took from Chris’ seminar as well as knowledge I’ve gained over the years in this profession.

In the Australian National Health Survey, Australian households reported that 19% of adults were using medication (either prescribed medication and/or vitamins/herbal supplements) for their mental wellbeing. Of these 27% reported using anti-depressants, 23% used sleeping tablets, and 10% said they used medication for anxiety. Anti-depressant medications are the most common psychotropic.

When it comes to the anti-depressant conversation there are a number of things to consider:

• Is an anti-depressant really needed?
• How should I feel about taking anti-depressant medication?
• What is the best anti-depressant and dosage for the individual?
• What are the potential adverse reactions to the medication (side effects)?
• What interactions could there be between the anti-depressant and other drugs?
• What is the risk:benefit ratio?
• What are the compliance considerations?
• Are they addictive?
• What is the withdrawal/half life process when it’s time to come off a drug?
• Are their other options for treating depression?
• What is the best way to talk about it with a GP?

So firstly, do you need an anti-depressant? The answer to this is likely to be less straight-forward than yes/no. It depends on your symptoms, circumstances, medical history and more. The best person to ask if your GP. I’ve heard many people tell me their GP was almost too happy to give them a prescription for anti-depressants, and made their own decision to try other things before going down that path. Ultimately, it’s your mind and body, so do your research, consult those with accurate, up-to-date knowledge and be willing to try a few things to get the improvement you’re seeking.

If you do take anti-depressants, there’s nothing to be ashamed about. Like I mentioned earlier, you’re in good company with many other Australians. It’s not a sign of defeat, or being weak, or lazy. They are there to help you get back on track. You wouldn’t feel the same about taking a needed medication for a physical illness, so recognise the fact you’re helping yourself and feel good about that.

When it comes to the treatment of depression, there are a number of options available including:

• SSRIs (“selective serotonin reuptake inhibitors”) -these act on a chemical in the brain called serotonin. The SSRIs include drugs such as Prozac, Zoloft, and Paxil.
• “Tricyclic” antidepressants – chemical compounds used primarily as antidepressants. TCAs were first discovered in the early 1950s and marketed later in the decade. They are named after their chemical structure, which contains three rings of atoms. E.G. Amitriptyline (Elavil), Amoxapine, Clomipramine (Anafranil), Desipramine (Norpramin), Doxepin (Sinequan), Imipramine (Tofranil), Nortriptyline (Pamelor), Protriptyline (Vivactil)
• Non-selective MAOIs – chemicals that inhibit the activity of the monoamine oxidase enzyme family. They have a long history of use as medications prescribed for the treatment of depression. They are particularly effective in treating atypical depression. E.G. Isocarboxazid (Marplan) Phenelzine (Nardil)
• Psychotherapy – anything from counselling,  Cognitive-Behaviour Therapy (CBT) to Mindfulness-based therapies and other things more outside the box like Neuro-Linguistic Programming (NLP), Hypnosis and Emotion Freedom Technique (EFT) just to name a few. Under our Medicare system, you can access Medicare funding for up to 10 sessions with a psychologist each year, so help from a registered, understanding and experienced psychologist (like me!) is accessible to all.
• Electroconvulsive Therapy (ECT) – yes, it’s still an available treatment, and for those with the most severe and treatment-resistant depression, it’s quite effective to improve mood. There are many things to consider before taking this course of action, and you can discover more about ECT here.
• “Augmented therapy” (lithium, liothyronin, pindolol) – often used alongside another anti-depressant medication, these types of psychotropics can be used to improve the effectiveness of the drug they augment. Read more here.
• Natural or herbal supplements –  St John’s Wort is the primary one with an evidence base for its effectiveness although there are others as well. Best to consult a naturopath or qualified herbalist for what options are available and are safe to use with other medications

A really interesting point raised during Chris Alderman’s presentation was about which anti-depressant was the best. I found it surprising to learn that based on all the research to date, there is no significant difference in efficacy between any of the anti-depressants. They all work about the same (they all have an approximately 1/3 chance of working), whether they are older ones (like Prozac) or newer ones. When it comes to selecting the best anti-depressant, a GP or psychiatrist has to take many things into consideration, and Prof Alderman’s advice is expect to trial up to 3 different anti-depressants before finding the one that’s right for you.

A major concern for most people, and rightly so, is the potential for adverse or side-effects. All anti-depressants have side effects. If you look at the packaging and read the adverse reaction warning list, it’s mighty long. The most common reactions include gastrointestinal symptoms (e.g. diarrhoea, constipation, nausea), sleep disturbance, weight fluctuations, and loss of interest in sex. For some people, a side effect is suicidal ideation. This is where the concept of risk:benefit ratio comes in, as an individual has to decide if the side effects are tolerable to gain the benefit of the anti-depressant. So if there is more risk or discomfort, than reward for taking the medication, most people will stop taking the drug. This article is a good read on this point.

If you’re taking other medications, it’s vital your prescribing doctor has duly considered any interaction effects between those medications and an anti-depressant. Some things can simply not be combined, or produce very unpleasant symptoms. If there’s a short-term introduction of drugs (e.g. at the dentist, pre- and post-surgery) and you’re on anti-depressants, you may need to ask the dentist/surgeon/doctor if there are any possible interaction effects that need to be taken into consideration.

One of the biggest frustrations doctors have is non-compliance. The reality is most people will forget to take their medication from time to time. Some people don’t give the medication a chance to do it’s thing. For most anti-depressants there’s a 6-12 week ramp up period for the full effects of the drug to occur. A lot of patience is required. Good doctors inform their patients of this, and arrange follow up consultations to check in on how the patient is doing with their medication, and if any adverse effects have occurred.

So, are anti-depressants addictive? Antidepressants aren’t addictive in the same way substances like alcohol and heroin are. Those abusing antidepressants do not experience the cravings that other drugs cause. Most consider these drugs non-addictive. Others point to the withdrawal symptoms of antidepressants as evidence that a dependence can form, however those symptoms can be minimised if a monitored, GP-directed protocol for withdrawal is followed. Some anti-depressants are extremely unpleasant to simply go cold turkey on, and it can be dangerous. So ask your GP what the process of coming off of any medication is expected to be like.

Chris Alderman had a great piece of advise for people when talking to their GP about anti-depressants, in the form of 5 questions:

1. What are all the names this medicine goes by?
2. Why are you prescribing me this medicine? Or, What is it’s purpose?
3. What should I expect to feel when I take this medicine?
4. I’m already taking X medication(s), will this medication be alright with these others?
5. I have X medical condition(s), so will this new medicine have an adverse effect on my condition(s)?

I think this is an invaluable strategy for making an informed decision, and making sure your busy doctor is taking everything into consideration when writing you out a prescription. Research information for yourself, get a second opinion if you think you’d like one, and consider combining any drug therapy with psychotherapy. Anti-depressants are not a ‘cure’ for depression, but a way of helping manage the symptoms so you can get life back on track, and sometimes the best way to do this is learn how to get your brain to work better for you.

An Alternative Perspective

There is conflicting perspectives with the mainstream view that anti-depressant medication is safe and necessary. The following is a different perspective that has valid research to support it’s part in the debate and if you would like to do more of your own research, you may like to start with the documentary Who Cares in Sweden: http://www.whocaresinsweden.com/en/

The three main problems with antidepressant medications from this alternate perspective is:

1. Drug companies do not disclose the true incidence of the unwanted effects.   They are serious and one cannot know who will fall victim to them.
2. There is the assumption that the drugs are beneficial, but RCTs (meta analyses) show poor evidence of benefit. Often the improvement is negligible in comparison with a placebo treatment.
3. There is little disclosed about the true addictive nature of these medications.One study showed that after 5 years, 40% are still taking them.  Either they did not work so they are still on them; or they are addicted and cannot stop.  Since they are given to children they may be on them for 50+ years.  What will the effects be?  And many young women will be stuck on them when getting pregnant, risking birth defects (heart risk).

So why take them, given the risk / benefit profile?

In the USA one in 13 adults are on anti-depressant medication.  Prozac is like an amphetamine, and the other SSRIs are derivatives of prozac.  A side effect of amphetamine use is depression.  So using ADM has the side effect of more depression.  “Treatment Resistant Depression” increased in 10 years from 15 – 20% to 40%.  Treatment resistant depression blames the patient, when it should really be called “ineffective treatment,” putting the blame on the drug.

There is much to consider when it comes to considering your own mental health or that of someone you love or treat, it’s best to complete your own research and make a truly informed decision.

If you have any questions about this article, please post your comments below. Alternatively, you can contact me at miriam@miriamhenke.com for further information.