The statistics are truly shocking—more than one out of every 10 Americans takes an antidepressant. That includes nearly 4% of all adolescents (ages 12 to 17) and more than 20% of women ages 40 to 59.
Use of antidepressants is controversial. Some people believe that they’re extremely dangerous…some think they are little more than overused “happy pills”…and others insist that these medications are literally lifesaving for people who suffer from depression.
What’s the truth?
To explore some of the deeper issues related to antidepressant use, Bottom Line/Health spoke with an expert who has studied every aspect of these drugs—psychopharmacologist Michael D. Banov, MD, author of Taking Antidepressants: Your Comprehensive Guide to Starting, Staying On, and Safely Quitting.
How does one decide whether to take an antidepressant? Whether or not to take an antidepressant is a personal decision. There are many forms of depression and no diagnostic test to tell when an antidepressant is “absolutely necessary.”
But there are a number of basic clues. How well are you functioning? Perhaps you’ve lost your job or someone close to you has died, and you’re very sad about it. But if you still get up each morning, go to work, see friends, do what needs to be done, you may not benefit from an antidepressant. In fact, medication may have a negative effect, masking normal emotions and the grieving process. Mild-to-moderate depression, such as this, often responds well to psychotherapy alone—without the use of medication. But even in these cases, you may want to try an antidepressant if you and your doctor believe that you could benefit.
With more severe depression—for example, you are not eating or sleeping…you’re not getting out of bed—it’s usually more clear-cut that you need medication. Also, if you have a family history of depression…have been depressed a number of times before…or if depression first started when you were an adolescent or younger, this indicates that your depression is biochemical in nature—that is, there may be a shortage of certain mood-regulating neurotransmitters or a dysfunction in how neurons respond to them. With biochemical depression, medication is typically an important part of treatment.
Some people prefer to avoid medication if at all possible. What are the best alternatives to antidepressants? Psychotherapy helps. Just be sure to choose one of the types shown to work for depression, such as cognitive behavioral therapy (which tries to change habits of self-destructive thinking and behavior) or interpersonal psychotherapy (which addresses patterns in your relationships that promote depression). This may also be a good first step with children and adolescents because the evidence that antidepressants work isn’t as strong for them, and the possible side effects, such as increased risk for suicide, are greater.
Some people also have found natural remedies such as the herb St. John’s wort, omega-3 fatty acids or SAMe to be helpful. Methylfolate (Deplin), a prescription compound related to the B-vitamin folic acid, is the newest addition to the “natural antidepressant” roster. Some people are unable to convert folic acid, which is found in food and dietary supplements, to methylfolate, which appears to help regulate mood.
If you try any of these treatments, just be sure to do it under the supervision of a psychiatrist who is knowledgeable about natural medicine and mental health. Above all, do not let depression go untreated, and be ready to reconsider antidepressants if other methods don’t work or your symptoms worsen within four to six weeks.
For an individual who is depressed, is an antidepressant sufficient treatment? Even if an antidepressant corrects biochemistry, lifestyle adjustments and sometimes psychotherapy are critical for recovery. Lifestyle changes help alleviate symptoms as they do for other medical conditions such as heart disease.
Regular exercise is also important. It can be as effective as antidepressants for some people with mild depression. In addition, take time for activities you enjoy, reach out to friends, get enough sleep, control stress, eat properly and if you drink alcohol, do so only in moderation.
Does your family doctor have the expertise to prescribe an antidepressant effectively, or should you see a psychiatrist or other mental-health professional? Most antidepressant prescriptions are written by primary care physicians (such as a family doctor, internist, pediatrician or ob-gyn), and there’s nothing wrong with this if he/she has stayed up-to-date on the use of these medications through reading medical literature and/or taking classes.
But not all doctors, competent as they may be in other areas, are expert in diagnosing depression and knowing when to prescribe an antidepressant, how to deal with side effects, and when to adjust the dose, switch or add drugs. Far too often, nonspecialists are familiar with only three or four antidepressants, among the roughly 50 that are available, making it hard to get the best one for you.
Besides psychiatrists, certain clinical nurse specialists or nurse practitioners have advanced training in psychiatry and are proficient in prescribing antidepressants. Check with your mental-health insurance provider to find a referral.
Can taking an antidepressant damage your brain over time? There’s been no evidence of long-term detrimental effects on the brain. But, of course, there are no guarantees…issues with some medications have come to light only after years of use.
On the other hand, we do know that untreated depression can damage the brain. Imaging studies show that areas such as the hippocampus actually shrink, which can cause severe memory and thinking problems. The more severe your depression and the longer it goes untreated, the worse and more lasting these deleterious changes are likely to be. So the goal should be to take an antidepressant as long as necessary—but no longer.
How do you know whether it’s time to stop taking an antidepressant? Generally, six to 12 months of medication are sufficient for a first episode of depression. If this is your second episode, longer may be better. And after three or more episodes, research shows that it may be advisable to stay on an antidepressant indefinitely.
In any case, you should not stop until you are no longer depressed (the more residual symptoms you have, the more likely it is that depression will come back)…your physical health is good (or any chronic medical condition is being controlled)…and you’re maintaining a healthy lifestyle. If you are under unusual stress at work or at home, have recently dealt with a loss, like a death in the family, or you are drinking more than moderately, consider waiting.
Some people have trouble stopping antidepressants. Is this like narcotics withdrawal? “Discontinuation syndrome” bothers about 20% of people when they stop antidepressants, probably due to a drop in the neurotransmitter serotonin or norepinephrine. It’s not true withdrawal, because your body isn’t dependent on these medications as it might be with narcotics and other drugs that can be abused.
Discontinuation problems include flulike symptoms, fatigue, unusual sensations (like pins and needles in hands or feet) or anxiety. In most people, they are relatively mild and go away within a week, but they may last up to a month or two.
To minimize discontinuation problems, taper the dose slowly under the guidance of your doctor. If you are particularly sensitive, the process may take up to six weeks.
Sometimes it helps to switch from a drug that leaves the body very quickly, such as paroxetine (Paxil) or venlafaxine (Effexor), to one that is naturally eliminated slowly, like fluoxetine (Prozac). Or switch to a liquid formulation (if one is available for your drug) or have the druggist compound very small doses—both approaches allow you to slow the tapering process. Antidepressants available in liquid form include Prozac, Lexapro, Celexa, Zoloft and Paxil.
