Given we now know that although depression shows itself as very low mood, inside us a subtle form of brain damage is being caused by the illness, this highlights the urgency with which those prone to depression should seek treatment. The earlier the underlying processes leading to depression are reversed the more of the brain could be saved from damage, so making future relapses into depression less likely.
Q. How long do anti-depressants need to be taken for, and is one type stronger than the other?
A. Antidepressants are highly effective treatments for depression but roughly a third of patients will not respond to the first antidepressant drug they are given, so in a large number of cases, more than one drug should be tried, sequentially. Approaching 90% of the depressed will eventually respond to at least one or a combination of drugs. It used to be said that these drugs would have to be taken for at least four weeks before any improvement could be detected, to encourage patients to persist with treatment until the chemical action kicked in. Although that is true for most patients still, it is also the case that a large number of patients notice a difference of some kind within a few days of starting treatment.
It is vital patients do not discontinue these drugs before they have had a chance to work. Even if the depression has not lifted, small signs of change, like some improved sleep, are indications the drug is beginning to work and should be persisted with.
Once the depression has lifted - from the time of complete recovery to stopping treatment should be around six to nine months. For those who have had more than two relapses of depression, treatment should probably not stopped for a full year after recovery. This is a difficult instruction for patients to follow because they understandably want to stop treatment once they feel better. But they must continue for at least roughly six months if this is a first or second episode of depression, to ensure they reduce the chances of relapse once they have stopped treatment.
This is vital because depression is a relapsing illness and the chances of a relapse in the first six months of getting over an episode are particularly high if the antidepressant has been discontinued too soon.
Q. Are anti-depressants addictive?
A. Antidepressants are not addictive but stopping them suddenly can lead to what are called discontinuation syndromes. These are not the same as a withdrawal reaction you would get with addictive drugs, but merely a sign that antidepressants that have been taken for many months need to be discontinued gradually, over a period of two months roughly usually.
With the older tricyclic antidepressants the following have been well-described discontinuation symptoms that occur when the drugs are stopped too suddenly. Gastrointestinal symptoms like abdominal pain, nausea, vomiting and diarrhea; 'flu-like symptoms, fatigue, anxiety and agitation, nightmares and sleep disturbance are the most common features.
With the newer SSRI drugs the most common symptoms on stopping medication too suddenly are dizziness, nausea, lethargy, headache, insomnia, nightmares and 'shock-like' sensations. Because antidepressants are not addictive patients will not experience any craving for these drugs once they have been stopped and the depression has been successfully treated.
Q. Sleep disturbance is common in people with depression and many patients complain the antidepressants can actually make matters worse in the short term. Is this true?
A. The problem is sleep disturbance is a very common side effect of depression so it is easy to confuse having trouble sleeping at night as being caused by the treatment rather than the illness. It is true that antidepressants can be divided into two groups - sedative and non-sedative types.
The sedative types are useful to take at night if insomnia is a particularly bad side effect of the depression. The non-sedative kinds are often alerting or activating and should be taken in the morning. Prozac is a good example of a more activating drug and should be taken in the morning, while Paroxetine is a good example of one that helps with sleep and should be taken at night. If the depression episode is characterized by a good deal of anxiety as well, then the antidepressant of choice would be a sedative type.
Q. Are antidepressants the only option - can counselling and psychotherapy help?
A. The treatment of any illness is rarely only ever just one approach. Similarly with serious depression, antidepressants are vital but once they have begun to work and a patient has become more accessible, then being able to talk to someone about feelings and plans, not necessarily a professional, is also useful. If talking to a professional is being considered then checking the therapist has proper qualifications is a necessity, and that the talking treatment has clear goals, and a deadline set for the number of sessions, which could be around six.
The danger of open-ended treatment is often, patients might be lured into staying in expensive therapy for many years, when this is not necessary. There are also dangers in becoming dependent on the relationship with a therapist if the sessions are not limited to just a few in number. The evidence is having a non-professional to confide in can be just as protective from relapsing into depression in the face of stress as talking to a therapist. One patient used to take her best friend to lunch once week and in return for paying for the meal just required her friend to listen to her talking about herself. This turned out to be cheaper and more pleasant than therapy.
The key qualities to look for in a friend to talk to instead of a therapist would be someone who will keep your confidences, be non-judgemental and also be imaginative in coming up with possible plans for the future.
Q. What happens if an anti-depressant does not seem to be working ? How long should someone wait before considering another option?
A. If no clinical improvement has been shown whatsoever then after four weeks treatment with a high dose of an antidepressant there is no benefit from continuing the drug. But as often inexperienced doctors will have prescribed too low a dose of an antidepressant, then continuing until six weeks is worthwhile in those patients on a low dose, or showing even modest improvement. Generally speaking an antidepressant not working is usually a problem of being on too low a dose. As these drugs take so long to work, it is worth persisting by increasing the dose of one that does not appear to be working, than being too eager to stop and try another one.
Q. Is depression a recurring problem?
A. Often it is. Without continuing treatment about 1 in 3 hospital patients will have a relapse of a recently treated acute episode within six months and up to half will have a relapse or a new episode of depression within 2 years. Recurrence is more likely if there is a history of previous episodes; the acute illness is severe; residual symptoms persist at the end of treatment; the patient has ongoing chronic medical or social problems (eg unemployment or relational difficulties) lacks social support, or is aged under 25 or over 60 years at the onset of illness.
Q. Do you know of any alternative or complementary approaches that have been proven to be effective for people with depression?
A. There is a good deal of evidence that for mild depression St John's Wort is as effective as antidepressant medication and may have fewer side effects. The problem is that taking St John's Wort will usually be in a self-prescribing situation with no opportunity to discuss doses, side-effects and when to stop with a professional who has experience of treating depression. So while considering alternative remedies is worthwhile, getting access to information and experience with the illness must be the priority.
Author
DR RAJ PERSAUD IS A CONSULTANT PSYCHIATRIST WORKING IN THE NHS AT THE MAUDSLEY HOSPITAL IN SOUTH LONDON. FURTHER INFORMATION ON HIS WORK, ADVICE AND CURRENT PROJECTS CAN BE ACCESSED AT HIS WEBSITE: www.btinternet.com/~rajendra.
HIS BESTSELLING BOOK 'STAYING SANE: HOW TO MAKE YOUR MIND WORK FOR YOU' IS PUBLISHED BY METRO AND AVAILABLE FROM www.amazon.co.ukwww.amazon.co.ukwww.amazon.co.ukwww.amazon.co.ukwww.amazon.co.ukk
We are indebited to the Depression Alliance for their help in compiling this section.
