alt.support.depression FAQ
Part
2 of 5
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**Causes** (cont.)
- What initiates the
alteration in brain chemistry?
- Is a tendency to depression inherited?
**Treatment**
- What sorts of psychotherapy are effective for depression?
**Medication**
- Do certain drugs work best with certain depressive
illnesses? What are the guidelines for choosing a drug?
- How do you tell
when a treatment is not working? How do you know when to switch treatments?
- How do antidepressants relieve depression?
- Are Antidepressants just
"happy pills?"
- What percentage of depressed people will respond
to antidepressants?
- What does it feel like to respond to an antidepressant?
Will I feel euphoric if my depression responds to an antidepressant?
-
What are the major categories of anti-depressants?
- What are the side-effects
of some of the commonly used antidepressants?
- What are some techniques
that can be used by people taking antidepressants to make side effects more tolerable?
- Many antidepressants seem to have sexual side effects. Can anything be done
about those side-effects?
- What should I do if my antidepressant does
not work?
Causes (cont.)
--------------
Q. What initiates
the alteration in brain chemistry?
It can be either a psychological or
a physical event. On the physical side, a hormonal change may provide the initial
trigger: some women dip into depression briefly each month during their premenstrual
phase; some find that the hormone balance created by oral contraceptives disposes
them to depression; pregnancy, the end of pregnancy, and menopause have also been
cited. Men's hormone levels fluctuate as deeply but less obviously.
It
is well known that certain chronic illnesses have depression as a frequent consequence:
some forms of heart disease, for example, and Parkinsonism. This seems to be the
result of a chemical effect rather than a purely psychological one, since other,
equally traumatic and serious illnesses don't show the same high risk of depression.
Q. Is a tendency to depression inherited?
It seems there are
some people whose brain chemistry is predisposed to the depressive response, and
others who are at much lower risk of depression even if exposed to the same physical
or psychological triggers. The genetic relations of manic-depressives are at a
higher risk for unipolar depression than the population at large or their adopted/by
marriage relations. There seems to be a link between high creativity and the gene
for manic-depression: artists and writers often are not manic-depressive themselves,
but have a family member who is. Studies of families in which members of each
generation develop manic-depressive illness found that those with the illness
have a somewhat different genetic make-up than those who do not get ill. However,
the reverse is not true: not everybody with the genetic make-up that causes vulnerability
to manic-depressive illness has the disorder. Apparently additional factors, possibly
a stressful environment, are involved in its onset.
Major depression
also seems to occur, generation after generation, in some families. However, depression
can occur in people with no family history of any form of mental illness. And
I would be reluctant to suggest that there is any human who is entirely immune
to depression under all possible conditions.
Psychological triggers:
many, if not most, people with depression can point to some incident or condition
which they believe is responsible for their unhappiness. Of course, people with
severe depression are prone to astonishingly virulent and inappropriate guilt
and self-hatred.
The (genuine) life events that most often appear in
connection with depression are various, but there is one distinguishing feature
that appears in many cases, over and over: loss of self-determination, of empowerment,
of self-confidence. More profoundly: a loss of self, of the abilities or activities
that a person identifies with herself. Stereotypically: a man loses the job that
had defined him to himself and others, whether that definition was "executive"
or "breadwinner"; a woman who had spent her whole life preparing for
and living the role of wife, supporter, caretaker, is suddenly left alone by divorce
or death. In general, any life change, often caused by events beyond one's control,
which damages the structure that gave life meaning.
The ability of a
person to respond to such an event will depend on many factors, including genetic
predisposition, support from friends, physical health, even the weather. It can
also depend on internal psychological factors which may best be explored in talk
therapy: why is the person's self-esteem so bound up in the position or state
that has been lost? Can she find a new source of self-esteem? Therapy can be immensely
helpful here.
Obviously, not everyone to whom this sort of event happens
becomes depressed, and not every person who becomes depressed has had this sort
of catastrophe befall them. In fact, if a person suffers a loss and then becomes
depressed, it may well be that they weathered the loss in fine style and then
succumbed to a much less obvious trigger, psychological or physical.
Some depressions may well be caused by a spontaneous aberration in brain chemistry,
with no trigger that we can currently identify, just as a seizure or migraine
may have an obvious trigger or be apparently spontaneous.
However, once
the depressive state has set in, both physical and psychological problems will
be generated in abundance. What faster way to lose a job or a spouse than to be
too depressed to work or to communicate? What worse psychological state for coping
with a blow to identity can there be than a chemically promoted, pathological
self-hatred? And what can be worse for self-esteem than watching one's appearance
and household disintegrate as one loses the motivation to shower, straighten up,
wash dishes or laundry, or choose attractive clothes? Health deteriorates as well:
some depressed people can't sleep or eat, others sleep constantly (a real help
on the job!) and eat incessantly, sometimes in order to stay awake, sometimes
because it's the only thing that gives a little pleasure or comfort. (Carbohydrates
induce production of serotonin, so there may be an element of self-medication
here); almost no one has the impulse to exercise or get fresh air and sunshine.
Most if not all of these effects form feedback loops, increasing in magnitude
and becoming triggers for further depression.
The question, "Is
depression mostly physical or psychological," is rather beside the point.
Depression may be triggered by either physical or psychological events. Most commonly,
both seem to be involved, though it is often difficult to separate the two when
one is talking about psychology and neurochemistry. But however it begins, depression
quickly develops into a set of physical and psychological problems which feed
on each other and grow. This is why a combination of physical and psychological
intervention has been shown to give the best results for most patients, regardless
of any classifications that doctors may have tried to impose on their depression
and its cause.
Treatment
---------
Q. What sorts of psychotherapy are effective for depression?
Two effective methods of psychotherapy for people with depressions are
cognitive therapy and interpersonal therapy. Both psychoanalysis, and insight
oriented psychotherapy have not been shown to be effective treatments for people
with a depressive disorder. Cognitive (and cognitive-behavioral) therapists can
be found in most major cities.
For a referral to a properly trained cognitive
therapist practicing close to your location, contact:
Aaron T.
Beck, MD.
The Center for Cognitive Therapy
3600 Market Street
Philadelphia, PA 19101
(215) 898-4100.
While many therapists
call themselves cognitive therapists and interpersonal therapists, only a few
have had proper training. To find an interpersonal therapist with the best training,
contact:
Myrna Weissman, Ph.D.
New Your State Psychiatric
Institute
722 West 168th Street
New York, NY 10032
(212) 996-6390
Medication
----------
Q. Do certain
drugs work best with certain depressive illnesses? What are the guidelines for
choosing a drug?
There are very few kinds of depression for which there
are specific antidepressant treatments. When it comes to people with Bipolar Disorder
who are depressed there are some major problems. Most importantly, with any antidepressant,
there is a possibility that the antidepressant treatment will cause depressed
bipolar people not just to come out of their depressions, but to develop manic
episodes. The possibility of an antidepressant causing mania is least when the
antidepressant is bupropion (Wellbutrin). The possibility of mania is greatly
reduced if depressed bipolar folks are on a mood stabilizer such as lithium, Tegretol
or Depakote when they are started on an antidepressant.
Q. How do
you tell when a treatment is not working? How do you know when to switch treatments?
Antidepressant treatment is clearly not working when the individual receiving
the treatment remains depressed or becomes depressed again. When a recently started
antidepressant fails to cause improvement, the depressed individual often asks
that the medication be stopped, and a new one started. It generally does not make
sense to change antidepressants until 8-weeks at the maximum tolerated dose have
elapsed. With some tricyclic antidepressants, it is important to check the blood
level of the antidepressant before it is stopped. The blood test can tell if the
amount in the blood has been adequate. Only after an adequate trial of one antidepressant
should another be tried. To have been on four antidepressants in an 8-week period
means that one has not had an adequate trial on any of them.
Q.
How do antidepressants relieve depression?
There are several classes
of antidepressants, all of which seem to work by increasing levels of certain
neurotransmitters (most commonly serotonin, norepinephrine, and dopamine) in the
brain. It is not entirely clear why increasing neurotransmitter levels should
reduce the severity of a depression. One theory holds that the increased concentration
of neurotransmitters causes changes in the brain's concentration of molecules,
receptors, to which these transmitters bind. In some unknown way it is the changes
in the receptors that are thought responsible for improvement.
Q. Are
Antidepressants just "happy pills?"
No matter what their exact
mode of action may be, it is clear that antidepressants are not "happy pills."
There is no street-market in antidepressants, for unlike "speed" which
will improve the mood of almost everybody, antidepressants only improve the mood
of depressed people. Also unlike the almost instant effects of speed, the mood-improving
effects of antidepressants develop slowly over a number of weeks. "Speed"
induces a highly artificial state, antidepressants cause the brain to slowly increase
its production of naturally occurring neurotransmitters.
Q. What
percentage of depressed people will respond to antidepressants?
Generally,
about 2/3 of depressed people will respond to any given antidepressant. People
who do not respond to the first antidepressant they have taken, have an excellent
chance of responding to another.
Q. What does it feel like to respond
to an antidepressant? Will I feel euphoric if my depression responds to an antidepressant?
The most common description of the effects of antidepressants is that of
feeling the depression gradually lift, and for the person to feel normal again.
People who have responded to antidepressants are not euphoric. They are not unfeeling
automatons. The are still able to feel sad when bad things happen, and they are
able to feel very happy in response to happy events. The sadness they feel with
disappointments is not depression, but is the sadness anyone feels when disappointed
or when having experienced a loss. Antidepressants do not bring about happiness,
they just relieve depression. Happiness is not something that can be had from
a pill.
Q. What are the major categories of anti-depressants?
There are many classes of antidepressants. Two kinds of antidepressants have
been around for over 30 years. These are the tricyclic antidepressants and the
monoamine oxidase inhibitors. While there are newer antidepressants, many with
fewer side-effects, none of the newer antidepressants has been shown to be more
effective than these two classes of drugs. In fact, many people who have not responded
to newer antidepressants have been successfully treated with one of these classes
of drugs.
The tricyclic antidepressants (TCAs) include such drugs as
imipramine (Tofranil, amitriptyline (Elavil), desipramine (Norpramin), nortriptyline
(Aventyl and Pamelor).
The monoamine oxidase inhibitors (MAOIs) include
tranylcypromine (Parnate), phenelzine (Nardil), and isocarboxazid (Marplan) which
has recently been taken off the market in the U.S.A. for marketing rather than
safety or efficacy reasons.
One of the popular new classes of antidepressants
are the selective serotonin reuptake inhibitors (SSRIs). The first of these drugs
to be marketed in the USA was fluoxetine (Prozac). Sertraline (Zoloft), and paroxetine
(Paxil) soon followed, and fluvoxamine (Luvox) is scheduled to be marketed in
late 1994, or early 1995.
Bupropion
(Wellbutrin) is the only drug in its class, as is trazodone (Desyrel). The most
recently marketed antidepressant (4/94) is venlafaxine (Effexor), the first drug
in yet another class of drugs.
Q. What are the side-effects of some
of the commonly used antidepressants?
Below is a list of some of the
more frequently prescribed antidepressants, and their most common side effects.
The figure following each side effect is the percentage of people taking the medication
who experience that side effect.
Aventyl (nortriptyline): Dry mouth
(15); Constipation (15);
Weakness-fatigue (10); Tremor (10).
Effexor (venlafaxine) Nausea (35); Headache (25); Sleepiness (25);
Dry
mouth (20); Insomnia (20); Constipation (15).
Elavil (amitriptyline):
Dry mouth (40); Drowsiness (30); Weight gain
(30); Constipation (25); Sweating
(20).
Nardil (phenelzine): dry mouth (30); insomnia (25); Increased
heart
rate (25); Lowered blood pressure (20); Sedation (15); Over
stimulation (10);
Norpramin (desipramine): dry mouth (15); increased
pulse (15);
constipation (10); reduced blood pressure (10).
Pamelor - see Aventyl
Parnate (tranylcypromine) Dry mouth (20); Insomnia
(20); Increased
pulse rate (20); Lowered blood pressure (15); Over stimulation
(15);
Sedation (15).
Paxil (paroxetine): Decreased sexual interest
and/or problems
achieving orgasm (30); Nausea (25); Sedation (25); Dizziness
(15)
Insomnia (15)
Prozac (fluoxetine): Decreased sexual interest
and/or problems
achieving orgasm (30); Nausea (20); Headache (20); Nervousness
(15);
Insomnia (15); Diarrhea (15).
Sinequan (doxepin): Dry
mouth (40); Sedation (40); Weight gain (30);
Lowered blood pressure (25);
Constipation (25); Sweating (20).
Tofranil (imipramine): Dry mouth
(30), Reduced blood pressure (30),
Constipation (20), Difficulty with urination
(15).
Wellbutrin (bupropion): Agitation (30); Weight loss (25), Dizziness
(20); Decreased appetite (20);
Zoloft (sertraline): Decreased sexual
interest and/or problems
achieving orgasm (30);Nausea (25); Headache (20);
Diarrhea (20);
Insomnia 15); Dry mouth (15); Sedation (15).
Q. What are some techniques that can be used by people taking antidepressants
to make side effects more tolerable?
Listed below are some frequent side
effects of antidepressants, and some techniques to reduce their severity:
Dry mouth: Drink lots of water, chew sugarless gum, clean teeth daily, ask
the dentist to suggest a fluoride rinse to prevent cavities, visit the dentist
more often than usual for tooth and gum hygiene
Constipation: Drink at
least six 8-ounce glasses of water every day, eat bran cereals, eat salads twice
a day, exercise daily (walk for at least 30 minutes a day), ask your doctor about
taking a bulk producing agent such as Metamucil, also ask about taking a stool
softener such as Colace, be sure to avoid laxatives such as Ex-Lax.
Bladder
problems: The effects of some antidepressants, especially the tricyclic medications
may make it difficult for you to start the stream of urine. There may be some
hesitation between the time you try to urinate and the time your urine starts
to flow. If it takes you over 5-minutes to start the stream, call your doctor.
Blurred vision: The tricyclic antidepressants may make it difficult for you
to read. Distant vision is usually unaffected. If reading is important to you
the effects of the antidepressant can be compensated for by a change in glasses.
As you may compensate for the change in your vision, try to postpone getting new
glasses as long as possible.
Dizziness: Dizziness when getting out of
bed or when standing up from a chair, or when climbing stairs may be a problem
when taking tricyclic antidepressants and monoamine oxidase inhibitors. Changing
posture slowly may help prevent this kind of dizziness. Drinking adequate amounts
of liquid and eating enough salt each day is important. Be sure to speak to your
doctor if this side-effect is severe.
Drowsiness: This side effect often
passes as you get used to taking the antidepressant that has been prescribed for
you. Ask your doctor if it is safe for you to increase your intake of caffeine,
and if so, by how much. If you are drowsy be sure not to drive or operate dangerous
machinery.
Q. Many antidepressants seem to have sexual side effects.
Can anything be done about those side-effects?
Both lowered sexual desire
and difficulties having an orgasm, in both men and women, are particularly a problem
with the selective serotonin re-uptake inhibitors (Prozac, Zoloft, Paxil and Luvox),
and the monoamine oxidase inhibitors (Nardil and Parnate). There is no treatment
for decreased sexual interest except lowering the dose or switching to a drug
that does not have sexual side effects such as bupropion (Wellbutrin). Difficulty
having orgasms may be treated by a number of medications. Among those medications
are: Periactin, Urecholine, and Symmetrel. None of these are over-the-counter
drugs and they must be prescribed by a physician. Unfortunately, many psychiatrists
are not familiar with using these medications to treat the sexual side-effects
of antidepressants.
Q. What should I do if my antidepressant does
not work?
Many people decide that their antidepressant is not working
prematurely. When one starts an antidepressant the hope is for rapid relief from
depression. What must be remembered is that for an antidepressant to work, you
must be on an adequate dose of the drug for an adequate length of time. A fair
trial of any antidepressant is at least two months. Prior to a two month trial
the only reason to abandon an antidepressant trial is if the medication is causing
severe side effects. With many antidepressants the dose has to be increased at
intervals far above the starting dose. Unfortunately, the two-month period mentioned
above, refers to two months following the most recent increase in the dose, not
the time from starting the particular antidepressant.
