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Antidepressants
How they work and when to use them

Almost everyone experiences feelings of stress and depression at some point. Such feelings are often appropriate to a situation. Clinical depression, on the other hand, is a medical condition.* Clinical depression and anxiety disorders are treated in many ways including antidepressant medications and counselling. Counselling and medications go hand-in-hand, each with their own advantages and disadvantages.

Antidepressants, one of the most widely prescribed classes of medications can help or harm. They are not a substitute for developing a good counselling relationship. The more you learn about antidepressants, the more likely it is that if they are prescribed you'll be able to help yourself, or someone you know.

How antidepressants work

Every antidepressant has side effects. The drug that saves the life of one can harm another. Sadly, health care professionals cannot always predict who will benefit and who will respond differently.

Serotonin and norepinephrine are natural brain chemicals (neurotransmitters). They help brain cells, known as neurons, communicate with each other. In depression and anxiety disorders, we believe certain neurons do not talk to each other as much as they should. Increased brain neurotransmitter levels, antidepressants, a life change, or counselling can help reverse this underlying chemical imbalance. Increased communication between neurons can promote re-growth of damaged brain cells. Scientists call this neuroplasticity.

MAOI antidepressants

Modern psychiatric pharmacology and the use of antidepressants started in the 1950s. Since other treatments of the time were usually unsuccessful, patients could spend years in long-term institutions. New treatments were needed. Antidepressant qualities were then discovered in a drug used to treat tuberculosis.

This first class of antidepressants is known as the monoamine oxidase inhibitors (MAOIs). When these medications are used, the diet must be severely restricted. If the wrong food or alcoholic beverage is eaten, a sudden life-threatening elevation of blood pressure can result. Sometimes we call this a 'cheese reaction,' since eating certain aged cheeses can send blood pressure soaring. Understandably, MAOIs are usually reserved for cases of depression and anxiety that are difficult to treat.

TCA antidepressants

Another class of drugs, the tricyclic antidepressants (TCAs), were also discovered during the fifties. The TCAs are so named because each drug has three cyclical rings in its chemical structure. These became the standard antidepressants as they had no dietary restrictions and were thought safer than the MAOIs. The main antidepressants used from the sixties to the eighties, the TCAs are still in use today. Generic names in this class include amitriptyline, nortriptyline, imipramine, desipramine and doxepin.

The TCAs are used to treat clinical depression, anxiety disorders, insomnia, migraine headaches and chronic pain syndromes. They too have hazards. The TCAs have the potential to cause heart problems. They are often sedating, which helps with sleep, but can make users feel drugged or sedated during the day. They can affect co-ordination, which can be dangerous for those who drive or work with power tools. It is common to gain weight on the TCAs, which can harm self-esteem. TCA-type antidepressants can interact with other medical drugs, street drugs and alcohol.

SSRI antidepressants

Prozacª, the first of the selective serotonin reuptake inhibitor (SSRI) antidepressants became available in the late 1980s. It is a breakthrough drug for several reasons. It has no dietary restrictions, does not usually sedate, is less likely to cause weight gain, and is safer for the heart than the previous generation of antidepressants. Five other drugs in this class are sold under their trade names, Celexaª, Cipralexª, Luvoxª, Paxilª and Zoloft.ª

Since SSRIs are much safer in comparison to older antidepressants, doctors could introduce treatments earlier for depression. This was significant, since we have found that the longer a person remains depressed, the longer it takes to completely recover. Evidence also shows that those who leave their depression untreated are at increased risk for cardiovascular problems. Both psychological and physical damage can occur when clinical depression is left untreated.

In following years, researchers have found that serotonin-based antidepressants are also effective for treating anxiety. Doctors prescribe antidepressants for anxiety disorders since they are considered non-addicting and can be used long-term, unlike minor tranquilizers such as Ativanª, Rivotrilª or Xanaxª.

While all of the SSRIs work in a similar way, they differ in such areas as dosing, side effects, and drug interactions. This means if one antidepressant doesn't work or causes side effects, another drug in the class may be more effective.

Other antidepressants

Effexor XRª is a serotonin norepinephrine reuptake inhibitor (SNRI). It increases both serotonin and norepinephrine. Effexor XR has a similar side effect profile to SSRIs. Although other types of antidepressants work in more complex ways, they are less commonly used. It is worth remembering that the more areas in the brain affected by a drug, the greater the chance of experiencing side effects.

Wellbutrin SR, (Zyban), used to help smokers quit, may also help improve thought process. Unlike the SSRI and SNRI type antidepressants, it usually does not cause sexual side effects but, insomnia headache and dizziness can be problematic.

Some studies have found St. John's Wort to be as effective as some TCAs and SSRIs in treating mild to moderate depression. However, quality control can be a problem, since concentrations of different brands vary.
This herb may also cause side effects and drug interactions, just as standard antidepressants do. Consumers often do not know this fact. For instance, birth control pills and blood thinners may not work as well when taken along with St John's Wort. Combining St. John's Wort with standard antidepressants can be potentially life threatening. You will not recover from depression more quickly by taking more St. John's Wort.

Talk to your pharmacist or health care professional before using herbal products, just as you would do before taking a drug. Be cautious about using a sales clerk as a source of medical advice.

Do antidepressants work?

Yes. If you take an antidepressant, there is over a sixty-percent chance you will respond to the first drug you are given. About 10 to 15 per cent of cases of depression are resistant to treatment. Antidepressants and counselling have both been found to help prevent relapse of depression. No one antidepressant is considered to work better than the others.

Antidepressant issues

Antidepressants are not for everyone. Some specific issues with antidepressants are worth addressing, such as sexual dysfunction, discontinuation syndrome and suicide risk.

Sexual dysfunction - One important side effect associated with antidepressants is sexual dysfunction. Men may experience delayed ejaculation (release of semen) or less desire. Women may have decreased sexual desire or less ability to orgasm. Sometimes side effects disappear over time, but in most cases the problem remains unless the drug is changed. It can be hard to tell if decreased sexual desire is relationship-based, due to depression, or a result of taking the drug. Sexual side effects can mean marital discord and a difficult choice. The choice is to remain depressed and function sexually, or treat the depression and suffer with sexual side effects. Not all antidepressants cause this problem, and certain interventions can help.

Discontinuation syndrome - A discontinuation syndrome can occur if the antidepressant dose is stopped suddenly or lowered too quickly. This can occur 24 to 48 hours after the last dose. The symptoms are flu-like in nature. They include some unusual features such as dizziness, balance problems and a sensation of electric shocks going through the body. In most cases, symptoms lessen after five to seven days or within hours of reintroducing the antidepressant. It is not considered a life-threatening condition but can be very unsettling.

Antidepressants and suicide - Depression will be the number two cause of disability worldwide by the year 2020, according to the World Health Organization. It is estimated that as many as one in seven of those who suffer from the condition will take their own life. Clinical depression is not a weakness of character. It is a devastating medical condition.

Given the frequency and severity of clinical depression, health care professionals try to use any means at their disposal to treat the condition, including antidepressants. Some people feel worse on antidepressants. In early phases of treatment, some have more suicidal thoughts. Since this is a higher-risk period, close monitoring is necessary. Currently, among adults, there does not seem to be any specific antidepressant or class of antidepressants that increases suicide rates.

Children and teens below the age of 18 may not respond to antidepressants in the same way that adults do. Suicide thoughts may be increased with this group. While this does not mean antidepressants should not be used, they should be used with greater caution.

The last word

Although antidepressants have improved over the last 50 years, they can both help and harm. They do not replace care and counselling, taking personal responsibility or solving life problems. It is important to discuss starting on or stopping the use of an antidepressant, with your doctor, pharmacist or other health care professional. No decisions should be made about using any medications based solely on the information contained in this or any other article. Each individualÕs situation is unique and professional advice is needed for a safe and healthy outcome.