In this SERIES of monthly COLUMNS Dr. Stephen will help you:
• Find out more about your depressed mood
• Name that tune: A description of depressive and mood disorders
• Change your depressed mood through action
• Decide if you need medication

COLUMN FOUR: DECIDING IF YOU NEED MEDICATION

Let me begin by reminding you that I am a psychologist and, therefore,
do not prescribe medications. Medications are prescribed only by MDs,
either psychiatrists or general practitioners. My knowledge of
medication management comes from 37 years of being in practice and
working closely with the psychiatrists or other MDs who have prescribed
medications for my patients.

In this month\’s column I want to give you some general advice to help
you decide whether you might need to be medicated for your depression.

Anti-depressant medications, especially the serotonin enhancing ones,
are among the most widely prescribed medications in our country.
Remember those twelve plus million woman and six million men suffering
from depression? A significant percentage of these depressed persons
end up being prescribed medication for their condition. Over 80% of
those prescriptions come from their general practitioners, not from
psychiatrists.

Q & A ON MEDICATION
When are anti-depressants most likely to be effective?
When you have been suffering from a major depression that has
lasted two to three months or longer and have checked off most of the
symptoms in the checklist presented in Column One of this Series,
anti-depressant medication is more likely to be effective.

You may not want to consider antidepressant medication for a brief
period of acute upset. Even though you may have very intense symptoms
when you get served with the divorce papers or your loved one dies,
this is a normal, though unpleasant, reaction to a very distressing
event. By the time anti-depressant medication would kick in, your
symptoms would be improving anyway. Plus, if you are in the middle of
ongoing trauma, medication is not likely to be of much benefit.
Medication does make you impervious to unpleasant life events.

However, you may want to consider taking medication for sleep problems
during major upsets, even though an anti-depressant is not yet
recommended. Interestingly enough, several of the older
anti-depressants (such as Trazadone) are effective medications in
treating insomnia (particularly onset insomnia, when it\’s difficult to
fall asleep) because of their sedating side effects. And they are not
addictive. Over the counter products such as Benadryl, Tylenol-PM, and
melatonin can also effective in the short term for many persons.

Are anti-depressant medications addictive?
No. Medications classified as tranquilizers, narcotic pain
medications, and many sleep medications can and often do lead to
physiological dependency or abuse. Anti-depressant medications do not
lead to physiological dependency or abuse. However, going off
anti-depressants too rapidly can produce what is called a
discontinuation syndrome with very unpleasant effects. Always discuss
discontinuing or tapering off your anti-depressant medications with
your physician.

Will I have to take anti-depressant medication forever?
Not necessarily. Many persons suffer only one episode of major
depression in their lifetimes. When they have been stable for six
months to a year, they can try going off the medication (with their
doctor\’s approval and instructions). If their symptoms return within a
few weeks or months, or even years later, they can always go back on
the medication.

Others, who have recurrent episodes of major depression, may indeed have to stay on anti-depressants much of the time.

How long does it take anti-depressants to work?
You have to take anti-depressant medication on a regular daily
basis, gradually building up to a therapeutic dosage level (the level
where you are noticing beneficial effects). This takes at least three
to six weeks. You need to wait this period of time to find out whether
the medication is going to work for you or not.

What are the side effects of anti-depressant medication?
Some mild side effects such as drowsiness, stomach distress,
slight agitation, and headaches can occur when you first start taking
anti-depressant medication. These mild side effects are usually gone by
the time the medication kicks in. The side effects of anti-depressants
that are most bothersome, and cause most people to stop taking their
medication, are sexual side effects (the loss of ability to become
sexually aroused or to perform sexually). There are other types of
anti-depressants that can be prescribed in these cases.

As with any medication, there can be rare but very serious side effects
of anti-depressant medication. Your doctor will review these side
effects with you when prescribing the medication.

Do anti-depressant medications make you go crazy or become homicidal or suicidal?
There has been a tremendous amount of news about the potential
risks of taking anti-depressant medications, especially for children
and teens (now well documented on medication packaging inserts).
Overall, there is substantial evidence that treating depression with
medication has made a significant contribution to a reduced suicide
rate in the total population (studies conducted in many nations around
the world), especially in the elderly and the adolescent populations.

However, there are certain cases, and those of us in practice have all
experienced it, where a particular individual\’s reaction to
anti-depressant or other mood altering medication increases their risk
of severe agitation, psychotic behavior, and either homicidal or
suicidal ideation and behavior.

The risk of that happening can be reduced with proper diagnosis (for
example, mood disorders should not be treated with anti-depressant
medications) and close and frequent monitoring during medication
trials. In addition, a thorough assessment of risk factors for suicide
and homicide should be conducted before prescribing anti-depressant
medication (something that doesn\’t always happen in the general
practitioner\’s office) and, if present, reviewed on a regular basis.

My own experience in over 37 years in practice is that anti-depressant
medication has saved many more lives (literally thousands, in my case)
in terms of overall reduction in the risk of suicide than have been
lost to adverse effects (less than a half dozen, in my case). This
benefit needs to be taken into consideration, although it is always
very tragic (for practitioners as well as for families) when side
effects or an unpredicted reaction to medication of any kind results in
a death or the worsening of a psychiatric condition.

What medication should I ask for?
You should let you physician decide what particular medication is
best for you in terms of your age, your symptoms, and your diagnosis.
You should not decide on a particular medication because you saw an
advertisement on television. Psychiatrists have the most experience in
dispensing all types of psychiatric medication, but general
practitioners actually prescribe the most anti-depressant medication,
meaning they have considerable experience in this area.

Will my depression get better without medication?
It certainly can, especially with cognitive-behavioral therapy,
exercise, and structuring your days. Some people are opposed to
medication, in general; others cannot take it because they are so
sensitive to side effects. Studies, in fact, have compared
anti-depressants to sugar pills—both worked!

However, with moderate to severe symptoms of major depression, you may
not be able to pull yourself up by your own bootstraps. If you have
tried many of the behavioral and cognitive strategies described in
Column Three of this Series and your symptoms are persisting, then a
trial of anti-depressant medication may be very worthwhile.

And, as mentioned before, mood disorders (the bipolar spectrum of
disorders) do not usually respond to therapy alone, medication is
usually necessary.

How do the most common anti-depressant medications work?
Imagine that the back end of one nerve is like your right hand
with the fingers spread out. The front end of the next nerve is like
your left hand in a fist. Put your hands a half inch apart. The gap in
between is called the nerve synapse. Chemical substances made by the
body carry messages across this gap from one nerve to the next. One
such substance is serotonin. When too much serotonin is taken back up
by the body and not enough is left in the gap, you feel depressed.
Serotonin-enhancing drugs (like Prozac, Paxil, and Zoloft) allow more
serotonin to remain in the gap and your mood improves.

A Note in Closing: Giving Up What Doesn\’t Work

I hope the general information I have provided in these four
columns on depression have been helpful in giving you a direction to
head in. Remember that the most highly recommended treatment for
depression is a combination of medication and cognitive-behavioral
therapy. Doing nothing is the only sure path to staying depressed.

So please give up putting on a happy face to cover up your depression.
You know that wide smile with too many teeth showing that makes your
cheeks ache and your stomach churn? You feel as empty as the little
round circle with the two eyes and the big grin. Try it for one minute.
Pull the corners of your mouth back, bare those teeth, and hold it.
Within 5 seconds your cheek muscles are in spasm, your teeth are drying
out and forming an attractive landing pad for the nearest flying insect.

Now try this. Yawn. Big yawn. Then let your jaw close slowly. Let your
lips gently close but don\’t let your teeth touch. Imagine your jaw
hanging loose back at the joint near your ear. Let your jaw drop. Let
your tongue to relax. Think to yourself, “My jaw is hanging loose.”
Now, inhale through your nose. Track the air as it comes in through
your nostrils. Imagine the air flowing past your chest all the way to
your abdomen. Then let the air out in a relaxed puff. Repeat several
times.

Don\’t you feel better? Now you\’re ready to buy that book on treating
depression or calling your health care provider and making that
appointment to have your depressed mood evaluated and treated. Good
luck to you.

Former Associates