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F A Q P A R T 2
back to the main page 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.
IVAN: ANOTHER COMMENT THAT I LEAVE TO YOUR JUDGEMENT: Ref your depression FAQ :
Periactin is available w/out prescription in UK. It is a category "P"
medication , i.e. it may be bought from a pharmacy when the pharmacist is
present, but no prescription is necessary. Of course, self-medication is
not necessarily a good idea and you may do best to talk to your doc.
first. 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. Q. Can someone build up tolerance to Prozac or other anti-depressants so that they stop working after a while? Tolerance to Prozac and the other SSRIs is a relatively rare phenomenon. What looks like tolerance may develop because the SSRIs also have effects on the dopamine systems of the brain, and these effects can slow one down dramatically. When an SSRI sems not to be working as well as it once did, it often can be helped to work once again by adding small doses of a dopaminergic agonist such as dextrroamphetamine, Ritalin, or bromocriptene. Also, certainly with Proxzac, and possibly with other SSRIs, too much of the drug is as ineffective as too little. If raising the dose does not help, an certainly if it makes things worse, a lowering of the dose may do much to bring back a response. I am convinced that many patients respond best is they are treated with one of the SSRIs + a tricyclic antidepressant such as desipramine (Norpramin), or nortriptyline (Aventyl). Such combinations are often effective when an SSRI by itself fails to do the job Q. What about the rumors and studies that Prozac causes suicide and/or acts of violence? PROZAC-VIOLENCE LINK NOT PROVED BUT MOOD DRUG DOES HAVE LITANY OF NEGATIVE EFFECTS Medical Information Service Q. I am an inmate in the state correction system serving 10 years for repeated driving under the influence of alcohol and vehicular manslaughter. My problems started when I was diagnosed as suffering from depression and was prescribed an anti-depressant called Prozac. Before using that drug, I was devoutly against drunken driving, but about three months after starting it I became very jumpy, restless, got three arrests for driving while drunk and then the vehicular manslaughter charge. Could Prozac have caused me to act differently? What problems occur with Prozac?
-- M.J., Grovetown, Ga. DEPRESSION COMMON An estimated 20 million Americans experience depression at some time in their lives, although most are never diagnosed. Depression is a serious disorder and considered life-threatening. Nearly 80 percent of all depressed people contemplate suicide, and 20 percent to 40 percent of those attempt it. Over the past 25 years, anti-depressant drugs have been the dominant treatment for depression. Most anti-depressants are descendants of and improvements on one of the very first mood-controlling drugs, imipramine. The newer types of anti-depressants are called selective serotonin reuptake inhibitors, or SSRIs, which have the positive qualities of imipramine but try to remove or reduce some of its negative aspects, such as abnormal heart rhythms. SSRIs include serraline, paroxetine, fluvoxamine and fluoxetine, known by its brand name of Prozac. ABOUT THE DRUG Manufactured by Eli Lilly and Co., Prozac was first introduced in 1986 and is the most widely used anti-depressant. More than 10 million people have been prescribed it. Studies show it is as effective as other anti-depressants, but it has fewer side effects. According to several studies, the side effects of Prozac can include nervousness, tremor, jitteriness, nausea, insomnia, headache, fatigue, mania or manic symptoms, dizziness and, rarely, seizures. REPORTS ABOUT PROZAC Over the past several years, there have been numerous reports of violent acts and suicide by Prozac users. Although medical journals have numerous reports of such acts, medical studies have not found evidence that Prozac causes violence or suicide. A recent study of 3,065 depression patients taking Prozac by Gary Tollefson, a researcher at Eli Lilly, supported other researchers' studies in finding that there was no increased risk of suicide. The study was published in the June issue of the Journal of Clinical Psychopharmacology. In Tollefson's study, about 2 percent had suicidal ideas and 0.2 percent of the patients attempted suicide. ''Suicide is so common in a population suffering from depression that you can't necessarily blame the drug. As an analogy, if a migraine sufferer is given medication and then has a headache, do you blame the medication? The situation is similar with depression,'' said Susan Sonne, a researcher in the department of psychiatry at the Medical University of South Carolina, Charleston, in an interview. However, people taking Prozac or anti-depressants may experience personality changes for a range of reasons, experts say: -- Most depressed people do not seek help until their problem is serious and often desperate. When placed on anti-depressants, including Prozac, the side effects of the medicine start immediately but the therapeutic benefits may take four to 12 weeks. During the first few weeks, a patient may become more distressed and panicked that the drug hasn't made significant changes, and as a result may act even more irrationally. -- There may be too little or no therapeutic effect from the medication. The drug may reduce the symptoms by 50 percent, which is considered a therapeutic level, but the effects experienced by the patient are not enough. Or the drug may have no therapeutic effect at all, which occurs in about 30 percent of patients. The drug dosage may also be too low and thus ineffective. Experts believe this can panic the patient and make the depression much worse. These situations may also trigger new or increased alcohol consumption ''A depressed person who isn't responding to medication may resort to self-medication with alcohol,'' said Dr. Alexander Morton, professor of psychiatry and behavioral sciences, also at Medical University of South Carolina, in an interview. Alcohol and drug abuse occurs in more than half of those with depression. -- The patient may be receiving treatment for depression, but actually has an underlying, undiagnosed bipolar disorder, such as manic-depressive disorder. Research shows that an anti-depressant can somehow trigger a switch from depression to a manic state. Symptoms typical of mania include euphoria, high energy level with poor judgment, risk-taking, delusions of grandeur and a need for excitement. ''Since a patient suffering from depression may be very compromised and, by virtue of their condition, incapable of helping themselves, it is important for family and friends to intervene when strange behavior is seen. For instance . . . after one uncharacteristic DUI I would intervene, find an alcohol or drug treatment program and try to receive a full evaluation of the situation,'' Morton said.
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Mercury News, 750 Ridder Park Drive, San Jose, Calif. 95190. .IVAN: HERE ARE SOME SUGGESTIONS/QUESTIONS THAT HAVE COME IN ON THE MEDICATION SECTION: The FAQ's are excellent. In the next edition, I would like to put in plug for protriptyline (Vivactil). It's not widely used and not widely known, but probably should be included in the list of medications. It's claim to fame is that it is a tricyclic antidepressant with a very uncharacteristic tricyclic effect--it is very stimulating and doesn't cause an increase in appetite. For people whose symptom profile includes a low energy level and for whom the SSRI's just don't seem to work, Vivactil can often do the job, because it's main action is on reuptake of norepinephrine, not serotonin. It does increase constipation (like the other tricyclics), but it's not an antihistamine and it's other main side effect is also dissimilar to the other tricyclics--insomnia. I suspect that if the SSRI's had never been invented, Vivactil would be a lot more popular than it is; however, for some people, it's just right. Again--great work on the FAQ's.
Scott Newman 2) would like definition of 'half-life'
3) would like alternate names of drugs used in other
countries (e.g. Canada!), though I realize this might
be a bit of a nightmare.
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