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mental health mondays :: when to say when, part 2

so you've decided to take drugs. congratulations, you've made a big step in dealing with your depression/ anxiety and hopefully one that you've thought a lot about. if you haven't. maybe you want to hit the pause button and go back to read part one of this post.

myself, i'm kind of ambivalent on depression meds. i think they're grossly over-prescribed and i think some people need them. i think some types of depression are better treated with chemicals and some aren't. what i have very little patience for are people who know they have problems and who have categorically decided that they will not take medication because "they can handle it themselves" without bothering to learn anything about depression or about the drugs used to fight it. these reactions hearken back to those same old prejudices about mental illness being somehow less serious than other forms of illness, something that shouldn't require actual treatment. i also find that "taking care of it themselves" is usually code for ignoring the problem and assuming it'll go away on its own, or finding ways to convince oneself that the problem can be dealt with by blaming it on other people, or by simply getting drunk/ high a lot. some people can deal with their depression and anxiety themselves, no question. and they're easily distinguished because they're the people who can articulate how they do it without resorting to sarcasm.

think of depression/ anxiety meds the way you would pain medication: if you take something for every little ache, you're not allowing yourself to deal with the fact that pain is real and that sometimes, you just have to work through it. when it gets a bit more serious, you might want to think about something to take the edge off and so on. and, as with pain medications, it's important to remember that drugs aren't correcting the underlying problem, ever. they're just easing the symptoms so that they aren't screwing up your life.

i am a big fan of knowing what you're getting yourself into and depression meds are serious chemicals that play with how your brain works. you should understand what the dangers and potential benefits are and you do that by collecting information. get on line and find information from the manufacturer, from current and former users, from medical professionals. look for case studies and, again, ask your doctor, counselor, therapist or whoever is helping you where you can find case studies and testimonials from sources not funded by the proponents of that drug. take the opportunity to get to know your brain and how it responds to various stimuli.

to get you started, here is some very basic information on the types of anti-depressants your doctor or psychiatrist is likely to prescribe. virtually everything about these meds is in a constant state of dispute, so i've tried to stick to claims that have been broadly accepted, or that have significant statistical data to back them up. i am not a medical profession. my medical training is limited to a few first aid and cpr classes back in the 1920s some time. this is only intended to tell you what's out there and what's being said. if you want more specific details, you need to ask a professional.

selective serotonin reuptake inhibitors :: by far the most common type of anti-depressant and normally the first line of therapy for those who opt for anti-depressant medication. prozac, paxil, celexa and zoloft are better known than the names of major constellations; they've been around long enough that they're well understood, safe and, when used correctly, effective. [note: correct usage means that you actually need drugs. it's a neat little trick that the effectiveness of anti-depressants and the seriousness of the depression are directly proportional. so if you're mildly depressed, you might as well be taking tictacs.]

the name is actually descriptive of what they do, which is to more or less regulate the flow of the neurotransmitter serotonin in the brain, allowing it access to serotonin for longer, which is what's supposed to be happening naturally. unlike earlier anxiolytics and anti-depressants, these medications do not have an immediate effect (although you may feel certain effects immediately). your brain needs time to change how it processes serotonin and so it takes at least a few weeks, if not a month or two, to get the full benefit. so unless there's a serious negative reaction, give your meds at least a few months before saying categorically that they're not working. 

just as well-known as the drugs themselves are their side effects. what isn't well-known is that the popular understanding of their side effects is often grossly exaggerated and that those effects can vary in intensity from person to person and drug to drug. no one is going to be able to tell you what side effects you will experience from these drugs. you'll just have to see for yourself. keep in mind that some of the side effects (lethargy, insomnia, agitation, dry mouth, upset stomach, bloating and others) pass within a couple of weeks of starting the drug. sure, you might feel like you have a mild but persistent case of the flu, but give it time and chances are, it'll go away.

but if you're worried about side effects, chances are it isn't dry mouth that's on your mind anyway. chances are, you're worried about the "big two": weight gain and sexual dysfunction. it's fear of these two things that probably keeps a lot of people off meds to begin with and not without reason; ssri's as a group do tend to make you pack on pounds and they do have sexual side effects both mental (loss of libido) and physical (loss of sensation and, for men, loss of... you know). sometimes you get those side effects... sometimes you don't... sometimes they go away over time... sometimes they don't... the likelihood and severity of these side effects varies by drug, although it's hard to find hard science that says one is better or worse than another and almost nothing that compares all players in the same study. anecdotally, paxil is the worst for both weight gain and sexual dysfunction, prozac is more likely to make you lose weight than gain it, cipralex generally has the greatest balance between tolerability (i.e., incidence of side effects) and effectiveness, followed by zoloft. take that for what it's worth, which isn't very much. chances are that you're only going to find out how a specific drug effects you when you start taking it.

multiple reuptake inhibitors :: related to ssri's but more complex are the multiple reuptake inhibitors. there are three that are widely prescribed- effexor, cymbalta and wellbutrin- two of which (effexor, cymbalta) are similar. these first two drugs regulate serotonin, norepinephrine and sometimes dopamine, which means they hit all the major neurotransmitters generally thought to be responsible for the vast majority of depression/ anxiety disorders. 

some side effects are more noticeable than others
these still aren't generally used as first-line therapy because the side effects are reportedly significantly harsher than those of ssri's (cymbalta is supposed to be better than effexor) and because of something called "discontinuation syndrome". that term is the drug company's way of telling you that getting off these drugs is akin to getting off crack. it usually takes time and pain and can mess you up in ways you've only dreamed of.

the third and least-known multiple reuptake inhibitor is wellbutrin. wellbutrin works solely on the dopamine and norepinephrine. its side effects are generally the opposite of all other anti-depressants and as a bonus, it's marketed under another name as a drug that can help you quit smoking. all that sounds great until you get to the part about it potentially causing epileptic-style seizures in higher doses. there is no perfect solution.

tricyclic antidepressants :: these are an older type of anti-depressant which has largely been supplanted by the two categories listed above. although the chemical structure is quite different, tca's also work by regulating serotonin and norepinephrine in the brain. they were actually developed from antihistamines back in the 1940s and their potential as a psychiatric medication was first noticed in the early 50s. although still used in cases where other anti-depressants have failed, chances are you're not going to be getting a prescription for these any time soon.

for starters, these are the anti-depressants that give psychiatric meds a bad name. although there are a small number who claim their side effect profile is no worse than ssri's, these drugs are most likely to produce the "zombie" effect that most people fear awaits them if they go down the path of anti-depressants.

second, these drugs are prone to "abuse". i don't mean recreational use. i mean that, taken in quantities larger than prescribed, they're far more likely to kill you than more modern drugs. strange how doctors have grown hesitant to supply suicide aids to depressed people.

if you're looking at having to take these, chances are you know more about the world of psychiatric meds than i do and i feel for you. it might still be worth getting an outside opinion on whether or not you have other options. if you have a doctor who has prescribed one of these as a first time medication, leave immediately and get another doctor.

it's what's for dinner
monoamine oxidase inhibitors :: by the time you've reached these, chances are you're running out of options. because of the side effect profile, they're pretty much never prescribed until depression has proved resistant to at least a few other drugs. on the positive side, these have been around a long time, they're well understood and generally pretty effective. there are tons of them (they're even found naturally in some forms) and the newer ones aren't quite as tricky to deal with (although there are some studies which suggest that they aren't as effective either.

if your doctor has prescribed one of these, my advice is to go to your refrigerator, open the door and wave goodbye to a lot of foods you love. unlike other anti-depressants, where mixing them with certain foods, beverages or drugs (usually alcohol, caffeine and sedatives) is discouraged but up to the individual, the maoi diet restrictions are serious business. maoi's react with a variety of foods (notably almost every form of cheese, but you'll need to be very careful about finding an exhaustive list) and a lot of medications (particularly cold medications), as well as natural supplements and remedies. the potential reactions can be fatal, which is why these drugs are going to run your life once you've started taking them. they can't be taken while any other psychiatric meds are still in your system, so you're potentially looking at a few weeks of unmedicated fun before and after you take these.

chances are, no doctor is going to recommend an maoi unless things are pretty serious and many doctors avoid them entirely. it's a toss-up in terms of what you'd prefer to deal with, but personally, i think i'd still choose one of the modern maoi drugs over a tca.

benzodiazepines :: i think we covered this pretty well last week.

there. now you know everything.

well, you probably know enough to get started, at least, but because there's no such thing as too much information, here are a few tips gleaned from my experience and that of others close to me:

- don't expect that you're not going to get depressed again. you will. that's life.
- remember that drug companies often court doctors to get them to recommend their product over a competitor's. it's a dirty little secret and it happens with every type of drug. doctors are also prone to recommending drugs they've grown comfortable with. keep those things in mind when you're given a prescription. just because your doctor likes it doesn't mean it's the right one for you.
- try to keep a detailed written record of your reactions to the meds you're on. don't worry about figuring out what's related to the meds and what isn't. just keep notes and talk to your doctor about them.
- getting an initial anti-depressant prescription from your general practitioner is fine, but insist on seeing a psychiatrist as soon as possible to get a specialist's evaluation. your family doctor does not have an in-depth knowledge of mental disorders and may miss telltale signs that depression isn't your only problem. giving anti-depressants to people who aren't "simply" depressed can have serious consequences.
- remember that none of these drugs are addressing the root problem. unless you're comfortable spending the rest of your life on anti-depressants, taxing your liver for no reason, start looking into different types of therapy to find one you think will help you and try it out.

whew! that's a lot to take in for something that's no more than a cursory glance at the subject. the fact that this post is "bare bones" at this length should give you an idea of how complicated this business of brains can get. and what's more, brains are big business, so there are further developments happening all the time.

there are so many resources for information on the internet that i'd require a staff of thousands to vet all of them in order to find which ones to recommend. so i'll start with just two:

jerod poore's phenomenal crazy meds site. clever, accessible and incredibly well-researched, this is the best site on the internet for finding out what various sorts of psychiatric drugs will actually do to you. his site covers far more than anti-depression meds and, while his information is focused on the u.s. market, 95% of it is universally relevant.

neuroskeptic, a comparatively new discovery for me, this is a blog maintained by a professional in the field who isn't afraid to take his peers to task. it can get pretty dense, but there's a lot of fascinating information here that helps remind us that there are a lot of aspects to psychiatric meds and treatment that slip from view if we're not vigilant.

hopefully this helps you feel a little more empowered when it comes to anti-depressants. next week, we'll look at the flip side: mania- what happens when your mental stock market won't stop rising?


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