The amount of information we discuss with and present to patients during an evaluation can be overwhelming! The purpose of this article is to reinforce topics that were (hopefully) already discussed with you when you were prescribed antidepressants. This is a combination of things that I feel are important for patients to know along with some of the more common questions I receive when a patient starts an antidepressant.
Goal of treatment
The goal for your treatment is always complete 100% remission of symptoms with no significant medication side effects. Your input and open communication is vital in obtaining this goal. This is not always quick or easy, but most patients do experience significant, if not complete improvement. Antidepressants and/or traditional therapy are thought to work for roughly 70% of individuals.
How do antidepressants work?
While we are aware of some of the actions of antidepressants, we have not actually definitively proven that these actions are precisely what make them work. The most popular overarching theory is that these medications correct a “chemical imbalance” in patients with a biological or clinical depression. Antidepressants target chemical messengers in the brain known as “neurotransmitters.” Many are “reuptake inhibitors” which slow the natural elimination of these neurotransmitters to ensure they remain available in larger quantities where the brain can best utilize them. Serotonin, norepinephrine, and dopamine are the three types primarily targeted. These neurotransmitters may not be produced adequately or transported properly in depressed or anxious individuals. Antidepressants may also work in other ways such as increasing sensitivity to neurotransmitters or spurring the growth of healthy brain cells. These additional mechanisms of action can vary between antidepressant medications.
An antidepressant trial is a commitment; they take time to work
One of the most common reasons for antidepressant failure is believed to be that patients often give up on the medication before it could possibly work, and they are sometimes surprisingly never educated on this when the medication is prescribed. Waiting weeks for relief when you are not feeling well is understandably frustrating for patients. Unfortunately, antidepressants simply do not work quickly (for the vast majority of diagnoses). This is the harsh but realistic truth and cannot be stressed enough. They must be taken routinely, usually for several weeks before they will show maximum benefit. If this is a commitment you are not willing to make there is little reason to start this class of medication. It is characteristic of individuals struggling with depression to feel pessimistic about the likelihood of medications working and give up early. Before beginning antidepressants, it is important to acknowledge this and make a commitment to giving the medication a full trial. Sometimes several trials are necessary.
So how much time is enough time? Some antidepressants may begin working sooner than others, but it is generally believed that there will be no improvement for at least 2-4 weeks with most medications. I have certainly had patients report major improvement in less than 2 weeks, however this is the exception rather than the rule and some believe such early response is a placebo effect. Full strength effects may not be evident for 6-8 weeks or perhaps even longer at a given dose. The dosage often needs to be increased as well and each new dosage needs time to work. How quickly the dosage is increased depends on your circumstances, preferences, and how well you tolerate the medication.
The other common reason is believed to be that that providers do not increase dosages appropriately and individuals remain on a sub-therapeutic dosage or prematurely switch without increasing the dosage. This seems to be particularly common when providers are not psychiatric specialists.
What are the early signs that the medication is beginning to work?
Antidepressants will primarily help with physiological symptoms and these are also typically the first symptoms to improve. Examples of potential physiological symptoms in depression are daytime fatigue, middle of the night or early morning awakening, loss of appetite, reduced sex drive (although many antidepressants can also cause this – and yes there are ways we can eliminate that if it occurs), impaired concentration, diminished ability to feel joy or pleasure (anhedonia), and so on.
On the other hand, medications may only have a partial effect on psychologically-oriented symptoms such as low self-esteem, negative thought patterns, or depressed mood. Psychological symptoms will likely improve as an indirect result of the aforementioned physiological symptoms improving. When you feel better and are able to be more productive it is very likely you will feel better about yourself and have a more positive outlook. However, if your psychological symptoms do not have a biological origin, you will require therapy (in addition to medication) for full remission of these symptoms.
Managing Side Effects
Some patients report minimal or no side effects on antidepressants. Some individuals are more sensitive to medications and need to be started at lower doses with slower dosage increases. It’s fairly common to experience some mild side effect(s) at some point, particularly as treatment begins or dosage is increased. However, this does not mean that side effects will persist long-term or that we cannot find a way to eliminate them if they do. Remember the ultimate goal for treatment is 100% remission of symptoms with no significant side effects. When you experience side effects, communicate these with your provider so they can discuss the best course of action.
Side effects often fade over the course of a few days to a month or so as your body adjusts to the medication. If side effects are severe or significantly impair your ability to function, even temporarily, a medication switch is usually warranted. There are some typical “late onset” side effects that are more common later in treatment as the phrase implies. They are usually not difficult to treat with either a dosage adjustment or adjunct medication. Always report side effects so we can determine the best plan to manage these.
Should I take the medication in the morning or night?
If a specific time of day has not been discussed with you or listed on your prescription bottle it is generally best to take it at a time of day when you are the least likely to forget (for medications prescribed with once per day dosing). It is important to routinely take these medications for positive effect and to minimize side effects.
At the start of treatment, some antidepressants have a tendency to make individuals feel tired and it would be ideal to take those medications at night. Others may cause a little anxiety or insomnia (or be “activating,” as explained in the next section) and it would then be better to take them during the morning. After someone has been on an antidepressant for a while it is very likely that they will not experience any sedation or activation and it really does not matter what time of day they take it. So, unless prescribed otherwise, let your body be your guide.
I have anxiety, why am I receiving an antidepressant?
Many patients are surprised to discover that “antidepressants” are considered first-line treatments for anxiety symptoms and usually work well. Anxiety can often be caused by an underlying depressive disorder, but even when it is not, antidepressants can be very effective in the treatment of anxiety because they largely target the same neurotransmitters. However, in the short-term, antidepressants might temporarily increase anxiety, restlessness, and insomnia in some patients. This usually lasts a couple to days to a month. This is known as “activation” and is most common when treatment is first started or the dosage is increased. This can be a very problematic side effect, especially for those seeking treatment for anxiety.
Usually I will avoid those antidepressants known to be more “activating” when you already have significant anxiety symptoms. There are also techniques that we can use as prescribers to reduce or eliminate activation. It is important that you understand that activation is typically temporary and should go away as your body adjusts to the medication. Do not fear that the medication is going to make you feel that way permanently. However, please report these side effects promptly so we can treat or manage them.
Do I need to be on medication forever?
Maybe. The initial goal is complete remission of symptoms for one year. This does not mean you won’t have bad and good days but that your experiences should appropriately match the context of your life. After remaining symptom free for one year you may want to try to stop the medication slowly under supervision. If symptoms return, we would restart the medication. Depending on your personal or family history we may recommend you remain on the medication for life or try again after another year of remaining symptom free. If symptoms resume after a second trial, we recommend remaining on the medication for life.
Are antidepressants addictive? Do they cause dependence?
Antidepressants are not addictive but most can cause some level of dependence. Never stop these medications abruptly or you may experience a variety of low-grade flu-like symptoms. There are some antidepressants that do not typically cause dependence but even then a quick taper is prudent.
I have heard or read about someone who reported severe withdrawal symptoms when stopping antidepressants, is this common?
This is not common at all when the medications are slowly reduced under provider guidance. Most patients find withdrawal tolerable or even insignificant when the medication is slowly reduced. However, we all have unique biochemistry and some patients do report prolonged, significant withdrawal even with a taper. These patients may require an extended period of time to stop these medications. Anecdotally, individuals who report being extremely, chronically anxious seem more likely to report extreme or pronounced withdrawal symptoms.
While most antidepressants are fairly benign to withdraw from, some antidepressant medications are notorious for more intense withdrawal symptoms or for causing withdrawal quickly after missing a dose. Although they are effective, common, popular antidepressants they are never my first choice for this reason. When I use these particular antidepressants I discuss this quality with patients so they are aware beforehand.
Remember to Set Realistic Expectations
Although antidepressants can be highly effective, they are sometimes just one piece of a larger treatment strategy. Antidepressants are not “happy pills.” Their purpose is to prevent individuals from feeling unreasonably depressed or anxious and ensuring their mood is not at an abnormally low level. For someone who has been significantly depressed or anxious for a long time this difference may seem massive or even miraculous. However, by maintaining realistic expectations and an open mind to incorporate other elements into treatment, your chances of achieving long-term success in treatment are significantly higher.
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