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At least 30 years before modern antidepressants such as Prozac,
Paxil,
Zoloft,
Wellbutrin
and others were developed, the original 'tricyclic' antidepressants
Elavil,
Tofranil
and a number of others were widely and effectively used in the treatment
of depression. Publicity and media attention devoted to Prozac and
the newer medications misleadingly suggests that a wholly new or effective
treatment for depression commenced with their introduction. In fact
there is little or no evidence that the newer drugs are therapeutically
superior to the original antidepressants, Elavil(amitriptyline) and
Tofranil(imipramine) for the relief of depression. Where the most
modern drugs do excel, however, is in their ease of use, safety, and
generally mild or absent side effects. It is largely because of the
latter advantages, not as a result of their innate superiority or
greater effectiveness, that the new generation of antidepressants
beginning with Prozac(fluoxetine) have largely supplanted the original
tricyclic antidepressants in ordinary clinical practice. Antidepressants,
in other words, are not new - simply improved in regard to their non-essential
features such as side effect profiles.
Not all types of depression respond to antidepressant therapy. It is often difficult to
determine in advance which depressions will respond favorably to medication and which will
not - and the general, though perhaps not altogether fortunate trend these days is to
medicate liberally in hopes of not missing a potentially pharmacologically responsive
depression. Because of the exceptionally benign side effect profile of modern
antidepressants there is probably little direct harm in such generous prescribing
practices; but there is considerable risk of overlooking or slighting important and
remediable psychological and personal factors when excessive reliance is placed upon
medications as the sole treatment of all forms of depression.
The more severe depressions are characterized by physical symptoms such as persistent
fatigue, weariness, and lack of energy; significant sleep disturbance, either insomnia or
hypersomnia(too much sleep); major distrubances in mood, attitude and outlook; and
cognitive impairments such as difficulty concentrating, trouble making decisions, and
disturbances in recent memory. Such dramatic and frequently disruptive mood disorders
often respond promptly to appropriate antidepressant therapy, which restores the
individual to their normal mood and functional status. The picture is complicated,
however, by the fact that milder and more insidious depressions, often of years or even
lifelong duration, may also respond to antidepressant treatment.
Antidepressants in common use in the United States today include Prozac,
Paxil,
Zoloft,
Wellbutrin,
Serzone,
Effexor,
Remeron
and Celexa.
There are also a number of less commonly used medications, including
the monoamine oxidase inhibitors(MAOI) Nardil
and Parnate.
On the whole, no one of these medications has been consistently and
convincingly demonstrated to be superior to the rest of them in the
treatment of depression. In general, one is as effective as another
- although there are indeed individual differences in responsivity
such that a given patient may respond better to one and not at all
to another. Sometimes several medications may need to be tried for
an individual patient before the right drug is found.
Antidepressants are not habit forming, addictive, or abusable. They have no 'street value'
- meaning that they cannot be sold on the Black Market at inflated prices like certain
potentially habit forming drugs, e.g. Valium, can be sold. Drug addicts and alcoholics
cannot get 'high' on antidepressants and therefore do not seek them out for this purpose
nor do they frequently escalate their dosage of them for this purpose when prescribed for
depression.
The presumed mechanism of action of antidepressants is the correction
of those abnormalities of brain chemistry which cause symptoms
of depression. The actual neurophysiology
of depression is more complex than the widely known 'biogenic
amine'(serotonin, norepinephrine, dopamine deficiencies) model would
suggest. The basic idea, however, is that antidepressants act to normalize
or bring back into proper balance those chemical pathways in the brain
that are responsible for mood regulation and hedonic(pleasure and
reward) tone. Antidepressants can be compared to the medical use of
insulin in the treatment of diabetes mellitus in that certain types
of depression, like diabetes, appear to be 'deficiency' diseases in
which there is a relative or absolute lack of normal body chemicals
required for healthy functioning of the mind and body. Antidepressants
restore abnormal brain functioning to normal - they are not
illegitimate, artificial or 'cheating' approaches to feeling better.
The duration of antidepressant therapy varies from individual to individual. In serious
and recurrent depressions, indefinite prophylactic maintenance may be indicated. Most
experts advise that single or initial episodes of depression should be provided
maintenance therapy of at least 6 months and possibly one year before discontinuation of
medication is attempted. Depression tends to be a recurrent disorder, and many studies
suggest that longer treatment is superior to shorter treatment in the prevention of
relapse. Serious long term side effects of antidepressants have, fortunately, not
appeared.
Appropriate medical treatment of serious depression, far from impeding the
psychotherapy of personal issues, almost always enhances and accelerates progress when the
'millstone' of depression is removed.
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