Frequently Asked Questions About Antidepressant (and Psychiatric) Medication
See also: Frequently Asked Questions About Major Depression
Mark Vakkur, M.D.
Few issues stir up as much emotion and debate as the use of medications to treat mood symptoms. In talking to patients, clients, family members, and colleagues, it is clear that everyone has a strongly held opinion.
On one extreme, some believe Prozac (or whatever medication has been most recently in the news) will obliterate any sadness, anxiety, or other negative feeling they have ever had. They may know someone who responded dramatically to antidepressant medication, and they are hoping for a similar response.
Others just as strongly oppose even considering medications to treat mood symptoms, no matter how severe or debilitating. They may feel quite strongly that there is something unwholesome about using medication to reduce psychic distress.
Most of us lie somewhere between these two extremes, but it is useful to explore the issues surrounding the use of medications to treat mood disorders. These issues can be generalized - with some caveats - to other psychiatric conditions. Therefore, I have prepared the following series of questions, followed by my best attempt at an answer, in response to the questions and concerns most frequently posed by clients and family members.
What are psychiatric medications?
What are antidepressants (and why do you also use them for anxiety)?
Is there a risk I might get hooked?
Isn't it better to work out your problems in therapy than to take a pill?
What proof is there that medications work?
What on earth is a placebo-controlled, double-blind prospective trial?
Is it ethical to conduct medication research?
Using an example, how can you know if the medication really worked?
But how can you conclude that the medication is effective if only 65% got significantly better!
Can you predict who will get better or who will get side effects?
What are psychiatric medications?
Medications are concentrations of chemicals that have been shown to be helpful in treating the symptoms of various illnesses. In some cases, such as with lithium for manic depression, they seem to treat the underlying disease, much as an antibiotic treats a chronic infection. In some cases, such as with some anxiety medication, the medication reduces painful or life-inhibiting symptoms. Many other medications, such as antidepressants, fall somewhere in between - they treat symptoms, and it is believed they may be correcting the underlying disease process.
What are antidepressants (and why do you also
use them for anxiety)?
Antidepressant is a general term that is used loosely to describe a group of medications most of which originally were used to treat depression. The majority of these medications work by increasing the level of certain natural chemicals that your body already creates. For example, many antidepressants work by increasing the level of serotonin in your central nervous system. Serotonin is a chemical produced by your body that gives you a sense of well-being. Low levels of serotonin have been associated with depression, anxiety, irritability, and aggression. As you can imagine, increasing the level of serotonin has been shown to be very helpful in treating depression, anxiety, irritability, and aggression. So although these medications are often referred to as antidepressants, they actually treat a wide array of disorders, such as:
SSRI stands for "selective serotonin reuptake inhibitor." SSRI's are a type of "antidepressant" medication that work by specifically targeting the receptors in a cell responsible for pulling serotonin out of the synapse - the space between nerve cells - thereby boosting the level of serotonin available to your nervous system. Perhaps the most famous SSRI is Prozac (fluoxetine). Others include Paxil (paroxetine), Zoloft (sertraline), and several others that have since been developed and marketed.
Any substance you put in your body, including over-the-counter pain medications or vitamins, has the potential to be dangerous. Even foods can be dangerous, if they are contaminated with bacteria or cause an allergic reaction. Yet we eat foods every day. Why? Because our bodies need certain chemicals to be replenished on a regular basis. If we become deficient in those chemicals, we can suffer, even die.
Every medication I prescribe has been rigorously tested under controlled conditions in animals and in human beings. The FDA reviewed the results of all of the research in an exhaustive process before allowing the products to be marketed. The FDA continues to monitor the medications after they are released; sometimes, unfortunately, even medications that got through the rigorous, multiyear FDA approval process turn out to have very rare side effects that don't become apparent until millions of people take the medications. In those cases, the FDA may withdrawal its approval. However, the longer a medication has been prescribed without serious side effects, the less likely it is that the medication will cause any.
Yes, medications can cause side effects. But with antidepressant
medications, the side effects are mild and go away entirely when you stop the
medication. A helpful way of looking at medication is to do a risk: benefit
analysis. What is the risk of taking the medication? What is the potential
benefit? And don't forget the potential risk of NOT taking the medication. The
cost of living for 20 years with untreated depression, for example, can be
devastating, not simply in terms of emotional anguish, but also in terms of
lost opportunities, occupational and social impairment, and adversely affected
relationships. And never underestimate the risk of suicide, currently the 8th-leading
cause of death in the
The most common side effects from antidepressant medication include:
There are other side effects, but these are perhaps the most bothersome. All of them go away after stopping the medication. Very rarely, some predisposed patients, particularly those who suffer from bipolar disorder (manic depression) may develop mania (rapid, pressured speech, decreased need for sleep, euphoria, expansiveness, and impaired judgment) when treated with some antidepressant medications. Let your doctor know if you or a family member has been diagnosed with bipolar disorder, so appropriate medications can be chosen.
Recently the FDA has held hearings and issued warnings regarding a theoretical risk of suicide in adolescents and children on these medications. Although suicide risk is always highest whenever a treatment is started or stopped, it is unclear whether the data support the extreme measures taken by the agency:
"The reaction at the FDA is more emotional and
political than scientific," said Dr. Joseph Biederman,
chief of pediatric psychopharmacology at
"The vast majority of the risks are known, understandable and controllable," said Dr. F. Xavier Castellanos, professor of Child and Adolescent Psychiatry at New York University School of Medicine and author of "Stimulant Drugs and ADHD Basic and Clinical Neuroscience."
"If they put black boxes around everything, they will cease to have any relevance," he said.
- Reuters, March 21, 2006
Isn't it better to use "natural" or
"herbal" products, such as St.
John's Wort, rather than
"artificial" chemicals?
Recently in the United States and even more so in Western Europe there has been an explosion of interest in so-called "natural" or "herbal" products. The implication is that conventional medications - those that have been rigorously tested by academic and industry researchers and passed rigorous review by the Food and Drug Administration - are somehow not natural. However, there is a long and rich tradition within conventional medicine of using plants and naturally occurring compounds to treat illness. Lithium carbonate is a naturally occurring salt and one of the most effective drugs used to treat bipolar disorder. Digitalis is a plant extract used in the treatment of heart failure. When a naturally-occurring compound has been demonstrated to be safe and effective, it is adopted by the mainstream medical community, and is marketed and labeled under strict, tightly regulated conditions.
Conversely, the implication that all that is natural is good is easy to disprove. Cholera, for example, is natural, as is HIV and cobra venom, yet none of these is "healthy" for human beings. Both lithium and digitalis, although naturally occurring, are lethal in overdose.
If a compound has not (yet) been shown to be effective, it is illegal to market it as such. Those compounds are what are generally found on the shelves of stores catering to those in search of herbal or natural remedies. Although no doubt one day some will make it into the pharmacopoeia of modern medicine, others will just as assuredly be discarded as worthless or even dangerous.
Personally, I have several concerns about the herbal remedy market.
To address
At any rate, as an empiricist, I would always recommend whatever works for
you. If
But isn't taking a drug to feel better wrong? I mean, how is it any
better to take Prozac to feel better than it is to take cocaine to feel better?
This is a very important question and one of the most frequently asked. I think there are significant differences between using a recreational drug to achieve a euphoric escape from reality and using a prescribed medication to feel less miserable and more in touch with reality. (See the modules on cocaine addiction or substance dependence for more information.) These differences fall into three main categories.
O.K., but even so, isn't there a risk I might get hooked?
Some medications, such as benzodiazepines like Valium or clonazepam, have definite abuse potential, no question. But even these medications can be taken responsibly if monitored regularly by a physician.
The standard antidepressants, however, have no abuse potential. That means that they do not create dependence, a state in which it takes more and more of the drug to get the same effect, something you see with alcohol, nicotine, or caffeine. You don't get tolerance, meaning you have to take the medication just to feel normal, although if you suffer from major depression, let's say, you might find that your depression returns without treatment. In most cases, stopping the medication does not lead to withdrawal. Finally, if treated appropriately, you will be more functional in multiple life areas, including financial, social, cognitive, and psychological, whereas substances with abuse potential can impair you in multiple life areas.
The bottom line is that if you take an antidepressant and notice significant
improvement in mood, sleeping, appetite, and functioning, with no significant
downside, you and your loved ones will celebrate the improvement. If, on the
other hand, you were to take a recreational drug in an attempt to get the same
effect, not only would it not work, but no doubt your family and close friends
would notice a marked deterioration in you. In my mind (and probably in the
mind of anyone who has lived with someone who suffers from a successfully
treated mood or mental disorder) there is absolutely no comparison between
being addicted to a substance of abuse and being successfully treated with an
appropriately prescribed medication.
But isn't it better to work out your problems in
therapy than to take a pill?
Why can't you do both? Certainly, if you are severely depressed, you will be unable to benefit from therapy if for no other reason than your sleep, appetite, energy, and memory are so impaired you won't be able to marshal your inner strengths. On the other hand, if you are feeling only a little blue, a little down, maybe suffering from a disappointment or setback in your relationships or your work life, you should work through this. Almost no one advocates medicating everyday normal sadness.
You should only consider medications if you suffer not only mild mood symptoms, but also have decreased concentration, appetite, sleep, energy, and libido. If you find cry frequently, feel little motivation or energy, get pleasure from nothing, or are contemplating suicide, an antidepressant can be literally life-saving.
All of us from time to time suffer from one to a handful of these symptoms. Does this mean we should be treated with medications? Of course not. But when they cluster together and cause significant life impairment, then we should consider them. (See FAQ about Major Depression for more information on diagnosis.)
But don't medications just treat the symptoms? What
about the underlying cause of depression and anxiety?
I suggest you consider the research supporting the idea that major depression probably has multiple causes. It seems most likely that the causes of depression or any mood disorder are complex and multifactorial. A combination of genetic endowment, coping strategies, life events, and critical relationships seems to determine who gets depressed and who doesn't. Since we can't determine the cause (and there is likely to be more than one "cause"), taking a broad-front approach is probably best. Indeed, some studies demonstrate that psychotherapy and medication work better than either one alone.
Rarely, someone will get more from 2 weeks of antidepressant medication than from 10 years of psychotherapy. Others do poorly on medications but only make significant progress when they commit themselves to psychotherapy. Most clients fall between these two extremes, so may benefit from both medications and psychotherapy. In the end, it's whatever works and whatever is most aligned with your personal values. I would simply encourage you to keep an open mind and not rule any option out a priori.
But I've gotten depressed before and didn't take
medications and I'm just fine now. Why should I consider medications this time?
First of all, were you depressed or sad? There is a huge difference. We often say we are depressed after paying our taxes or doing badly on a test, but what we really mean is that we are unhappy or disappointed. This is a far cry from suffering from the illness of major depression. How many major appetites or areas of functioning were disrupted and for how long? If you bounced back to your old self within a few days, you weren't depressed. If it lasted for several weeks to months, you might have been.
If you were truly depressed in the past was there any virtue in not seeking treatment? Did you miss work, find your relationships suffered, or feel awful? Did you drop out of life for awhile? Did you lose those weeks or months when you were feeling down? Wouldn't it have been better to have tried to correct the problem early rather than suffering for so long?
Isn't taking medication a sign of weakness? If I
were strong, I could fight this depression on my own, right?
Is drinking water every day a sign of weakness? Without it, you would die. You are completely dependent on it as well as a host of other compounds and elements. Face it: none of us can get through this world entirely on our own. We are all interdependent on each other and our environments.
If you broke your leg, would you refuse a cast or a crutch while your leg healed? Probably not. In fact, you would probably view someone who refused to take advantage of the latest medical technology as being stubborn or foolish or both. Especially if they hobbled home then were completely dysfunctional and dependent on family members because of their refusal to get treatment.
But when the manifestations of an illness are more subjective or difficult to measure, such as depression of a set of drives or of one's mood, we tend to become judgmental. We would not expect someone with a broken leg to "work through" their fracture, but we continue to have societal expectations that mental disorders are at least partially a personal failure. If we were strong we would not get depressed. Well, if our bones were stronger, they would never break, but they do! Why should our central nervous system be any less susceptible to illness or injury than our skeletal system?
Research shows that depressed people have profound cognitive distortions. (See below.) They see themselves, the world, and their future through very dark glasses. Not only might they be in denial, but they are harshly self-critical. They may even feel that they deserve their depression, that it's punishment for something bad that they imagined they did, or that they don't deserve to get better. Furthermore, they may be unable to imagine ever feeling better, since they are hopeless about - among other things - the future. You can see how the individual effects of major depression are reinforced by the societal judgments and misconceptions about major depression, which is no doubt why most major depression goes untreated, even today.
Bottom line: it is very easy and not very helpful to get judgmental about depression, viewing it as a personal failure. "If you were stronger, if you worked through your problems, if you just did what I did, you wouldn't be depressed," is a commonly heard but more or less useless admonishment. The depressed person, who is often feeling very down on herself to begin with, does not usually find such statements helpful.
Depression perhaps should be viewed best as an illness, like diabetes or asthma, that has many causes but once present requires treatment, regardless of whether anyone can figure out what ultimately "caused" it.
My religion/family/friends teach me that happiness
and fulfillment can only come through God/faith/hard work. Depression is a sign
that we are doing something wrong. Why should I medicate away something that
might serve as an important message about the decisions I'm making or how I'm
living my life?
Certainly, self-examination and evaluation to determine whether you are living your life in congruence with your religious and personal beliefs is extremely important. I would challenge the idea that someone who is depressed (not just unhappy) can truly make such a evaluation. We know that people who are suffering from depression have sometimes profound cognitive distortions. They tend to be harshly self-critical, to have gloomy assessments of the future, to feel hopeless about anything. They often overweight negative, painful experiences, and discount or are unable to enjoy pleasurable experiences. They take an unrealistically harsh and self-centered view of their personal responsibility, viewing things they don't like as consequences of their behavior or of some intrinsic badness. In some cases, they can become actively delusional, believing they are the source of all evil in the universe for example, or that they have committed some terrible crime for which they are being punished.
In the most extreme cases, it is clear that someone with an untreated depression is incapable of an accurate and honest self-assessment. Whatever message or sign they might read into things, they are filtering it through the darkest and most distorted of lenses.
So by all means, seek happiness and make whatever changes you can so that you are living in alignment with your values and beliefs. But I would argue that if you have an untreated major depression, you will not be nearly as successful in your quest.
I have so many friends who are on Prozac or another
antidepressant. Aren't we overmedicated as a society?
No doubt there are people who receive medications, not just for depression, but also for colds, for example, who should not receive them. We do live in a society that is very enamored of the idea of using, perhaps in some cases overusing, medical technology to solve problems for which the technology was never designed.
However, what society does or does not do should not shape or influence what decisions you make about what is best for you. If you and your doctor decide a medication may be of benefit to you, then you should make the decision based on what you agree to be in your best interests. Taking or not taking a medication will not change the fact that your best friend is taking three different medications that you believe are not appropriate. (Of course, there may be reasons for the medications to which you are not privy, or your friend may do much worse without the medications.)
Keep it simple. Solve the problem with the most efficient solution. You can't fix the world, but you can take steps to help yourself.
What proof is there that medications work?
It varies by condition and medication. The evidence that major depression responds to antidepressants is overwhelming. Other highly effective medications include lithium and mood stabilizers for manic depression and antidepressants for anxiety (even though they are commonly referred to as antidepressants they seem to work well with anxiety disorders also). The gold standard for determining if a medication works is the placebo-controlled, double-blind prospective trial.
What on earth is a placebo-controlled, double-blind
prospective trial?
It sounds complicated, but the idea is actually pretty simple. Let's say you are testing a potential new medication for depression. So you gather a group of depressed patients who are willing to participate in the study. You divide the group up into at least two groups. One group gets the new medication. The other group gets a sugar pill (a placebo).
Here's the catch: neither the patients nor the researchers know who is getting the medication and who is getting the pill. That is, they are blinded as to who got the pill and who didn't. The reason it is called double-blind is that the researchers also don't know who got the medication and who got placebo. Each pill will look identical. Only a number will identify the pill, and only after the study will the researchers know who got the pill and who got placebo. To make the study even more sophisticated, if the new medication causes a side effect, such as dry mouth or dizziness, the researchers will often use a medication that has similar side effects, such as Benadryl, as the "placebo."
The reason it is called a prospective trial is that no one knows before hand who will respond and who won't. This is different from a retrospective trial, sometimes called a case control trial, in which you identify people who have a given illness or outcome and try to figure out what makes them different from a group of people who don't have the disease or outcome. Statistically and methodologically, prospective trials are the only way we can "prove" that a medication works. Researchers follow the subjects over time and monitor their symptoms. At the end of a certain period, they assess how many people got better. We then "unblind" the researchers, figuring out who got medication and who got a placebo.
Any study involving human subjects has to be reviewed by a panel of ethics experts. Certainly, abuses can occur, but if a research subject is informed of the risks and benefits of the study, and gives informed consent, then this type of research is not only viewed as ethical, but absolutely critical to help understand what works and what doesn't.
But why would anyone want to participate? There
is a chance they could be getting a placebo and not even know it. Why wouldn't
they just take a medication that has been proven to work?
There are several reasons.
First, in many studies there are actually 3 or more groups. In addition to the placebo group and the experimental medication group, there might be a third group that receives the best available treatment at the time of the study. In fact, this is much more common than a straight-up comparison to a placebo group. So in such a clinical trial, the subject would actually have a two-thirds chance of getting an active, effective treatment (1/3 chance of getting the tried-and-true medication, and 1/3 chance of getting the new experimental treatment that might be even more effective).
Second, many research subjects are motivated by a sincere desire to help researchers understand a disease better. They understand that the study may only help them indirectly if at all, but it will help others. Never underestimate the power of altruism.
Third, in some studies volunteers have not done well on the traditional treatments. They are willing to take a chance on a new experimental treatment because nothing has worked so far, even if there is a chance that they will receive a placebo.
Finally, subjects often are given additional perks, such as free, detailed psychiatric assessment and treatment, follow-up, and often ancillary medication screening that may be part of the research protocol. They are usually reimbursed for travel and may even be paid for their services.
OK, so getting back to the experiment, how would you
know if the medication really worked?
We might have results like the following:
|
|
New medication: |
Placebo |
|
Depressed at beginning of study: |
100% |
100% |
|
After 6 weeks of treatment: |
|
|
|
Marked improvement (50% or more reduction in symptoms): |
65% |
10% |
|
Some improvement (25% or more reduction in symptoms): |
10% |
25% |
|
Still depressed (< 25% reduction of symptoms) |
25% |
65% |
In this case, it's clear that almost two-thirds of the subjects receiving the new medication were significantly better in 6 weeks versus only 10% of those on placebo. Depending on the sample size, it is very likely that this is a statistically significant difference (it has a less than 5% probability of occurring by chance alone). Only 1 out of 4 of the subjects was "still depressed" in 6 weeks, whereas 65% of those who got a sugar pill were still depressed. 75% of the experimental group had a 25% or greater response whereas only 35% of the placebo group had this type of a response.
But how can anyone conclude that the medication is
effective? Only 65% got significantly better!
That is an excellent observation. No treatment is 100% effective. In fact, many researchers would love to have results like this. Usually it is a much closer call.
But let's consider why we can conclude that the medication is effective. First, although not everyone got better, the majority did. If you generalize from this study, you might conclude that maybe as many as two-thirds of those suffering from depression would have a significant benefit from this medication. (In reality, the number will be lower because research studies often screen out patients with complicating other factors such as alcohol abuse or other medical conditions that might worsen the response to treatment.) That's better than zero and more importantly it's better than 10% (the rate of response to placebo). How much better? Well, you can run a statistical test to see how many times out of a hundred you might expect to get results like this from chance, the so-called "p value". You might find that the "p value" is .0001, meaning that only one time out of 10,000 would you expect to get these results from chance. That means that what you are observing is probably not a fluke.
But some people got better without the medication at
all! Wouldn't it be better to give everyone a sugar pill?
Medical researchers sometimes joke that they got ill, they would hope to be in the control group (the ones who receive placebo) in a research trial, since this group often does much better than the general population. Most conditions tend to improve with time on their own. This is as true in a research study as anywhere else. By chance, 10% of the people could have gotten better without any treatment. Most likely, the suggestion that they might be taking an effective medication - the so-called "placebo effect" - made some people respond who would not otherwise have. The problem with waiting and hoping for the best is that someone may be depressed for several weeks or months before getting better. During that time, they are not only miserable, but are probably not eating or sleeping well, their relationships and work life is suffering, and they are at a very real risk of suicide, which is currently (2001) the 8th leading cause of death in the United States.
Remember, it is all a matter of probability. If it was you or your mother who was suffering from depression, would you rather try something that had a 10% chance of working or a 65% chance of working? Remember also that 75% of the experimental group had a 25% or greater response whereas only 35% of the placebo group had this type of a response.
What effect has the negative publicity on antidepressants
in adolescence had on the treatment of depression?
According to the New England Journal
of Medicine ("The Antidepressant Quandary - Considering Suicide Risk When
Treating Adolescent Depression", Gregory E. Simon, M.D., M.P.H.), "after
the initial [FDA] advisory was issued, prescriptions for antidepressants for
children and
adolescents fell by nearly 25%, whereas the rates of
appropriate follow-up care showed no improvement. Among adults who
began taking antidepressant medication, only 20% received a minimal level of
follow-up (three or more visits over a 3-month period) - one of the poorest
performances in the entire
Can you predict who if anyone will get better or will get side effects?
Yes and no. We can speak of probabilities, such as up to 70% of people suffering from major depression will benefit from an antidepressant medication. However, to say that Mrs. Smith will definitely respond to Prozac is something we cannot do. Mrs. Smith may respond to Prozac, or she may respond to a second (or third) medication. Many studies have attempted to pinpoint which patients are most likely to respond to which medications, but there are few good predictors.
The good news, however, is that through a process of trial and error, we can often find a medication that works for you.
End Notes