About 18 million Americans, two thirds of them women, suffer from depression, and most don’t seek help. That’s I largely because people who are depressed often think they can, and should, handle personal problems on their own. “Many are convinced it’s just a matter of toughing it out,” says Donald Klein, M.D., a professor of psychiatry at Columbia University College of Physicians & Surgeons in New York City. “Others believe nothing will help,” says Ellen Leibenluft, M.D., a mood-disorders researcher at the National Institute of Mental Health (NIMH) in Bethesda, MD. “That’s one of the symptoms of this illness.”
But depression is treatable: Up to 80 percent of patients who seek help–through talk therapy or prescription drugs-get relief. These days, more people are turning to antidepressant medications, partly because increasingly cost-conscious health insurers often prefer to pay for drugs than for many years of psychotherapy. Another reason is that the newest generation of antidepressants-including fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft)-are believed to be safer and have fewer side effects than the older medications, so doctors are usually more comfortable prescribing them. (These drugs are also being used to treat disorders other than depression, including PMS, anorexia, and bulimia.)
Some psychologists (who, it should be noted, cannot prescribe drugs) have criticized the increasingly widespread use of medication to treat depression, arguing that talk therapy works just as well. Although psychiatrists agree that mild cases are best treated with talk therapy, they say patients often do best with combined treatment: drugs to gain relatively quick relief of symptoms, and therapy to learn how to deal with stress over the long haul.
To help you decide on treatment, consider seeing a psychiatrist or psychologist even for just a consultation-rather than your family doctor. “Many general practitioners [GPs] don’t know enough about depression to diagnose or treat it–they just don’t have the training,” says Eliot Kaplan, M.D., chairman of psychiatry at Underwood Memorial Hospital in Woodbury, NJ. Experts are concerned that GPs may be too quick to dole out pills to people who are slightly stressed, but not depressed. “And when antidepressants are warranted, they may not be prescribed in appropriate doses,” Dr. Kaplan adds.
If you or a loved one does decide to, try an antidepressant, keep the following in mind:
* Medication won’t work overnight. “A lot of patients have heard so much about these drugs, they think it’s their fault if they don’t get relief,” says Brian Doyle, M.D., clinical professor of psychiatry at Georgetown University School of Medicine in Washington, DC. But because the antidepressant must build up in the bloodstream, improvement can take six weeks or more. The first medication you try may not work, as is the case for a third of all patients. Doctors may also have to fiddle with the dosage to get the desired effect.
* You can’t stop taking the medication as soon as you get relief. “In order for the drug to work correctly, you must stay on it for a minimum of six months after the symptoms of depression are alleviated,” says Peter Ross, executive director of the American Society of Clinical Psychopharmacology. By the same token, if this is your first bout with depression, doctors usually advise that you try to go off the drug after about a year. No matter how long you’ve been taking a drug, never stop without your doctor’s knowledge.
* Antidepressants have side effects. The older antidepressants, such as amitriptyline (Elavil) and phenelzine (Nardil), can cause serious side effects ranging from elevated blood pressure to weight gain of 30 pounds or more. (These drugs can also be toxic when taken with certain other medications.) Although Prozac and its cousins–known as selective serotonin reuptake inhibitors (SSRIs)–aren’t associated with these problems, they do have bothersome side effects of their own, including loss of appetite, dry mouth, nausea, diarrhea, insomnia, sexual dysfunction, and agitation in people who are predisposed to manic-depressive disorders. These side effects usually begin within the first week or two of treatment and may taper off over time. Often, a doctor will start a patient on a low dose, and then increase it slowly to achieve the most effective dosage with the fewest side effects. And some problems can be dealt with easily. “Sleep difficulties can be alleviated by taking the drug earlier in the day,” says Regina Casper, M.D., professor of psychiatry at Stanford University Medical School.
Sexual problems, which affect one third to one half of those who take SSRIs, are often the most troublesome for patients. Men often can’t get an erection or have difficulty ejaculating; women frequently have trouble achieving orgasm. For both sexes, desire can be diminished. While these problems sometimes abate or fade away, in many cases, they can linger for as long as the drug is taken.
One solution, say experts, is to take an occasional “drug holiday” of two or three days, allowing desire–but not depression–to reemerge. (Doctors say this may work with Paxil and Zoloft, but not Prozac.) Other options include trying a lower dose or switching to another SSRI. Fluvoxamine (Luvox), the newest SSRI, is thought to be less likely than the others to cause sexual dysfunction.
Another alternative is to switch out of the SSRIs altogether. About 10 to 15 percent of patients can’t tolerate the side effects, or the drugs just don’t help at all, according to Dr. Doyle. Two relatively new, frequently prescribed drugs that aren’t in the SSRI family are bupropion (Wellbutrin) and nefazodone (Serzone). Although neither has been associated with sexual dysfunction, both can produce other side effects, including dry mouth, constipation, and insomnia.
* Supplement your drug regimen with nature’s antidepressants. That means eating right, getting a good night’s sleep, trying to eliminate sources of stress, and getting regular exercise.
The new medications should not be taken lightly. But if properly prescribed and monitored, “they really can make a difference in people’s lives,” says Dr. Doyle.
WARNING SIGNS
Depression isn’t simply “the blues,” or a problem that can be wished away. It is a collection of symptoms that lasts two weeks or more and interferes with the ability to enjoy activities that used to bring pleasure. These symptoms include:
* Feelings of emptiness, guilt, hopelessness, or despair
* Lack of energy
* Feeling irritable or overwhelmed–as if “everything’s too much”
* Difficulty thinking or concentrating
* Loss of interest in sex
* Changes in eating or sleeping patterns
For more information, contact the National Institute of Mental Health.