Medication tricks in complicated depression


Unfortunately, using antidepressants is very much an inexact science.  This is hardly surprising since we discovered antidepressants by accident, we do not understand how they work, and we do not understand exactly what is wrong in depressive illness.  What we do understand is that we can get dramatically good results with antidepressants in treating depressive illness.


There is really no way of predicting which antidepressant will suit a particular person.  Most doctors therefore are guided in their choice by antidepressants  which produce the fewest side effects, or produce side effects which would be a benefit in a particular patient, such as using very sedating antidepressants in someone who is very anxious and cannot sleep.


Any antidepressant has a seventy per cent chance of stopping depressive illness in the patient to whom it is given.  However, after a period of time, one third of the people who have initially responded to an antidepressant will need to be changed to another antidepressant, as they lose the initial benefits they got from the antidepressant.  We do not really understand why this happens.


After trying a number of antidepressants, until one is found that wipes out the symptoms, doctors are usually left with the situation where most people are well, but a significant number have not responded at all, or are left with distressing symptoms they never had before they got sick.  Here are a few of the available techniques which seem to increase the benefits of antidepressant medication treatment: –


  1. Getting the dose of the antidepressant right:  if a patient is improved with a particular dose of antidepressant, but still has symptoms left, the usual approach is to increase the dose of antidepressant.  However, if it is necessary to go outside the manufacturer’s recommended guidelines, this usually requires specialist supervision by a psychiatrist interested in this approach.  Blood levels of the antidepressant, cardiographs and EEGs may be necessary in this situation.


In some cases, especially using the SSRIs, the symptoms of being over-medicated may be misdiagnosed as the patient becoming depressed again.  Symptoms suggesting over-medication, (which will respond to reducing the dose rather than changing the antidepressant) are yawning, nodding off to sleep during the day, difficulty finding the right word, and simple errors in spelling or calculations that would not previously have occurred.


2. Adding Lithium:  Lithium is normally used to prevent attacks of depression, or of hypomania in the small number of depressed people who get this complication.  However, in a minority of people, adding Lithium to their antidepressants will make the antidepressant work better, usually within a few weeks of starting the Lithium.


3. Adding Thyroid Hormone:  In a very small number of people, adding thyroid hormone to antidepressants makes the antidepressants work better.  The thyroid hormone known as T3 is reported to be better than the more commonly available thyroid hormone known as T4.


4. Combining Antidepressants:  This is a rapidly developing area in psychiatry, although still seen as controversial by a minority of psychiatrists.  There is very limited research in this area, but many psychiatrists practise combining antidepressants, based on their clinical experience.  Others are apprehensive about the unknown risks of various combinations.  However, faced with a patient who has failed to respond adequately to multiple antidepressants used singly, many practising psychiatrists feel there is no alternative for the patient’s sake but to attempt to get even more benefit by combining antidepressants.  Your doctor will advise you about this possibility.


5. Adding Benzodiazepines:  There is considerable research evidence that anxiety and depression are different facets of the same chemical disturbance.  Benzodiazepines, such as Valium, are very effective at dealing with anxiety, and it does seem that anxiety fuels depression.  If one can stop the supply of anxiety, so to speak, by high dose Benzodiazepines, antidepressants may have more scope to work.


6. Adding antipsychotic drugs:  For thirty or forty years, it has been known that combining antidepressants with the old antipsychotic drug, Melleril/Thorazine, was a very effective technique in treating complicated depression.  In the past few years, Seroquel, Abilify and Zyprexa, have been introduced onto the market as antipsychotic drugs.  In very many patients with complicated or resistant depression, low doses of these drugs combined with antidepressants are very effective.


7. Adding Buspar: This unusual anti-anxiety agent may help some people.


8. Adding Dexamphetamine:  This stimulant medication causes stored chemicals in the brain to be released.  Accordingly, patients who take Dexamphetamine, either with or without antidepressants, will usually feel better for a few days.  However, without antidepressants, this effect will be temporary, as the brain runs out of stores of chemicals which can be released by the Dexamphetamine.  In a number of people taking antidepressants which make them sedated, reducing the dose of the antidepressants causes their symptoms to return.  In such cases, low dose Dexamphetamine over a prolonged period of time allows the patient to be able to tolerate the necessary dose of antidepressants.


9. Adding anticonvulsant medications:  While their role in preventing depression and hypomania has been reliably proven by research, there is still some uncertainty about the benefits of adding anticonvulsants to antidepressants in people with resistant or complicated depressive illness.  However, many psychiatrists have had very good results when adding Sodium Valproate to antidepressants.  Adding Carbamazepine is also widely practised in various countries.


I emphasise that the information in this site is not medical advice or treatment, which can only be decided by your doctor.  However, it is also important to be informed that you do not have to tolerate years of uncontrolled symptoms of depression, affecting you or someone close to you, when there is a range of treatments you may not yet have been given.  Do keep in mind that combined medication and psychotherapy (especially cognitive therapy and interpersonal therapy) produce better results than either medication or therapy used alone.  Also, do keep in mind that electroconvulsive therapy (ECT, shock therapy) is an extremely powerful and effective treatment in selected cases of very severe depression, even if it’s public relations profile over the years has been less than ideal.


This information is intended to improve your knowledge of the treatment you are receiving.  Any further points can be discussed at your next consultation with your doctor.


Important Disclaimer:  This site is medical information only, and is not to be taken as diagnosis, advice or treatment, which can only be decided by your own doctor.

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