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Author: John McManamy

John McManamy Reproduced By Permission
"...while the right medication can be a godsend, there is no one-drug-fits-all ..."

It took nearly this entire century for the medical and psychiatric professions to come around to the obvious: namely that depression is not simply a condition of the mind. Rather, it is a disorder of the brain. Whereas the mind does not exist in space, the brain occupies all three dimensions and responds to physical intervention, not unlike the heart or liver, though perhaps in a far more complicated manner.

The advent of Prozac and its sister antidepressants in the 1980's blew the lid off decades of wrong thinking once and for all. All this business about depression being all in the mind went right out the window as patients by the millions streamed in from the cold to have the mechanisms in their brains repaired rather than their heads examined.

The psychiatric profession, in turn, responded by becoming a pharmaceutical dating service or sorts, matching patient to medication. There was still a place for therapy of the talking kind, but the task was largely taken over by a different class of professional using approaches that left Freud and his couch far behind. Talking therapy will be examined in future articles. This piece will examine medications as a treatment to depression:

The first thing to know is that while the right medication can be a godsend, there is no one-drug-fits-all, and the process of finding the one that works for you can sometimes turn into a nightmarish game of hit and miss.

Antidepressants are classified by their chemical structure and how they act. Even the experts do not know exactly how these medications operate, other than they optimize neurotransmitter activity in the brain.

The oldest class of antidepressants, MAO inhibitors, are mainly used as a medication of last resort, after the newer varieties have failed. Nardil is the best known. They operate by blocking out the enzyme, monomine oxidase, which gives the neurotransmitters a chance to do their work. Because of their action on other chemicals in the body, users must severely restrict their diets, at the risk of an extreme reaction. In addition, MAO inhibitors can be as subtle as the proverbial 800-pound gorilla. Possible side-effects range from nausea to weight gain or loss to insomnia to sexual dysfunction to just about everything in between.

The tricyclic antidepressants were introduced soon after the MAO inhibitors. Tofranil, Elavil, and Pamelor fall into this category. They work by preventing two neurotransmitters - norepinephrine and serotonin - from being absorbed by the brain's receptors, and can be a life-saver where other medications have failed. Overdoses can be fatal, and have a similar side-effects disadvantage to the MAO inhibitors.

The SSRI's (selective serotonin reuptake inhibitors) work in a similar fashion to the tricyclics, but without many of the side-effects, tending to make them the medication of first choice. Prozac, which came out in 1988, was the first in this class of drugs, followed by Zoloft, Paxil, Celexa, and Luvox. The hype that followed on the release of these drugs is finally dying down, and the public is at last beginning to see them for what they truly are - if not the proverbial 800-pound gorilla, then perhaps one that weighs in at 400 pounds.

Some of the newer drugs - Effexor, Wellbutrin, Remeron, Serzone, and others - technically belong in unique classes of their own, but are generally mentioned in the same breath as the SSRIs. Effexor has a reuptake inhibitor action similar to the SSRI's, but also works on norepinephrine, while Wellbutrin works mainly on the neurotransmitter dopamine. Remeron and Serzone both operate on the brain's alpha-adrenergic-receptors (don't ask) and serotonin. The point to be made here is that there exists a sufficient variety of newer medications to offer hope to even the hardest cases, however unsuccessful previous attempts may have been.

Then there is the flavor of the month, St John's wort, an over-the-counter herbal remedy which is worth a brief mention here, and will be the topic of a future article.

Whatever medication you find yourself on - no matter what class - the chances of recovery are about the same, about 70 percent, though it's not quite as simple as that: Many studies count partial recoveries as successes, and the phenomenon known as Prozac poop-out points to a high relapse rate (up to 50 percent) amongst SSRI users.

On the other hand, recovery rates would be higher if more people followed doctor's orders. And the odds dramatically improve (to perhaps 85 or 90 percent) for those willing to keep trying after their first attempts have failed.

Still, even the most perservering can be frustrated by a long and drawn out game of pill roulette that can take months or (in rare cases) even years to resolve, that is if they don't give up in despair, first.

But even the lucky ones are in for a difficult initial three to six weeks, for antidepressants have a perverse way of making their side-effects known almost at once, weeks before their healing power kicks in, when the depression is raging at its fiercest. The side-effects tend to diminish over time, but too late for many distressed patients who have given up long before then. Here - and this is tough - you must have faith. Barring some extreme side-effect or medical emergency, you need to give your prescription a full six weeks to work.

And another six weeks, should you have to switch medications. And again, another six weeks, if necessary. These heartbreaking searches for the right drug can cause as much despair as one's actual depression, but with one important difference: Those past struggles against depression were all in vain. This time you are battling for your own healing, a fight you have an excellent chance of winning.

Published March 4 1999 at Suite 101-Depression
John McManamy. Reproduced By Permission

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