Antidepressant Efficacy and the Benefit/Risks of Combining Them with Herbal Medicines

- All antidepressants, irrespective of category or class, have similar efficacy, however most of them have different side effects. With antidepressants, no one-size-fits-all, therefore it makes sense for many clients to choose their own initial antidepressant based on what side effects they are willing to tolerate.

- Fifty percent of depressed patients respond to antidepressants; only 43 percent attain sustained recovery from depression via their use. Being well-educated, female, employed, married, and white with no co-morbid conditions are the most salient predictors of a positive response to antidepressants. Co-occurring anxiety, substance abuse, physical illness and a poor quality of life are the key predictors of a poor response.

- The major benefit of taking complimentary therapies, such as Traditional Chinese Medicine, Bach Flower Remedies, St. John’s Wort and SAM-e is that these preparations can potentially enhance the actions of a prescription antidepressant, which for whatever reason, is not producing the desired outcomes. Herbal medicines with evidence of antidepressant properties can help “kick-start” the actions of traditional antidepressants. The risks of herbal medicines include poorly established guidelines for proper dosing, drug-drug interactions in patients using multiple prescription medications and an exacerbation of side effects of the prescribed antidepressant.

What About That Antidepressant You’ve Been Prescribed?

1.  First and foremost, you should know that depression is a real illness, not a character flaw or a weakness. In this regard, it is no different from diabetes or hypertension, and it is highly responsive to appropriate treatment, which may include more than just medication alone.

2. You should know what to expect from antidepressant medication. At least 50 percent of individuals who will respond to antidepressants begin to demonstrate improvement within a week of treatment initiation. Likely you’ll begin to notice an increase in your energy level first, followed by a gradual improvement in mood and overall physical functioning.

3. Typical side effects. All antidepressants have similar efficacy, but most antidepressants have different side effects. Your prescriber should have informed you about the typical side effects of the antidepressant that was chosen for you. If not, there are countless sources where you can find this information. My book, Psychopharmacology: Straight Talk on Mental Health Medications, (Pesi, 2008) discusses the side effects of all of the widely used antidepressants. It is important to understand that many of the side effects you initially experience will diminish over time. So stay with it!

4. Antidepressants are not habit-forming or addictive, so you won’t get “hooked” on them.

5. If the first agent prescribed does not help you after an adequate trial period, others may be tried. Until science unlocks more of the mysteries of the brain, we’ll just have to live with a “no one-size-fits-all” approach.

6. Take enough for long enough. The best chance you have of getting an antidepressant to work for you is to continue taking it day by day unless the prescriber recommends otherwise. Keep a running diary of the symptoms you’re experiencing. For example, if before starting the medication you felt sad, empty, had lost interest in pleasurable activities, were sleeping poorly and losing weight, make notations in your diary as to which of these symptoms are improving and which ones are not. Keep your doctor informed, schedule follow-up appointments and make sure to report any bothersome side effects that continue to persist.

7. Never abruptly discontinue an antidepressant. Although not considered dangerous, some people who suddenly stop these drugs report “shock-like” sensations in their extremities, particularly the hands and feet. Discontinuation of antidepressants is best done gradually to spare the consumer this unnecessary upset.

8. Take your medication at the same time every day, whenever possible. If you miss a dose and then take it within one to three hours after the regularly scheduled time, that’s fine. If you remember having skipped the drug several hours later, then take it at the next regularly scheduled time.

9. Too much information can fuel a climate of hypervigilance and alarm. Reading up on your medication on the internet or devouring every word of information stapled to the prescription bag can worsen your fears. Most of what you read will never happen, and all of that extraneous information is really for the prescriber, not the consumer.

10. Beware of direct-to-consumer advertising. Remember that the media is not necessarily on your side, they’re out to sell their product and will glorify its benefits while casually mentioning its risks. It’s perfectly okay to ask whether a specific antidepressant may be helpful, but optimally the decision as to what drug is best for you is between you and your doctor. And that decision optimally will hinge on your personal and family history of depression as well as any previous experiences you may have had with antidepressants.

Antidepressant treatment has come a long way. Gone are the days of debilitating side effects and other complications that in some instances were worse than the depression itself. And remember that finding the drug that is right for you should always include and value your input into the decision making process.

Do Antidepressants Really Deliver?

I suppose the answer to this question hinges on the definition of deliver. Let’s start up top with the bottom line: Treating depression pharmacologically is not easy!

A major study, the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) is the largest independently funded clinical trial for depression. The study’s primary objective was to develop a series of evidence-based steps for guiding prescribers in making sequenced treatment choices to enhance the odds of response rates and subsequent remission. The six-year study included approximately 3,000 clients. Initial results indicated that about 30 percent of depressed clients achieve remission (that is, their symptoms essentially disappeared) on their first antidepressant trial with competent care. Subsequent trials yielded a total remission rate of approximately 60 percent. After achieving full remission though, relapse rates are high: Only 43 percent of subjects realized sustainable recovery. Also, with quality care as a given, there is no difference in outcome whether the client was treated by a psychiatrist or a primary care physician.

At least 50 percent of clients who will respond (the rate of patients that experience at least a 50 percent reduction in the severity of symptoms) to antidepressants begin to demonstrate improvement within the first few days to a week of treatment, achieving symptom remission however, may span over an 8- to 12-week period. Achieving remission is important because clients that improve, but continue to have residual symptoms, are twice as likely to relapse to depression and are at an increased risk of suicide.

Since 2002, the only new antidepressants making it to market are Lexapro, Cymbalta, Emsam transdermal and Pristiq – an active metabolite of Effexor. Effexor is no longer under patent protection.

Escitalopram (Lexapro) Approved for Treatment of Major Depression in Adolescents

Escitalopram (Lexapro), has gained FDA approval for the acute and maintenance treatment of major depressive disorder (MDD) in adolescents ages 12 to 17 years.

“Adolescent depression can often be challenging to treat because there are limited treatment options that are proven to be effective and well tolerated in this patient population,” noted Graham Emslie, MD, professor of psychiatry at the University of Texas Southwestern Medical Center in Dallas, in an FDA news release.

Escitalopram (Lexapro) is the second antidepressant to be approved for major depression in adolescents. The first was fluoxetine (Prozac & others).