• Stress that the decision to begin antidepressants is not a sign of moral weakness. Although depression is still considered by some in this country to be a sign of moral weakness, the patient need not be one of them. Antidepressants have helped millions of people “get a leg up” on tackling their depression.
• Explain to patients that antidepressant response can manifest within one or two weeks of beginning the medication with a noticeable increase in energy and motivation. Mood symptoms, assuming the antidepressant is working, improve anywhere from 4-8 weeks, so staying with the medication is imperative.
• The patient should be aware that discernible side effects often diminish over time. Side effects are a part of the body’s adjustment to the introduction of something new to the system. Many of them pass within 2-4 days.
• These medications are not habit forming. Although they should not be discontinued abruptly, antidepressants are not considered drugs of abuse potential.
• Patients should be instructed that if their first antidepressant try is unsuccessful, others may be tried. Unfortunately, this remains a trial-and- error process whereby no-one-size-fits-all.
• It is important for patients to realize the importance of “taking enough for long enough.” It is not uncommon for antidepressant users to think they’re cured when they start to feel sufficiently better. This is a recipe for remission and relapse.
• Abruptly stopping an antidepressant can ignite an uncomfortable discontinuation syndrome. Patients should slowly taper off of these drugs if dosage reduction or complete stoppage is warranted.

• No one antidepressant or antidepressant class consistently outperforms another from an efficacy standpoint. There are no shining stars, just lights in the sky. With antidepressants treatment, there is no right way or wrong way, only possibilities. Just get the client started on a regimen.
• Actions among antidepressants are different. Typically, for the depressed, agitated, irritable client with concomitant insomnia, less activating agents like Celexa, Zoloft or Paxil should be considered. Prozac or Wellbutrin are likely better choices for the client with low energy, little motivation and hypersomnia.
• The different actions of antidepressants are not reliable predictors of overall treatment response.
• The most reliable predictors of antidepressant response are someone’s previous history with a particular agent (positive or negative) and family history regarding antidepressants. For example, if a first-degree biological relative of a client (mother/father, brother/sister) has benefited from Lexapro, starting the client on Lexapro is wise.
• If there’s no discernable symptom improvement within two weeks of a client beginning a particular antidepressant – most notably increased energy levels – future response is unlikely. A switch to another agent is warranted.
• Clients should be actively involved in their initial antidepressant choice. Since all antidepressants have equal efficacy but different side effects, the first selection should be based on what adverse effects the client is willing to accept or tolerate. Most physicians, particularly those in family practice, are willing to go along with a patient’s choice of antidepressant, assuming there is a clear rationale for its use and no obvious contraindications. However, if the patient needs to be switched to another drug or requires augmentation strategies, the physician should take the lead.
• Most antidepressant users will achieve partial remission of symptoms at best, so folks shouldn’t pin their hopes for improvement solely on these medications.
• Antidepressants will not do the heavy lifting when it comes to treating or managing depression, only an integrated, multimodal approach that incorporates competent psychotherapy, diet modification, regular exercise and other beneficial lifestyle changes will work. Depressed people have to want to get better, and the more moving parts the treatment plan possesses, the more positive the outcome.
• Clients may need us to cheer lead them when it comes to antidepressant compliance.

This is one of the key findings of a survey of 1500 readers of Consumer Reports who had sought medical help for depression and/or anxiety between January 2006 and April 2009. Nearly 80 percent of these respondents had received a prescription for an antidepressant after their diagnosis of depression or anxiety.

I wonder how many of these folks were aware of the following about antidepressants:

• Remission of depressive symptoms, via the use of antidepressants, may span over an 8-12 week period
• Only 30 percent of depressed people achieve remission on their first antidepressant trial
• Only 43 percent of antidepressant users realize sustained recovery

Unfortunately, most depressed individuals are unaware that the treatment of depression through pharmacological options alone is downright hard! Most of these folks are not informed about the above-mentioned bullet points by their treating prescriber, and needless to say, the pharmaceutical companies are not in the business of promoting drug failures. And because symptom remission is so slow, people tend to not take enough of the drug for long enough and flat out give up.

Depending of course on severity, there is no easy road out of depression. It takes commitment and a decision to want to get better. And because depression is a cluster of symptoms with many possible causes, there is NO one treatment modality adequate enough to cover for the multi-factorial aspects of the disorder.

Just like diabetics cannot rely on insulin or medication alone to manage their blood sugar, depressed people cannot rely solely on antidepressants to manage their mood and/or anxiety symptoms. Feeling better comes only from doing the work, and merely swallowing a pill is little work at all.

The big Pharma company Novartis owns the rights to market Valdoxan in the United States, but lists the drug as scheduled for submission to the FDA for possible approval no earlier than 2012.

Why? Well, this medication seems to be having difficulty outperforming placebo. And this makes sense because the regulation of circadian rhythms doesn’t necessarily mean that Valdoxan will have antidepressant effects.

Valdoxan promises enhanced norepinephrine and dopamine release, but the drug’s branding plays up its effects on melatonin, raising the question as to who would most likely benefit from its use. Those prone to seasonal affective disorder? Shift workers?

I suspect that Valdoxan will reduce sleep latency, helping people get to sleep faster. It also promises no sexual side effects or weight gain. But these advantages must not be sufficient enough to motivate Novartis to push for swifter FDA approval. Methinks something is amiss here.

Q. Why do so many antidepressants seem to cause sexual dysfunction?

Q. Is Prozac’s long half-life a drawback to its action?
A. Yes and no. Prozac’s long half-life can be an advantage to the individual prone to forget doses, but a disadvantage to those taking additional medications (and not only psychotropics). For example, Prozac has been reported to increase the effect of the cyclic antidepressant Norpramin (desipramine) by 400-fold in some subjects! It can also increase the effects of some benzodiazepines.

Q. Is Deplin an antidepressant?
A. No, Deplin is actually a methylfolate preparation. Depressed patients consistently have lower serum folate concentrations. Deplin helps normalize amounts of the neurotransmitters norpinephrine, serotonin and dopamine, thus enabling antidepressants to be more effective.

Q. In relationship to OCD, what is “PANDAS?”
A. PANDAS is the acronym for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections. This is actually a subtype of pediatric OCD, triggered by strep throat, in which the body’s own immune cells attack the basal ganglia within the brain rather than the strep. PANDAS OCD is usually consistent with the sudden onset of OCD symptoms.

- 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.

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.

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.

“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).