Initiating Antidepressant Selection: What’s Important

For clients being prescribed an antidepressant for the first time, here are some important considerations:

  1. How the depression presents. There are some 12 subtypes of major depressive disorder, but none of them are reliable predictors of antidepressant response. Nevertheless, there needs to be a starting point for the selection process. For example, is the client’s depression accompanied by anxiety and insomnia or is it characterized by melancholia, hypersomnia and a vegetative state? In the first example, any of the SSRIs except Prozac would be acceptable choices; the latter example would be better served by Prozac, SNRIs (Effexor, Cymbalta, Pristiq) or Wellbutrin.
  2. Family history. Does the client’s history include a family member who was prescribed an antidepressant drug and responded to it favorably? If so, use this DNA phenomenon to the client’s advantage by using the same medication.
  3. Drug characteristics. Prozac and Wellbutrin are examples of “energizing” antidepressants; whereas Paxil and Celexa tend to be more sedating. Initial choices therefore, should be predicated on how the depression presents – as outlined in #1 above. The point here is that one size does not fit all and selection should not be based on what samples are in abundant supply or what pharmaceutical representative just visited.
  4. Reasonable expectations. When anyone is started on an antidepressant, the individual should be informed as to what to expect from the drug. They should be made aware that antidepressants won’t do the heavy lifting when it comes to managing their depression nor will these agents change behavior. They should be counseled to take the medication as prescribed for a defined period of time – say six months – before a reassessment.
  5. Integrated recovery. An estimated 10 percent of Americans over age six now take antidepressants. Much of this use is being driven by television, internet and print ads through which pharmaceutical companies target consumers directly. The television commercials speak language the consumer can accommodate, and the compassionate, caring voiceover frames the drug as the pathway to relief. They have enormous appeal to a population of depressed people intent on getting a quick fix and instant gratification. I’d respect the ads more if they made an effort or even hinted at incorporating other treatment modalities into the improvement process. But they don’t – leading vulnerable people to conclude that hitching their wagon to a pill fills the bill for what they have to do to get better. This is understandable. The technology revolution alone has us all buying into the “I can have it now” mentality. So drug companies merely capitalize on this mindset.

Getting better and minimizing the possibility of relapse requires strategic planning on multiple levels. This is what integrated recovery means! In more studies than I could possibly give credence to in this space, psychotherapy for depression has a stellar track record. But nowadays treatment by medical doctors, any by psychiatrists in particular, nearly always means psychoactive drugs. And increasingly, I’m finding that non-psychiatric MDs aren’t pushing back against patient requests for antidepressants. More and more, I’m being referred patients who are already on antidepressants for no more than mild reactive dysphoria. The shift to drugs as the first-line treatment modality coincides with the increasingly controversial “chemical imbalance” theory that emerged over the last couple of decades.

Competent, focused and well-designed cognitive-behavioral treatment that focuses on belief system and behavior modification is a must for a truly depressed individual. So are diet changes, some semblance of an exercise regimen and even spiritual development. Many days with many clients though, I feel as though I’m paddling upstream. The power of the pill creates substantial headwinds.

I’m finding it increasingly difficult to get clients to do the “work” of recovery from depression. Some tell me doing anything else than swallowing medication is just too hard. Others say little and have a look of quiet resignation on their faces. With an attitude of victimization and impediment, and a reliance on only medication as a pathway for getting better, they’re boxing themselves in.

Breaking free from the bondage of depression is hard yes, and what I’ve said may sound harsh, but the quantity and quality of improvement derived is proportional to one’s effort. That’s the way it is with anything in life.

Joseph Wegmann, R.Ph., LCSW is a licensed clinical pharmacist and a clinical social worker with more than thirty years of experience in the field of psychopharmacology. His diverse professional background in psychopharmacology and counseling affords him a unique perspective on medication management issues. In addition to consulting with numerous psychiatric facilities, he has presented psychopharmacology seminars to thousands of clinicians in 46 states.

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