1) It’s important to know what you’re taking the medication for. This might seem like an obvious point, but I see patients all the time who are taking anti-depressants and don’t know why they’re taking them. What are you targeting with the medication? Anti-depressants can be described for different things: depression, anxiety, pain management, obsessiveness, vertigo. It’s a good first step to narrow it down to one of these categories, but it’s possible to be even more precise. Depression, for example presents with different symptoms in different people. For one person, depression may present with irritability, feelings of sadness and loss of interest in usually pleasurable activities. In another person, depression may present as loss of appetite and sleepiness. If you don’t know why you’re taking the medication, it will be impossible to know if the medication is doing what it was intended to do.
2) I see many patients who can’t say if the anti-depressant is working for them or not. Often they get put on an anti-depressant, and that’s that. There’s little follow up on the part of the doctor to determine if the medication is effective. If you’re not sure if an anti-depressant is working, there’s a good chance it isn’t. How do you know if a medication is effective? There are three main ways. 1) A doctor can use a questionnaire to assess the level of depression or anxiety. 2) A person will note a subjective improvement in mood that is a clear improvement. 3) A person will be more functional in his or her daily life: missing fewer days at work, performing better in school, improvement in sleep patterns, better appetite. The way you measure the effectiveness varies from person to person. It’s not as easy as measuring blood pressure to determine if a blood pressure medication is working, and there are more objective and more subjective ways of measuring improvement in mood, but there should be some attempt at a measurement. It’s not enough for a doctor to ask a patient whether a medication is working or not.
3) A scenario I frequently encounter is this. A person has been taking a medication for a long time, years even, and they don’t know whether it’s working, or if it ever did. Many people will continue to take an anti-depressant even if they’re not certain it is doing anything positive for them. If there’s any uncertainty as to whether an anti-depressant is working or not, the only way to know for sure is to stop it. This is called a discontinuation trial, and should be done under the guidance of a doctor, with the timing of the discontinuation taken into account. Since things could potentially worsen upon discontinuation of a medication, the doctor and patient should be prepared for this outcome, timing the trial during a summer break from school, for example, or when work responsibilities are at their lowest. A word of caution. Anti-depressants should not be stopped all of a sudden. A person can experience unpleasant or even dangerous effects when an anti-depressant is stopped suddenly. But continuing a medication just to continue it also exposes a person to risk, not to mention expense.
4) The effectiveness of any medication will vary from one person to another. The choice of an anti-depressant can be based on expected side effects. For example, an anti-depressant that typically causes sleepiness might be a good choice for someone who has trouble sleeping at night. But medications don’t always follow the textbooks, and what causes sleepiness in one person might cause insomnia in another person. Another way to guide the choice of an anti-depressant is if a medication works well for a close family member, that may be a good choice for you as well. But ultimately it’s a matter of trial and error. You can’t know how an anti-depressant will effect you until you try it. Also, effectiveness can wane over time. Many medications work well initially, but the effect doesn’t last.
5) If the situation is not urgent, start low and go slow. Start at a low doe and work upward gradually. Note that many anti-depressant take several weeks before they become effective. During the first few days after starting an anti-depressant, you may notice a feeling of jitteriness, nausea, insomnia or dizziness. The initial side effects during this period are not reflective of long-term side effects, so what I advise patients to do is push through these symptoms if they can. They typically do no persist beyond seven to ten days. Sometimes the side effects are severe, and it becomes clear right away that a medication is not tolerated. It is perfectly reasonable to halt the trial of the medication at that point.
6)Rather than adding a second medication to your regimen, consider stopping one. Sometimes two medications are better than one, but more often I have seen people take two medications unnecessarily, adding as second medication on top of an ineffective one. When you are more than one anti-depressant you expose yourself to more side effects. Sometimes a second medication, especially if it’s in a different class, can be helpful, but more often it is unnecessary.
7) You can't put it all on a pill. Mood disturbance and mental illness are not merely products of brain chemistry. We have an overly brain-centered, overly medicalized view of mood disturbance in our culture today, both popular culture and medical culture. The more we tend to view mood and emotion as brain-centered phenomena, the more likely we are to prescribe or be prescribed a medication claiming to have an effect on mood or emotion by altering brain chemistry. But people are more than products of their brain chemistry. Mood and the expression of emotion play out, not at the level of the brain, but at the level of the whole human being, so treatments should be focused there. Talk therapy, or body-centered therapies should be considered as well. If you’re only considering treatments that operate at the level of brain chemistry, you’re neglecting other potentially more helpful approaches. Other factors that can affect mood are: nutrition, sleep habits, alcohol or marijuana use, overall medical health, thyroid or other endocrine disease, medication side effects, dysfunctional relationships
8) Side effects from anti-depressants are not negligible. They range from life-threatening—liver toxicity, suicidality, allergic reaction—to merely unpleasant—nausea, dizziness, dry mouth, erectile dysfunction—and vary from person to person. A person will not experience every side effect from a medication, and most people tolerate the newer anti-depressants quite well, but there is no way to know what side effects will occur for any given person on any given medication without trying. A woman came to see me once because she continued to experience “brain zaps” after stopping an anti-depressant. The official name for it is “antidepressant discontinuation syndrome” and it’s when a person experiences the feeling of a current of electricity or a vague shock-like wave traveling through their heads after stopping a medication. It can also be accompanied by flu-like symptoms and sleep distrubances. The textbooks say that these symptoms typically go away in four to six weeks. But this patient I saw had been experiencing brain zaps for four months when she saw me. She said that she was angry that her doctor never warned her that this could be a problem. So I’m including this side effect here because of her. Other possible side effects I always mention to patients: weight gain.
9) Sometimes it’s hard to tell whether a symptom is a side effect from a medication or due to something else. The only way to tell if a medication is causing a side effect is to determine the answer to these two questions 1) Did the side effect in question start after the medication was started? 2) Did it stop when the medication was stopped? It doesn’t matter what the textbooks or apps say. If it’s a side effect for you, it’s a side effect for you. I’ve seen so many people whose complaints of medication side effects were dismissed, only to discover, after stopping the medication, that indeed it was a side effect.
10) The decision to take or not to take a medication is up to each person. Don’t rely on anyone else’s moral, religious or personal positions. It’s easy for people who don’t have significant mood disturbances to speak from a place of unacknowledged privilege when they look down on you for taking a medication.
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