Feeling Good: The New Mood Therapy (62 page)

As a general rule, it is usually not necessary (or even beneficial) to take two or more different antidepressant drugs simultaneously. The two drugs may interact in ways that are unpredictable, and the side effects may increase substantially. There are exceptions to this, of course. For example, if you are restless and having trouble sleeping, your doctor may sometimes add a small dose of a second, more sedating antidepressant at night to help you get a good night’s sleep. Or your doctor may add a small dose of a second antidepressant to try to increase the effectiveness of the first antidepressant This is called an “augmentation” strategy, and I will discuss this approach in greater detail
in Chapter 20. But on the average, one drug at a time usually works best.

It typically requires a minimum of two or three weeks before an antidepressant medicine begins to improve your mood. Some drugs may take even longer. For example, Prozac may not become effective for five to eight weeks. It is not known why antidepressants have this delayed reaction (and whoever discovers the reason will probably be a good candidate for a Nobel prize). Many patients have the impulse to discontinue their antidepressants before three weeks have passed because they feel hopeless and believe the medicine is not working. This is illogical, since it is unusual for these agents to become effective right away.

I have seen many patients who failed to respond adequately to one or many antidepressants. In fact, at my clinic in Philadelphia, most of the patients were referred to me after unsuccessful treatments with a variety of antidepressant drugs and therapy as well. Most of the time we were eventually able to get an excellent antidepressant effect, often through a combination of cognitive therapy and another medication that the patient had not yet tried. The important thing is to keep persisting in your efforts until you recover. Sometimes this requires enormous dedication and faith. Patients often feel like giving up, but persistence nearly always pays off.

I have stated earlier that the feelings of hopelessness are probably the worst aspect of depression. These feelings sometimes lead to suicide attempts because patients feel so
convinced that things will never get any better. They think that things have always been this way and that their feelings of worthlessness and despair will go on forever. In addition, there is a kind of genius about depression. Patients can be so incredibly persuasive about their hopelessness that even their doctors and families may start believing them after a while. Early in my career I grappled with this and often felt tempted to give up on particularly difficult patients. But a trusted colleague urged me never to give in to the belief that any patient was hopeless. Throughout my career, this policy has paid off. No matter what type of treatment you receive, faith and persistence can be the keys to success. I cannot emphasize this enough.

Of course, you should always check with your physician before making any changes in your medication, but on average, a trial of four or five weeks should be adequate. If you do not have a clear-cut and fairly dramatic improvement in your mood, then a switch to another drug is probably indicated. It is important, however, that the dose be adjusted correctly during this time, since doses that are too high or too low may not be effective. Sometimes your doctor may order a blood test to make sure the dose you are taking is adequate for you.

One of the commonest errors your doctor may make is to keep you on a particular antidepressant for many months (or even years) when there is no clear-cut evidence that you have improved. This makes absolutely no sense to me! However, I have seen many severely depressed individuals who reported that they had been treated continuously with the same antidepressant for many years but were not aware of any beneficial effects from the medication. Their scores on the mood test in Chapter 2 usually indicated they were
still severely depressed. When I asked them why they were taking the drug for such a long time, they usually said that theirs doctors told them that they needed it, or that it was necessary because of their “chemical imbalance.” If your mood has not improved, it seems clear that the drug has not worked, so why keep taking it? If a drug does not have fairly substantial beneficial effects, as indicated by a clear and continuing improvement in your score on a depression test like the one in Chapter 2, then it is usually appropriate to switch to another antidepressant medication.

You and your doctor will have to make this decision together. If this is your first episode of depression, you can probably go off the medicine after six to twelve months and continue to feel undepressed. In some cases, I have discontinued antidepressants after only three months with good results, and rarely found that treatment for more than six months was necessary. But different doctors have different opinions about this.

One of the strongest predictors of relapse in research studies is the degree of improvement at the end of treatment. In other words, if you are happy and completely free of depression, and this is documented by a score below 5 on the depression test in Chapter 2, the likelihood of a prolonged depression-free period is high. On the other hand, if you are partially improved but your depression score is still somewhat elevated, the likelihood is much greater that the depression will worsen or return in the future, whether or not you continue to take an antidepressant medication.

This is another reason why I like to combine antidepressant medications with cognitive behavioral therapy. The patients usually have a much better response, and very few
patients in my private practice appeared to relapse and return for additional treatment following recovery.

Patients with certain kinds of depressions will almost definitely need to take medications on a long-term basis. For example, if a patient has bipolar (manic-depressive) illness with uncontrollable highs as well as lows, long-term treatment with a mood-stabilizing medication such as lithium, valproic acid, or carbamazepine may be necessary.

If you have had many years of unremitting depression or if you have been prone to many recurrent attacks of depression, you might want to consider maintenance therapy for a longer period of time. Since doctors are becoming more aware of the relapsing nature of mood disorders, the use of antidepressants on a long-term or prophylactic basis is gaining greater favor.

Some doctors routinely recommend therapy with antidepressants indefinitely, in much the same way they might insist that patients with diabetes must take daily insulin to regulate their blood sugar. Several research studies suggest that such maintenance therapy can reduce the incidence of depressive relapses. However, research studies also indicate that treatment with the cognitive therapy techniques described in this book can also reduce depressive relapses. In addition, these studies suggest that the preventive effect of cognitive therapy may be greater than the preventive effect of antidepressant medications. One important advantage of cognitive behavioral therapy is that you learn new skills to minimize or prevent future depressions. For example, the simple exercise of writing down and challenging your own negative thoughts when you are under stress can be invaluable.

In my private practice, the vast majority of the depressed patients I have treated have not had to stay on antidepressant
drugs indefinitely following recovery. Most of them did extremely well with no medications simply by using the cognitive therapy skills they learned whenever they became upset again in the future. This is very encouraging, and it shows there is quite a bit you can do not only to treat your own depression, but also to minimize the probability of severe and prolonged depressions in the future. It also suggests that if you are taking an antidepressant, it might be very helpful for you to study and practice the methods in this book.

Once you discover how to change your own negative thinking patterns using the techniques I describe, you may find that you will be able to remain undepressed without any medications. But certainly, you will want to discuss this with your physician. It is never smart to go off a medicine or to change the dose of a medication unless you talk this over with your doctor first.

This is actually pretty common, and I will tell you how I have handled it in my own practice. First, I make sure the patient continues to take the depression test in Chapter 2 at least once or twice a week while she or he is tapering off the medication. Then we develop a plan for slowly reducing the dose of the antidepressant. I tell patients that if they start to feel depressed again while tapering off the drug, and this is reflected by an increased score on the depression test, then they should temporarily raise the dose slightly for a week or two. This usually leads to an improvement in mood again. Then they can slowly continue to taper off the drug again. This approach is reassuring because it puts the patient in control. After a couple tries like this, most patients have been able to taper off their antidepressants without becoming depressed again.

If your depression returns, the chances are excellent that you will again respond to the same drug that helped you the first time. It may be the proper biological “key” for you. So you can probably use that drug again for any future episode of depression. If any blood relative of yours develops a depression, this drug might also be a good choice for them because a person’s response to antidepressants, like the depression itself, appears to be influenced by genetic factors.

The same reasoning applies to the psychotherapy techniques. I have found that for most people, the same kinds of events (for example, being criticized by an authority figure) tend to trigger depression, and the same kinds of cognitive therapy technique usually reverse the depression for a particular patient. In most cases patients have been able to reverse a new episode of depression fairly rapidly without having to take the medication again. I encourage my patients to come in for a little “tune-up” if they become depressed again in the future. Often these “tune-ups” consisted of only one or two therapy sessions, since we were usually able to reapply the same technique that had helped them so much the first time I treated them.

As discussed in Chapter 17, all the medications prescribed for depression, anxiety, and other psychiatric problems can cause different kinds of side effects. For example, many of the older antidepressants (such as amitriptyline, trade name Elavil) cause fairly noticeable side effects such as dry mouth, sleepiness, dizziness, and weight gain, among others. Many of the newer antidepressants (such as fluoxetine, trade name Prozac) can cause nervousness, sweating,
upset stomach, or a loss of interest in sex as well as difficulties having an orgasm.

I will describe the specific side effects of every antidepressant in Chapter 20. You will see that some medications produce lots of side effects whereas others produce very few.

The Side Effects Checklist on pages 494–496 can provide you and your physician with extremely accurate information about any side effects that you experience while you are taking a medication. If you take this test a couple times per week, this will show how the side effects change over time.

Remember, however, that many of these so-called side effects can occur even if you are not taking any medication, since many side effects are also symptoms of depression. Feeling tired, having trouble sleeping at night, or a loss of interest in sex would be good examples. So it can be very useful to complete the Side Effects Checklist at least once or twice before you start any medication. That way, you can see if a side effect began before or after you started the drug. Obviously, if you had the same side effect before you started taking a drug, then the drug is probably not to blame for it.

It is also good to remember that patients who only take placebo medications (sugar pills) during research studies tend to report lots of side effects. This is because they think they are taking a real drug. So there is no proof that a particular side effect is necessarily caused by the drug you are taking. When in doubt, talk this over with your physician.

Let me give you a particularly vivid example of how the mind can occasionally play tricks on us. I once treated a high school teacher for depression. She was not responding well to the psychotherapy and I had the hunch that she would respond to a particular antidepressant drug called tranylcypromine (Parnate) that is described in Chapter 20. However, she was somewhat stubborn and had a strong fear of taking any medication. She complained that she would not be able to tolerate the side effects. I explained that I planned to prescribe a low dose and that in my experience most patients did not have many side effects with this medication, especially when the dose was low. But my efforts were to no avail—she insisted the side effects of the drug would be unbearable, and refused to accept a prescription.

Side Effects Checklist*