If you are one of the approximately 13 million Americans struggling with depression, your options for treatment have increased dramatically over the past 2 decades. The release of Prozac (fluoxetine) in 1988, with its favorable side effect profile and high efficacy rate in clinical trials, offered hope to depression sufferers and spawned a meteoric rise in the use of antidepressants. The media hype surrounding this development did much to erase the social stigma associated with depression medication and, seemingly overnight, Prozac became a household word. Antidepressants are now the most frequently prescribed medications in the United States, accounting for a $21 billion dollar per year industry.
Prozac was the first in a new class of depression medications called selective serotonin reuptake inhibitors (SSRIs). Serotonin is a neurotransmitter, or brain chemical, thought to be decreased in depression. It is released from the brain cells and then reabsorbed. SSRIs prevent that reabsorption, effectively increasing serotonin levels and elevating mood. There are now at least 6 available SSRIs (e.g. Lexapro, Zoloft) as well as even newer agents, such as selective serotonin norepinephrine reuptake inhibitors (SSNRIs, e.g. Effexor) and tetracyclics (e.g. Remeron). Although the mechanism of the more recently developed drugs differs from that of SSRIs, the actions are essentially the same: elevating levels of neurotransmitters to improve mood and sense of well-being.
Because improvement of symptoms due to antidepressant drug treatment is dependent upon increasing levels of brain chemicals, relief is not immediate. You should expect to feel some changes after approximately 2 weeks of therapy, but the full effect may not be apparent for up to 4-6 weeks. Initially you may experience an increase in anxiety, but this should subside within a week or two. Most studies show that approximately 60% of depressed patients achieve symptom relief with antidepressant medication, but up to 40% of these do not respond to the first drug tried. It is important to monitor your symptoms and, if you are not feeling considerably better after 6-8 weeks, see your doctor and try a different agent. It is a trial and error process, with no one drug being clearly superior to any other. Fortunately, there are now more than a dozen choices and perseverance frequently pays off. The salutary effects of the medication are often bolstered by non-pharmacologic interventions, such as talk therapy, lifestyle modifications (e.g improved diet, exercise and sleep habits), peer support, and stress reduction techniques.
As with all drugs, antidepressant medications can have side-effects. The most common ones are relatively mild, and include nausea, headache, anxiety, sleep disturbances and sexual dysfunction. A small percentage of patients may experience increased depression, aggression or suicidal thoughts or behavior. This is especially likely in children and adolescents and use in these age groups requires careful monitoring.
There have been several recent studies suggesting that antidepressant medications are no more effective than placebo in all but the most severely depressed patient group. Jay C. Fournier of the University of Pennsylvania recently pooled data from 6 well-designed clinical trials and concluded that, although the benefit of antidepressant medication in severely depressed patients is “substantial”, improvement is minimal to nonexistent in those with mild to moderate depression. Fournier’s results are consistent with earlier work done by Dr. Irving Kirsch of the University of Hull, England. He, too, reported that only the most severely depressed patients respond to antidepressant medication. The American Psychiatric Association and others have challenged these results, suggesting that the study did not adequately account for the fact that many depressed patients do not respond to the first drug tried, but require a trial and error process to achieve optimal results.