Feeling Good: The New Mood Therapy (61 page)

Certainly many depressed people have been treated successfully with antidepressants and swear by them. They are valuable tools and I am glad to have them available in my treatment arsenal. Sometimes antidepressants are helpful, but they are rarely total answers, and often they are not necessary.

I always ask my patients during their initial evaluations whether or not they would prefer to take an antidepressant. If a patient strongly feels that she or he would prefer to be treated without an antidepressant, I treat with cognitive therapy alone, and this is usually successful. However, if the patient has been working hard in therapy for six to ten weeks without any improvement, I sometimes suggest we try to add an antidepressant to put some “high octane” in the tank, so to speak. In some cases, this makes the psychotherapy more effective.

If a patient feels strongly that she or he would like to receive an antidepressant at the initial evaluation, I treat with a combination of an antidepressant medication and psychotherapy right away. However, I almost never treat patients with antidepressant medications alone, as noted previously. In my experience, the drugs-only approach has not been satisfactory. The combination of medications with psychotherapy seems to produce better results in the short term and in the long term than treating patients with drugs alone.

It may sound unscientific to base the medication decision on the patient’s preferences, and certainly there are exceptional cases where I feel I have to make a recommendation that differs from my patient’s wishes. But the majority of time, I have found that patients do well when treated with the approach they are most comfortable with.

So if you are depressed and you have strong positive feelings that an antidepressant drug will help you, this increases the likelihood that you will be helped by one of these medications. And if you feel strongly that you would prefer to be treated with a drug-free form of therapy, the likelihood of a successful outcome is also good. But I would urge flexibility in your thinking. If you are receiving a medication, I strongly believe that cognitive or interpersonal psychotherapy can enhance your recovery. If you are
receiving psychotherapy and your progress is slow, an antidepressant might accelerate your recovery.

Most people can, but competent medical supervision is a must. For example, special precautions are indicated if you have a history of epilepsy, heart, liver, or kidney disease, high blood pressure, or certain other disorders. For the very young and elderly, some medications should be avoided, and smaller dosages may be indicated. And, as noted above, if you are taking medicines in addition to an antidepressant, special precautions are sometimes required. Properly administered, an antidepressant is safe and may be lifesaving. But don’t try to regulate it or administer it on your own. Medical supervision is a must.

Should a pregnant woman use an antidepressant? This sensitive question often requires consultation between the psychiatrist and the obstetrician. Since fetal abnormalities might occur, the potential benefit, the severity of the depression, and the stage of pregnancy must all be taken into account. Other treatment approaches should usually be employed first, and an active self-help program of the type described in this book might eliminate the need for a medication. This would give optimal protection to the developing child, of course. On the other hand, if the depression is very severe, there may be cases where it makes sense to use an antidepressant.

Your chance of responding to an appropriate drug may be enhanced:

Your chance of responding to an appropriate drug may be diminished:

These guidelines are of a general nature and are not intended to be comprehensive or precise. Our ability to predict who will respond best to a medication or to psychotherapy is still extremely limited. Many people with all the positive indicators may fail to respond to antidepressants, and many people with all the negative indicators may respond beautifully to the first drug they receive. In the future, the use of antidepressant drugs will hopefully become more precise and scientific, just as the use of antibiotics has become.

If you have many of the negative indicators, is this bad? I don’t think so. Most patients with all the negative indicators can be treated quite successfully, but it may sometimes take a little longer. In addition, as I have emphasized repeatedly, a combination of medication with good psychotherapy along the lines described in this book is sometimes more effective than treatment with antidepressant drugs alone.

Most studies indicate that approximately 60 percent to 70 percent of depressed patients will respond to an antidepressant medication. Since approximately 30 percent to 50 percent of depressed patients will also respond to a sugar pill (a placebo), these studies indicate that an antidepressant will increase your chances for recovery.

However, remember that the word “respond” is different from the word “recover,” and the improvement from an antidepressant is often only partial. In other words, your score on a mood test like the one in Chapter 2 may improve without going into the range considered truly happy (less than 5). This is why I nearly always combine antidepressant medication treatment with cognitive and behavioral techniques like those described in this book. Most people are not interested in just partial improvement. They want the real McCoy. They want to get up in the morning and say, “Hey, it’s great to be alive!”

As I have emphasized, most of the depressed and anxious people I have treated have problems in their lives such as a marital conflict or a career difficulty, and nearly all of them beat up on themselves with negative thinking patterns. In my experience, medication therapy is usually more effective—and more satisfying—when it is combined with psychotherapy. Many doctors do prescribe medications alone without psychotherapy, but I have not found this approach to be satisfactory.

All of the currently prescribed antidepressant drugs tend to work about equally well, and equally rapidly, for most patients. So far, no new type of antidepressant medication has been shown to be more effective or faster-acting than
the older drugs that have been available for several decades. However, there are dramatic differences in the costs of the different types of antidepressants and in the side effects they have. Essentially, the newer medications are much more expensive because they are still on patent. However, they are far more popular because they usually have fewer side effects than the older, cheaper drugs. If you have certain kinds of medical conditions, some antidepressants will be relatively safer for you than others. I will discuss these issues in greater detail in Chapter 20.

Sometimes a patient will respond particularly well to one antidepressant or kind of antidepressant. Unfortunately, we cannot usually predict this ahead of time for the individual, and so most physicians use a trial-and-error approach. There are, however, a few generalizations about the kinds of antidepressants that work best for certain kinds of problems. For example, drugs that have stronger effects on the serotonin systems in the brain are generally considered to be effective for patients who suffer from obsessive-compulsive disorder (called OCD for short). These patients have recurrent illogical thoughts (like a fear that the stove will catch fire and burn the house down) and perform compulsive rituals over and over (such as checking repeatedly to make sure that the stove is turned off). Drugs often prescribed for OCD include several of the tricyclic antidepressants, including clomipramine (Anafranil), one of the SSRIs, such as fluoxetine (Prozac) or fluvoxamine (Luvox), or one of the MAOIs, such as tranylcypromine (Parnate).

If a depressed patient also has symptoms of anxiety, such as panic attacks or social anxiety, the physician might also choose one of the SSRI or MAOI antidepressants, since these often seem to be quite effective. Or the physician might choose one of the more sedative antidepressants, such as trazodone (Desyrel) or doxepin (Sinequan), thinking that the relaxation might help reduce the anxiety.

In my practice, I have treated many patients with a particularly difficult type of chronic and severe depression known as borderline personality disorder (called BPD for
short). Patients with this disorder have intense and constantly fluctuating negative moods such as depression, anxiety, and anger. Patients with BPD also experience lots of turbulence in their personal relationships. In my experience, quite a few BPD patients have responded dramatically to the MAOI antidepressants, and so I might be more inclined to choose an MAOI for patients with these features. Of course, some patients with BPD have poor impulse control, and they may do better with one of the newer and safer antidepressants. This is because the MAOIs can be quite dangerous if patients mix these drugs with certain forbidden foods and medications that I will describe in detail in Chapter 20.

There are a number of other guidelines as well, but they should not be taken too literally because there are so many exceptions to them. The bottom line is this: any depressed patient has a reasonably good chance of having a positive response to almost any antidepressant medication if it is prescribed at the correct dose for a reasonable period of time. You can ask your physician if she or he has a reason for recommending a particular antidepressant. However, most physicians will prescribe antidepressants they are familiar with. This is good practice. Few doctors can master the myriad details about all the currently prescribed antidepressants, and so most doctors try to become familiar with the one or two agents they use most frequently. In this way, they will have the greatest expertise about the medication they are recommending for you.

My own philosophy is to use a depression test like the one in Chapter 2 as a guide. Take the test once or twice a week during treatment. This is
really
important. The test will show whether and to what extent you have improved. If you are not getting better, or if you are getting worse,
your scores will not improve. If your scores are steadily improving, this indicates the drug is probably helping.

Unfortunately, most doctors do not require their patients to complete a mood test like the one in Chapter 2 between therapy sessions. Instead, they rely on their own clinical judgment to evaluate the effectiveness of the treatment. This is quite unfortunate, because studies have indicated that doctors are often poor judges of how patients feel inside.

Your aim should be to reduce the score on the depression test in Chapter 2 until it is in the range considered normal and happy. This is true whether you are being treated with an antidepressant, with psychotherapy, or with a combination of the two. Treatment cannot be considered completely successful if your score remains in the depressed range.