Feeling Good: The New Mood Therapy (84 page)

Suppose that all these strategies fail to bring about an optimal antidepressant response. What then? In my experience this is not unusual. I have seen lots of patients who were treated for years with all kinds of medications and yet they were still severely depressed. Early in my career, I realized that drugs did not provide the answer for many people. That is why I devoted so much of my career to the development of new psychotherapeutic techniques, such as those described in this book. I wanted to have more tools available than just drugs.

In my experience, the idea that a pill alone will solve your problems and bring you joy is not productive. In contrast, the willingness to use these cognitive therapy tools, often in combination with a compassionate, persistent, and creative therapist will often lead to substantial improvement.

The various types of antidepressants I have described are the ones that in my opinion have a clear-cut indication in the treatment of depression. I will describe several types of drugs that you might want to avoid, although there are exceptions to this rule.

Minor Tranquilizers (Benzodiazepines
). Some doctors use minor tranquilizers (called benzodiazepines) or sedatives to treat nervousness and anxiety. The benzodiazepines include many familiar drugs such as alprazolam (Xanax), chlordiazepoxide (Librium), clonazepam (Klonopin), clorazepate
(Tranxene), diazepam (Valium), lorazepam (Ativan), oxazepam (Serax) and prazepam (Centrax). Minor tranquilizers may be added to the mix of drugs your doctor prescribes if you are depressed. Because most depressed patients also experience anxiety, this practice is unfortunately quite common.

I usually do not recommend minor tranquilizers because they can be addictive, and the sedation they produce might make your depression worse. In my experience, anxiety can nearly always be treated successfully without using these drugs. Two highly esteemed colleagues from Canada, Dr. Henny A. Westra from the Queen Elizabeth II Health Sciences Center, and Dr. Sherry H. Stewart from Dalhousie University, recently reviewed the world literature on the treatment of anxiety disorders with cognitive behavioral therapy versus medications. Based on their careful review of many clinical outcome studies, the authors recommended treatment of anxiety disorders with cognitive behavior therapy instead of medications.
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The authors concluded that cognitive behavioral therapy without drugs is a highly effective and long lasting treatment for anxiety. In comparison, they emphasize that benzodiazepines may give some limited relief but only for a short period of time, tend to lose their effectiveness over time, and are very difficult to discontinue. If you have a serious interest in this topic, the scholarly article by Drs. Westra and Stewart would be worth reading.

Although the benzodiazepines such as Ativan, Librium, Ritrovil (available in Canada), Valium, Xanax, and others can have wonderfully calming effects almost immediately after you take them, the main problem is that these relaxing effects do not last. As soon as the drug leaves your body a few hours later, there is a high likelihood you will feel nervous again. In addition, if you take these drugs daily for more than a few weeks, you may experience withdrawal effects when you try to go off them. The most common withdrawal symptoms are anxiety, nervousness and trouble sleeping. Ironically, these are the exact reasons you started taking the drug in the first place. These withdrawal symptoms
trick you into thinking you still need the drug, and so you start taking it again. This is how the pattern of drug dependency develops. Fortunately, antidepressants are also effective in treating anxiety, as are the cognitive and behavioral therapy techniques described in this book, and these treatments are not addictive. This is why I avoid the benzodiazepines in the treatment of depressed or anxious individuals.

There are other reasons to avoid minor tranquilizers in the treatment of anxiety. One of the cardinal treatment principles is that anxious individuals must face their fears and surrender to their fears in order to overcome them. For example, if you have a fear of heights, you may have to climb to the top of a ladder and stand there until the anxiety goes away. I could give you dozens of examples of patients who have experienced dramatic improvements or even complete recoveries when they faced their fears in this way. Anxious individuals who face their fears often feel tremendous relief because they discover their fears were not realistic in the first place. This realization may not occur if you are simply taking tranquilizers and not facing your fears. Even if you do manage to face your fears with the help of tranquilizers, the medication will tend to reduce the effectiveness of your efforts. In fact, when doctors prescribe tranquilizers for anxious patients, there is the danger that this will reinforce the idea that the fears really are dangerous and must be avoided and that the uncomfortable symptoms must be suppressed. These messages are the very antithesis of the newer exposure therapies that have shown so much promise in the treatment of anxiety.

If your doctor has been prescribing a benzodiazepine, or suggests this type of medication, a discussion of the pros and cons would be indicated. Remember that you are the consumer, and your doctor is working for you. You have every right to discuss your treatment in a frank and respectful way. This sense of teamwork and collaboration is quite important.

Sedatives
. Many prescription sleeping pills can also be addictive and are easily abused: They can lose their effectiveness
after only a few days of regular use. Then greater and greater doses may be required to put you to sleep. This can lead to a pattern of drug tolerance and dependency. If you take them daily, these pills can disrupt your normal sleep pattern. Severe insomnia is a withdrawal symptom from sleeping pills, and so every time you try to stop taking the pills you will falsely conclude that you need them even more. Thus they can greatly worsen your sleeping difficulties.

In contrast, mere are several sedative medications that enhance sleep without requiring increased doses. In my opinion, these drugs represent a superior approach to treating insomnia in depressed individuals. Three that are often prescribed for this purpose are 25 to 100 mg of trazodone (Desyrel) or doxepin (Sinequan) or 25 to 50 mg of diphenhydramine (Benadryl). The first two are antidepressants that require a prescription. Benadryl is an antiallergy medication that is now sold without a prescription. Make sure that you consult with your doctor before taking any medication, even one that is sold over the counter, to make sure there are no dangerous drug interactions with other medications you are taking. Remember that many over-the-counter drugs, like Benadryl, were once available only on prescription, so they can be just as dangerous as prescription drugs. The new anticonvulsant, gabapentin, also has sedative and antianxiety effects without being habit-forming, and some doctors are prescribing it for this purpose.

If you are having trouble sleeping, you may have personal problems that make it hard to get to sleep. It could be anything—a problem at school or work, or a conflict with a family member or friend. Some people sweep these problems under the carpet so they won’t have to deal with them. Then they develop a variety of symptoms instead. Some people become anxious, others have trouble sleeping, and some develop aches and pains that have no organic causes.

I have always felt it is better to try to identify and solve the problem rather than masking it with tranquilizers or sleeping pills. In our culture, the idea of a quick cure is
tremendously appealing to patients and physicians alike. It is easy to prescribe a drug that will make the problem go away. This contributes greatly to the enormous popularity of sleeping pills and minor tranquilizers.

Stimulants
. How about the “pep pills” (stimulants) such as methylphenidate (Ritalin) and the amphetamines that used to be so commonly prescribed for weight loss? It is true that these drugs can produce a temporary stimulation or elation (much like cocaine), but they can also be dangerously habit-forming. When you come down from the temporary high state, you may tend to crash and experience an even more profound sense of despair. When given chronically, these drugs can sometimes produce an aggressive, violent, paranoid reaction resembling schizophrenia.

I have not prescribed stimulants for depressed patients (or for any other problem) because of my concerns about these drugs, but this is clearly an area of controversy. Some psychiatrists do prescribe stimulants for elderly depressed patients under certain circumstances, and they are quite popular for treating hyperactive children and adolescents. If your doctor recommends taking such pills, you should certainly discuss the pros and cons. You might also want to obtain a second opinion if you feel uncomfortable about the treatment.

There are exceptions to this rule, like any. Because of its energizing properties, some doctors add methylphenidate (Ritalin) to a tricyclic antidepressant. This combination may be helpful for some patients who are very sluggish and unmotivated. However, methylphenidate also inhibits the breakdown of most tricyclic antidepressants by the liver, and so the blood level of these other antidepressants will increase. This may lead to greater side effects and may require a reduction in the dose of the antidepressant.

Antipsychotic Medications (Neuroleptics
). What about the antipsychotic medications (also called neuroleptics or “major tranquilizers”)? Some of the older drugs in this
category include chlorpromazine (Thorazine), chlorprothixene (Taractan), haloperidol (Haldol), fluphenazine (Prolixin), loxapine (Loxitane), mesoridazine (Serentil), molindone (Moban), perphenazine (Trilafon), pimozide (Orap), thiothixene (Navane), thioridazine (Mellaril), and trifluoperazine (Stelazine). Some of the newer drugs include clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), sertindole (Serlect), and ziprasidone (trade name not yet available). These agents are usually reserved for patients with schizophrenia, mania, or other psychotic disorders. They do not play a major role in the treatment of most depressed or anxious patients. Pills that combined an antidepressant with an antipsychotic medication were marketed and promoted in the past, but most clinical studies have not documented any superior efficacy of such preparations in the treatment of depression.

Only a minority of depressed individuals benefits from antipsychotic agents. These include depressed patients who are delusional—that is, patients who draw false and highly unrealistic conclusions about external reality. For example, a depressed patient might have the delusion that there are worms in his or her body or that there is a conspiracy against him or her. Elderly depressed patients seem more likely to develop paranoid delusions. Depressed patients who are extremely agitated and cannot stop pacing sometimes benefit from the antipsychotic agents as well. However, the major tranquilizers may also cause a worsening of the depression because of their tendency to cause sleepiness and fatigue.

In addition, unlike most antidepressants, many of the antipsychotic medications carry the risk of an irreversible side effect called tardive dyskinesia. Tardive dyskinesia is an abnormality of the face, lips, and tongue; it involves repetitious, involuntary movements, such as smacking the lips over and over or grimacing. The abnormal movements can also sometimes include the arms, legs, and torso. The major tranquilizers can also cause a number of other alarming but
reversible side effects. Therefore, these drugs should be used only when they are clearly needed so that their potential benefit outweighs the potential risk.

Polypharmacy refers to the practice of prescribing more than one psychiatric drug at a time to a particular patient. The idea is that if one drug is good, two, three, or more will be even better. Doctors may combine antidepressant drugs with other types of antidepressants as well as with other types of drugs, such as minor and major tranquilizers. The patient ends up taking a cocktail of many different types of drugs.

Polypharmacy used to be frowned upon. Now the practice has become more accepted, and many psychiatrists routinely prescribe two or more drugs for many of their psychiatric patients. In contrast, if a family physician is treating your depression, then it is much less likely that she or he will prescribe more than one psychiatric medication at a time. This is because a family doctor is usually more concerned with your medical problems and much less aggressive in the treatment of emotional problems.

In some instances, polypharmacy can be helpful in the treatment of mood disorders. For example, I have described several augmentation strategies that might boost the effectiveness of an antidepressant. I have also described how the occasional use of a second medication can combat a drug side effect. Rational polypharmacy might also be helpful when a patient has separate disorders that both require treatment. For example, a patient with schizophrenia may also be depressed and may benefit from a combination of an antipsychotic medication along with an antidepressant. A bipolar (manic-depressive) patient may receive an antidepressant in addition to the lithium during an episode of depression. During an episode of mania, the doctor may prescribe a neuroleptic or a benzodiazepine in addition to lithium to
combat the acute symptoms, as described previously.

Although there are specific instances like these when combinations of drugs are indicated, I am usually not in favor of polypharmacy in the treatment of depression or anxiety because of the increase in side effects, drug interactions, and costs. In addition, polypharmacy has the tendency to convey the message that all the patient’s problems can be dealt with by drugs. The patient may take one or two drugs for depression, one or two additional drugs to treat the side effects of the antidepressants, one more drug to treat anxiety, and so on. And if the patient is angry, she or he may get yet another drug, such as a mood stabilizer, to treat the anger.