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Antidepressants.

Medicines for depression.

Antidepressant drugs are not happy pills, and they are not a panacea. They are prescription-only drugs that come with risks as well as benefits, and should only ever be taken under a doctor’s supervision. They are, however, one depression treatment option. Taking medications for depression is not a sign of personal weakness — and there is good evidence that they do help.

Whether antidepressant medication is the best treatment option depends on how severe the person's depression is, their history of illness, their age (psychological treatments are usually the first choice for children and adolescents), and their personal preferences. Most people do best with a combination of medications for depression and therapy.

What are antidepressants used for?
 
  • Moderate to severe depressive illness (Not mild depression).
  • Severe anxiety and panic attacks.
  • Obsessive compulsive disorders.
  • Chronic pain.
  • Eating disorders.
  • Post-traumatic stress disorder.

 

If you are not clear about why an antidepressant has been suggested for you, ask your doctor.

 

How well do they work?
 
After 3 months of treatment, the proportions of people with depression who will be much improved are:
 
50% and 65% if given an antidepressant
compared with
25 - 30% if given an inactive "dummy" pill, or placebo.
 
It may seem surprising that people given placebo tablets improve, but this happens with all tablets that affect how we feel - the effect is similar with painkillers. Antidepressants are helpful but, like many other medicines, some of the benefit is due to the placebo effect.
 
Are the newer ones better than the older ones?
 
Yes and no. The older tablets ( Tricyclics ) are just as effective as the newer ones (SSRIs) but, on the whole, the newer ones seem to have fewer side-effects. A major advantage for the newer tablets is that they are not so dangerous if someone takes an overdose.
 
What kind of Antidepressant have I been recommended?
 
At the end of the leaflet you can find a list of antidepressants, their trade names, and their type.
 
Do antidepressants have side effects?
 
Yes - your doctor will be able to advise you here. You should always remind him or her of any medical conditions you have or have had in the past. Listed below are the side effects you might experience with the different types of antidepressant::
 
Tricyclics.
 
These commonly cause a dry mouth, a slight tremor, fast heartbeat, constipation, sleepiness, and weight gain. Particularly in older people, they may cause confusion, slowness in starting and stopping when passing water, faintness through low blood pressure, and falls. If you have heart trouble, it may be best not to take one of this group of antidepressants. Men may experience difficulty in getting or keeping an erection, or delayed ejaculation. Tricyclic antidepressants are dangerous in overdose.
 
SSRIs.
 
During the first couple of weeks of taking them, you may feel sick and more anxious. Some of these tablets can produce nasty indigestion, but you can usually stop this by taking them with food. More seriously, they may interfere with your sexual function. There have been reports of episodes of aggression, although these are rare.
 
The list of side effects looks worrying - there is even more information about these on the leaflets that come with the medication. However, most people get a small number of mild side-effects (if any). The side effects usually wear off over a couple of weeks as your body gets used to the medication. It is important to have this whole list, though, so you can recognise side effects if they happen. You can then talk them over with your doctor. The more serious ones- problems with urinating, difficulty in remembering, falls, confusion - are uncommon in healthy, younger or middle-aged people. It is common, if you are depressed, to think of harming or killing yourself. Tell your doctor - suicidal thoughts will pass once the depression starts to lift.
 
SNRIs.
 
The side effects are very similar to the SSRIs, but, Venlafaxine is not recommended for people who have heart problems, high blood pressure or problems with the salt levels in their blood. They can be helpful if other antidepressants have failed but they should only be prescribed by doctors with special experience in mental health.
 
MAOIs.
 
This type of antidepressant is rarely prescribed these days. MAOIs can give you a dangerously high blood pressure if you eat foods containing a substance called Tyramine. If you agree to take an MAOI antidepressant your doctor will give you a list of foods to avoid.
 
What about driving or operating machinery?
 
Some antidepressants make you sleepy and slow down your reactions - the older ones are more likely to do this. Some can be taken if you are driving. Remember, depression itself will interfere with your concentration and make it more likely that you will have an accident. If in doubt, check with your doctor.
 
Are antidepressants addictive?
 
Antidepressant drugs don't cause the addictions that you get with tranquillisers, alcohol or nicotine, in the sense that:
 
  • You don't need to keep increasing the dose to get the same effect
  • You won't find yourself craving them if you stop taking them
However, there is a debate about this. In spite of not having the symptoms of addiction described above, up to a third of people who stop SSRIs and SNRIs have withdrawal symptoms.
 
These include-
 
  • Stomach upsets
  • Flu like symptoms
  • Anxiety
  • Dizziness
  • Vivid dreams at night
  • Sensations in the body that feel like electric shocks (see references).
In most people these withdrawal effects are mild, but for a small number of people they can be quite severe. They seem to be most likely to happen with Paroxetine (Seroxat) and Venlafaxine (Efexor). It is generally best to taper off the dose of an antidepressant rather than stop it suddenly.
 
Some people have reported that, after taking an SSRI for several months, they have had difficulty managing once the drug has been stopped and so feel they are addicted to it. Most doctors would say that it is more likely that the original condition has returned.
 
 
SSRI Antidepressants, Suicidal Feelings and Young People.
 
There is some evidence of increased suicidal thoughts (although not actual suicidal acts) and other side effects in young people taking antidepressants. So, SSRI antidepressants are not licensed for use in people under 18. However, the National Institute for Clinical excellence has stated that Fluoxetine, an SSRI antidepressant, can be used in the under - 18.
 
There is no clear evidence of an increased risk of self-harm and suicidal thoughts in adults of 18 years or over. But, individuals mature at different rates. Young adults are more likely to commit suicide than older adults, so a young adult should be particularly closely monitored if he or she takes an SSRI antidepressant.
 
What about pregnancy?
 
It is always best to take as little as possible in the way of medication during pregnancy, especially during the first 3 months. However, some mothers do have take antidepressants during pregnancy. There is some evidence that babies of mothers taking antidepressants may experience withdrawal symptoms soon after birth. Just as adults, this seems to be more likely if Paroxetine is the antidepressant being taken. Some recent studies suggest Paroxetine may also be more of a problem in the first 3 months of pregnancy. Until we know more, doctors have been advised to consider alternative treatment in pregnancy.
 
What about breastfeeding?
 
Women commonly become depressed after giving birth- this is called post-natal depression. It usually gets better with counselling and practical support.
 
However, if you are unlucky enough to get it badly, it can exhaust you, stop you from breast-feeding, upset your relationship with your baby and even hold back your baby's development. In this case, antidepressants can be helpful.
 
What about the baby?
 
He or she will get only a small amount of antidepressant from mother's milk. Babies older than a few weeks have very effective kidneys and livers. They are able to break down and get rid of medicines just as adults do, so the risk to the baby is very small. Some antidepressants are better than others in this regard and it is worth discussing this with your doctor or pharmacist. On balance, bearing in mind all the advantages of breast -feeding, it seems best to carry on with it while taking antidepressants.
 
How should antidepressants be taken?
 
  • Keep in touch with your doctor in the first few weeks. With some of the older Tricyclic drugs it's best to start on a lower dose and work upwards over the next couple of weeks. If you don't go back to the doctor and have the dose increased, you could end up taking too little. You usually don't have to do this with the SSRI tablets. The dose you start with is usually the dose you carry on with. It doesn’t help to increase the dose above the recommended levels.

 

  • Try not to be put off if you get some side effects. Many of them wear off in a few days. Don't stop the tablets unless the side effects really are unpleasant. If they are, get an urgent appointment to see your doctor. If you feel worse it is important to tell your doctor so that he can decide if the medicines are right for you. Your doctor will also want to know if you get increased feelings of restlessness or agitation.

 

  • Take them every day- if you don't, they won't work.

 

  • Wait for them to work. They don't work straight away. Most people find that they take 1-2 weeks to start working and maybe up to 6 weeks to give their full effect.

 

  • Persevere - stopping too early is the commonest reason for people not getting better and for the depression to return.

 

  • Try not to drink alcohol. Alcohol on its own can make your depression worse, but it can also make you slow and drowsy if you are taking antidepressants. This can lead to problems with driving - or with anything you need to concentrate on.

 

  • Keep them out of the reach of children.

 

  • Tempted to take an overdose? Tell your doctor as soon as possible and give your tablets to someone else to keep for you.

 

  • Tell your doctor about any major changes in how you feel when the dose of antidepressant is changed.

 

How long will I have to take them for?
 
Antidepressants don't necessarily treat the cause of the depression or take it away completely. Without any treatment, most depressions will get better after about 8 months.
 
If you stop the medication before 8 or 9 months is up, the symptoms of depression are more likely to come back. The current recommendation is that it is best to take antidepressants for at least six months after you start to feel better. It is worthwhile thinking about what might have made you vulnerable, or might have helped to trigger off your depression. There may be ways of making this less likely to happen again.
 
If you have had two or more attacks of depression then treatment should be continued for at least two years.
 
What if the depression comes back?
 
Some people have severe depressions over and over again. Even when they have got better, they may need to take antidepressants for several years to stop their depression coming back. This is particularly important in older people, who are more likely to have several periods of depression. For some people, other drugs such as Lithium may be recommended. Psychotherapy may be helpful in addition to the tablets.
 
So what impact would these tablets have on my life?
 
Depression is unpleasant. It can seriously affect your ability to work and enjoy life. Antidepressants can help you get better quicker. They can be prescribed by your GP and, apart from the side effects listed overleaf, should have very little impact on your life. People on these tablets, particularly the newer ones, should be able to socialise, carry on at work, and enjoy their normal leisure activities.
 
If you have been depressed for a long time, others who know you well (for example your partner) may have got used to you being like this. Some people in this situation have reported that, as they get better and developed a more positive outlook, their partners had difficulty in adjusting to the change. This can cause friction and is something that people need to be aware of and discuss openly if it happens.
 
What will happen if I don't take them?
 
It's difficult to say - so much depends on why they have been prescribed, on how bad your depression is and how long you've had it for. It's generally accepted that most depressions resolve themselves naturally within about 8 months. If your depression is mild it is best to try some of the other treatments mentioned later in this leaflet. If you can’t decide, talk it over with your doctor.
 
What other treatments of depression are available?
 
It is not enough just to take the pills. It is important to find ways of making yourself feel better, so you are less likely to become depressed again. These can include finding someone you can talk to, taking regular exercise, drinking less alcohol, eating well, using self-help techniques to help you relax and finding ways to solve the problems that have brought the depression on. For some tips on self-help, see our leaflet on depression.
 
Talking Treatments
 
There are a number of effective talking treatments for depression. Counselling is useful in mild depression. Problem solving techniques can help where the depression has been caused by difficulties in life. Cognitive Behavioural Therapy was developed to treat depression and helps you to look at the way you think about yourself, the world and other people. For information about these and other forms of psychotherapy, see our leaflets on Psychotherapy and Cognitive Behavioural Therapy.
 
Herbal Remedies
 
There is also a herbal remedy for depression called Hypericum. This is made from a herb, St Johns Wort, and is available without prescription.
 
Light
 
You may find that you get depressed every winter but cheer up when the days become sunnier. This is called seasonal affective disorder (SAD). If so, you may find a light box helpful - this is a source of bright light which you have on for a certain time each day and which can make up for the lack of light in the winter.
 
How do antidepressants compare with these other treatments?
 
Recent studies have suggested that over a period of a year, many of these psychotherapies are as effective as antidepressants. It is generally accepted that antidepressants work faster (see references). Some studies suggest that it is best to combine antidepressants and psychotherapy. Unfortunately some of these therapies are not readily available within the NHS in some parts of the country.
 
Hypericum, or St John's Wort, is widely used as an antidepressant in Germany. It seems to be as effective as antidepressants in milder depression, although there is little published evidence for its effectiveness in moderate to severe depressions.
 
Exercise and self-help books based on Cognitive Behavioural Therapy can be effective treatments for depression. If you have any further questions about antidepressants which haven't been covered in this leaflet, take a look at the further reading section and have a word with your doctor or psychiatrist. It's also good to talk things over with your family or friends.


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