Yet cognitive symptoms are quite common. “[They] are actually significantly prominent in depression,” said Deborah Serani, Psy.D, a clinical psychologist and author of the book Living with Depression.

And these symptoms are incredibly debilitating. “In my opinion, when cognitive symptoms of depression hit, they are more of a pressing concern than physical symptoms.”

Cognitive symptoms can interfere with all areas of a person’s life, including work, school and their relationships. Problem-solving and higher thinking, according to Serani, are greatly diminished. “This can leave a person feeling helpless and without a plan of action to defeat depression.”

Poor concentration can cause problems with communication, and indecisiveness may strain relationships, according to William Marchand, M.D., a clinical associate professor of psychiatry at the University of Utah School of Medicine and author of the book Depression and Bipolar Disorder: Your Guide to Recovery.

The cognitive symptoms of depression also may get confused with other conditions, complicating diagnosis. Here’s a specific list of symptoms along with similar disorders.

Cognitive Symptoms of Depression

“Cognitive symptoms can be subtle and often go unrecognized,” according to Dr. Marchand. Fortunately, psychotherapy can help individuals become more aware of these symptoms, such as distorted thinking, he said.

Marchand and Serani shared these cognitive symptoms of depression:

• Negative or distorted thinking
• Difficulty concentrating
• Distractibility
• Forgetfulness
• Reduced reaction time
• Memory loss
• Indecisiveness

Disorders That Mimic Depression

“The cognitive aspects of depression usually involve a person’s thinking being sluggish, negative or distorted in quality,” Serani said. However, there are many other disorders that share these similar symptoms, because they, too, inhibit cognitive function. Unfortunately, this means that the “risk for misdiagnosis is high,” she said.

For instance, Serani mentioned attention deficit hyperactivity disorder (the inattentive type), post-traumatic stress disorder and substance abuse.

Co-occurring disorders can add to the confusion. “In many cases there are comorbid conditions such as dementia (in elderly individuals), adult ADHD and generalized anxiety disorder, and it can be difficult to sort out which condition is causing the cognitive symptoms,” Marchand said.

It’s critical to receive a proper and comprehensive evaluation to make sure that you have depression or another condition. Again, psychotherapy and medication can improve cognitive symptoms along with other symptoms of depression. Also, there are many strategies you can try on your own to reduce symptoms and feel better (which are explored in another article).

While the book does tell the story of Zach Schidkunz, a young man convicted of murder, the real heart of it is the author’s journey as he attempts to come to grips with what has transpired. The reader is witness to how a parent can make sense of a world in which his beloved little boy can go from college, to suffering from serious depression, to prison.

We are introduced to Zach as a fairly typical, middle-class child. It’s not until college that he begins to show signs of depression, including self-injurious behavior. Eventually, Zach’s psychiatrist recommends a psychotropic medication — Zoloft. Things seem to be getting better until a shocking incident: Mr. & Mrs. Schmidkunz discover a female shooting victim in their home. Even more shocking, the evidence seems to point to Zach as the perpetrator.

Gail Schmidkunz is, understandably, utterly distraught by this idea, and attempts to piece together the possible causes for this incomprehensible situation. What could possibly drive his son, a young man who had no history of trouble with the law, to suddenly, fatally shoot a female friend? What role did Zach’s history of depression and psychiatric treatment play in the incident? Could Zach be held completely responsible for his actions, or were there mitigating factors on which accountability could fall?

All of these questions have been examined by the justice system as well as by Schmidkunz. The author provides us with a vivid picture of the confusion and torment that the ordeal led to. Not content to leave his son’s fate to the courts, Schmidkunz consults with lawyers and mental health professionals to try to make sense of this terrible situation.

After much investigation, the author arrives at a controversial conclusion. One of the medications that Zach had been prescribed, Zoloft, had reportedly caused bizarre side effects in a select number of people. One of these side effects is aggressive behavior. Perhaps, the father postulates, this medication could have been the underlying cause of his son’s actions. The difficult next step was to convince others that this was a possibility. Schmidkunz discusses his battles with doctors who disagreed with his theory as well as the legal team behind the pharmaceutical company that produces Zoloft.

The questions raised in I Am Not Silent are not necessarily easy to answer. How do we determine to what extent a person’s actions may have been caused by mental illness, or by a medication one was taking for that illness? And if medication does play a part in a criminal act, whom do we hold responsible: the person taking the medication, their doctor, the company who produced the pills? Is there some type of proactive monitoring that can take place in order to prevent stories like Zach’s from happening to others in the future? These are complicated legal and ethical issues to contend with.

Whether or not psychiatric medication played a part in Zach’s actions is certainly up for debate. Though Zach was ultimately found guilty, the reader will have to draw his or her own conclusions about the verdict based on the evidence Schmidkunz presents in his memoir. But whether you agree with the author’s assessment of the situation or not, I Am Not Silent is an intriguing read. Schmidkunz presents a heartfelt, honest portrayal of the difficulties such circumstances can present to a family. Through his and his son’s story, we gain an inside look at the ways the criminal justice system deals with defendants who have a history of psychiatric diagnoses.

There is nothing that can be done to bring back the young woman that the Schmidkunzes found in their home. What caused Zach’s actions may never be fully understood. However, stories such as his can hopefully help us gain a clearer understanding of the effects of psychotropic medication and how to best utilize them in order to help those suffering from psychiatric symptoms. You may or may not agree with Gail Schmidkunz’s conclusion about his son’s crime, but it is nonetheless worth hearing his story.

I Am Not Silent: Oor Zoloft and Depression Story
InspiringVoices (July 9, 2012)
Paperback, 208 pages
$14.99

“Coming of Age on Zoloft” by Katherine Sharpe is one such memoir.

Prozac, the first and probably the most prominent of the Selective Serotonin Reuptake Inhibitors (SSRIs) was approved as treatment for depression in 1987.

By the 90s, it was so widely used that it had become embedded in American popular culture. The memoirs of Lauren Slater, “Prozac Diary,” Elizabeth Wurtzel, “Prozac Nation,” and the touting of its effectiveness by psychiatrist Peter Kramer, “Listening to Prozac,” were important factors in this embedding.

In the same spirit, Sharpe describes the experience of a new second generation of SSRI users in her “Coming of Age on Zoloft.” She tells the story of those who were put on the medication in their teens. In Sharpe’s words, “This is a book about what it’s like to grow up on antidepressants.”

The writing alternates skillfully between the memoir of Sharpe’s own coming of age, interviews with forty fellow depression sufferers ranging from late teens to early middle age, and chapters about the history and social meaning of this phenomena that are truly scholarly. This last should not deter readers, because the writing is very clear.

The author states that her hope is that the book will be useful to antidepressant users and their families as well as contributing to the ongoing debate about Zoloft and the “medicalization” of society to the extent that ordinary feelings of sadness and anxiety are treated as symptoms.

Memoirs of mental illness and recovery have proliferated in recent years and Sharpe is following people like Slater, Kay Jamison, Elyn Saks, Martha Manning, and Annie Rodgers among others. Sharpe’s memoir does not approach these others for emotional impact. However, it’s a convincing and worthwhile account.

The memoir portion is well supported by the interviews which address many of the questions that Sharpe dealt with: Who am I really on medication? Is having to take medication a weakness? Will taking medication over time harm me physically? Do I have a real mental illness? How do I quit the meds? My only criticism is that some of the interviews were repetitive s the redundancy of some of the interviews.

The portions of the book where Sharpe’s offers the big perspective are very strong. Having covered some of the same material that she did, I can say that she captured almost all of the main points of the SSRI revolution. She does an especially good job on the rickety theoretical foundation that underlies the antidepressants. She points out how backwards the theory is in that “the cure” was found first and then the condition of depression was fleshed out. In her words, “Antidepressants were invented by accident — twice — and scientists drew conclusions about the nature of the illness by investigating the action of the drugs.”

She’s also scathing about the theory that depression results from a chemical imbalance, i.e. an insufficiency of serotonin. “The phrase ‘chemical imbalance’ gestures at the truth, while deftly concealing all that we don’t know as well as the quotient of subjective reasoning that plays a part in any discussion of mental disorder.” She deals with the question of whether medication is more effective than psychotherapy through her own experience and research findings.

There are a number of issues covered in this book, including questions that people on antidepressants ask themselves.  Sharpe expresses the universal question, Who am I?, from her own drug-shadowed perspective. “When I first began to use Zoloft my inability to pick apart my ‘real’ thoughts and emotions from those imparted by the drugs made me feel bereft.”

She touches broader issues,  such as the “medicalization” of negative feelings and the incestuous relationship between big Pharma and psychiatry. Sharpe discusses the economics of contemporary psychiatric practice, where she points that a psychiatrist out can bill four patients an hour for med checks rather than seeing one patient for an hour of psychotherapy. She also mentions that the antidepressants  have made psychiatry less of the ugly stepchild of medicine.

This is a very solid book  that is thoughtful, well written, and wide ranging. I would have liked to see more discussion about if the drugs really work? However, I realize that she couldn’t explore every issue in detail.

I’m a retired clinical psychologist who uses antidepressants and confess my own fear that what I’m using not only may not work, but may cause long-term damage. I’m thinking of quitting, but fear a relapse of my depression if I stop. I recommend this book for anyone contemplating starting antidepressants, current users, affected families, and especially psychiatric residents.

Coming of Age on Zoloft: How Antidepressants Cheered Us Up, Let Us Down, and Changed Who We Are
Katherine Sharpe
Harper Perennial, June 5, 2012
Paperback, 336 pages
$10.94

Challenge: Uncontrollability

“Bipolar disorder can feel uncontrollable,” according to Sheri L. Johnson, Ph.D., professor of psychology at the University of California-Berkeley and director of the Cal Mania (CALM) Program. Symptoms, such as mood changes, can seem to appear suddenly and without provocation. And they can diminish daily functioning and ruin relationships, said Sheri Van Dijk, MSW, a psychotherapist and author of The DBT Skills Workbook for Bipolar Disorder.

Strategies: While bipolar disorder can seem unpredictable, there are often patterns and triggers you can watch out for. And even if you can’t prevent symptoms, you can minimize and manage them.

One way to monitor changes is to keep a mood chart, Van Dijk said. Depending on which chart you use, you can record everything from your mood to the number of hours you slept, your anxiety level, medication compliance and menstrual cycle, she said. (This is a good chart, she said.) For instance, you can anticipate a potential depressive episode if you see that your mood has been progressively sinking in the last few days, Van Dijk said.

Practicing healthy habits is an effective way to lessen the hold emotions have on you. Make it a priority to get enough sleep, going to bed at the same time and waking up at the same time, Van Dijk said. Create a calm bedtime routine, avoid substances such as alcohol – which disrupts sleep – and don’t exercise in the evenings, said Johnson, also co-author of Bipolar Disorder: A Guide for the Newly Diagnosed.

Sleep deprivation can trigger mania, and “it makes you more susceptible to being controlled by your emotions, such as irritability,” Van Dijk said. On the other hand, sleeping too much can cause lethargy and also reduce your ability to manage emotions, she said.

Exercise helps to reduce depressive symptoms. Eliminating caffeine can reduce irritability and anxiety and improve sleep, Van Dijk said. She suggested cutting out caffeine for two weeks and paying attention to any changes. Some people also find that certain foods exacerbate their mood swings. You can check by cutting out specific foods from your diet, and watching the results, she said.

You also can use a variety of strategies to stave off the negative consequences from your symptoms. For instance, if impulsive spending is a problem, gain control by having a low limit on your credit cards, Johnson said. When you’re experiencing early signs of mania, have someone else hold onto your checks and cards, Johnson said. If you do overspend, return your purchases, she said. You can even ask a friend to go with you, she added.

Challenge: Medication

“There is no ‘one size fits all’ medication that helps everyone with bipolar disorder,” Johnson said. Lithium is typically the first line of treatment. But for some people the side effects are especially troublesome, she said. Finding the right medication (or combination of medications) can seem like a daunting process.

Strategies: Learn as much as you can about mood-stabilizing medications, Johnson said, including their potential side effects. “Find a doctor who will work with you to make adjustments based on your experiences with the different medications,” she said. Expect that it might take several tries to figure out the best medications for you.

Many of the side effects dissipate after the first two weeks, Johnson said. Changing the dose schedule helps to minimize side effects. For instance, if you feel groggy, your doctor might suggest taking your medication in the evening, she said.

Support groups are another valuable tool, Johnson said. (She suggested looking at the Depression and Bipolar Support Alliance website for a group.) For instance, individuals in these groups are usually familiar with compassionate doctors in the area, she said.

Challenge: Relationships

Bipolar disorder is hard on relationships. The very symptoms – swinging moods, risky behaviors – often leave loved ones feeling confused, exhausted and like they’re walking on eggshells, Van Dijk said.

She also sees loved ones have difficulty distinguishing between the illness and the person. They might invalidate the person’s feelings and either blame everything on the illness or believe the person is making conscious choices when it is the illness.

Strategies: Bipolar disorder is difficult to understand, Van Dijk said. “Different affective episodes, [such as] depression versus hypomania, result in different symptoms, and one episode of depression or hypomania can be different from the next within the same person,” she said.

So it’s incredibly important for loved ones to get educated about the illness and how it functions. Individual therapy, family therapy and support groups can help. Refer loved ones to self-help resources and biographies or memoirs of people with bipolar disorder, Johnson said.

Getting a handle on your emotions also improves relationships, she said. Working on assertiveness is key, too, she said. Individuals with bipolar disorder tend to have a tough time being assertive. Therapy is a good place to learn assertiveness skills. But if you’d like to practice on your own, Van Dijk suggested using “I statements”: “ I feel _____ when you ______.” She gave the following example: “I feel scared and hurt when you threaten to leave me.”

Challenge: Anxiety

According to Johnson, about two-thirds of people with bipolar disorder also have a diagnosable anxiety disorder.

Strategies: Johnson stressed the importance of using relaxation techniques and not using avoidance behaviors. As Van Dijk explained, “the more you avoid things because of your anxiety, the more your anxiety will actually increase, because you never allow your brain to learn that there’s nothing to be anxious about.”

Psychotherapy is tremendously helpful for managing bipolar disorder and the above challenges. If you’ve been prescribed medication, never stop taking it abruptly – this boosts the risk for relapse – and communicate regularly with your doctor.

According to Silverman, Flaherty and Tobin (2006), …”[I]t is a better understanding of the psychology of dementia – how a person thinks, feels, communicates, compensates, and responds to change, to emotion, to love – which may bring some of the biggest breakthroughs in treatment….”

A parent, sibling or spouse has been just diagnosed with Alzheimer’s Disease or a related dementia (ADRD). In a somewhat perfect world, family members would receive an orientation to the disease, and learn how it affects their loved one’s behavior. They would quickly begin to learn how to deliver daily care and maintain best function. They would find out how to prevent many common, difficult behaviors, and address those that arise with some consistently applied, fairly easy-to-use psychosocial interventions.

The entire family and all other members of the care team in this somewhat perfect world would receive training and ongoing support to learn and apply Habilitation Therapy (HT), accepted as the best standard of care and psychosocial intervention by the Alzheimer’s Association (Massachusetts/New Hampshire Chapter), where it was first developed in the 1990s. (Alzheimer’s Association, Massachusetts/New Hampshire Chapter, 2011.) HT is considered the best practice in ADRD day-to-day care, in creating good environments for ADRD patients, and within all their relationships and activities. Though powerful and effective, HT is fairly simple to learn; even a child can understand and apply aspects of it.

So, what is this seemingly magical thing called Habilitation Therapy? Well, it’s not magic, but a comprehensive behavioral approach to caring for people with dementia. It focuses not on what the person has lost due to the illness, but on his or her remaining abilities. HT creates and maintains positive emotional states through the course of each day. The dementia patient’s capabilities, independence and morale are consistently engaged to produce a state of psychological well-being. In this way, difficult symptoms can be reduced or eliminated, even as the illness progresses.

Habilitation Therapy also benefits the patient’s family, friends and professional caregivers. The ability to enjoy time together and to share a relationship, activities, and feelings with a person with dementia can be uplifting for everyone involved. HT can reduce much of the stress and workload involved in living with Alzheimer’s Disease and other related dementias.

Note that this is “Habilitation Therapy,” not “Rehabilitation Therapy” (Alzheimer’s Association, Massachusetts/New Hampshire Chapter.) Rehabilitation returns patients to earlier, higher levels of functioning. There is no known rehabilitation for ADRD. Habilitation focuses on optimizing and extending what is possible now, not what was possible in the past.

The very best natural caregivers tend to spontaneously develop similar approaches to HT. Usually, though, they are unable to articulate why they do what they do, teach others except through example, or discover by themselves the totality of what Habilitation could teach. It can take months or years for talented caregivers to uncover just some of the techniques that could have been taught to them in a few hours through Habilitation Therapy training. Though it makes logical sense to provide such training on a regular, widespread basis, it is far from the norm.

A deeper understanding of Habilitation Therapy starts by looking at the way the brain is affected through dementia, and how large a presence emotions represent. This will be explored further in Part 2.

In this somewhat perfect world, medications such as antipsychotics would not be needed to manage the illness’s behaviors. (An antidepressant might be prescribed to help support positive mood and functioning, however.) Special dementia-specific behavioral methods — plus interventions such as gentle massage, music and art therapy, and wellness activities — would help the dementia patient be peaceful and happy, functioning best with what abilities still remain even as they decline. Caregivers (called “care partners”) would be happier and more peaceful, too.

People with ADRD living in this somewhat perfect world would be able to maintain as much independence as they safely could through an appropriately organized physical environment. Daily, they would experience a variety of emotions, including feeling safe, cared about, respected, purposeful and valued. Such positive emotional experiences bring them pleasure, comfort, laughter, happiness and even joy.

Nearly to the very end, they would share positive relationships and emotional experiences with their care partners – both family and professional – who experience time spent together as a close and profound (though not necessarily easy) experience. Most ADRD patients would live their final days in their homes, or would be stay living at home significantly longer due to this type of compassionate daily care. (Mittleman, Ferris, Shulman, Steinberg, and Levin, XXXX.) If and when they found themselves living in a facility, the entire staff, from janitors to nurses to administrative staff, would be fluent in the use of Habilitation Therapy.

Even in this somewhat perfect world, there would still be many, many tasks for care partners to perform every day. There would still be an emotional, physical and financial cost to delivering all the care necessary. The disease would still remain progressive, and the patient would continue to decline. Family and friends would still grieve as their loved one with dementia became more and more dependent and eventually died. But grief and loss would not be the only feelings those left behind would hold in their hearts and memories. There would be the close, enjoyable times that existed through much of the course of the disease.

This somewhat perfect world already exists in small pockets. A good or better quality of life could exist right now for many, many ADRD patients, their families, friends, and professional caregivers. One of the huge missing factors for the further manifestation of this somewhat perfect world is a lack of widespread awareness, training and adoption of Habilitation Therapy.

References

Silverman, N. M., Flaherty, G., Tobin, T. S. (March 2006). Dementia And Wandering Behavior: Concern for the Lost Elder. New York: Springer, p. 24.

Alzheimer’s Association, Massachusetts/New Hampshire Chapter. (August 2, 2011.) Caring for People with Alzheimer’s Disease: A Habilitation Training Curriculum [Training Course]. (Lawrence, MA)

Mittelman M.S., Ferris S.H., Shulman E., Steinberg G., Levin B. (1996). “A family intervention to delay nursing home placement of patients with Alzheimer disease. A randomized controlled trial.” Journal of the American Medical Association. Dec 4; 276(21):1725-31.

Alzheimer’s Association, Massachusetts/New Hampshire Chapter. (n.d.) Caring for People with Alzheimer’s Disease: A Habilitation Training Curriculum. (Watertown, MA). p. 62.

These are the top 25 psychiatric medications by number of U.S. prescriptions dispensed in 2011, according to IMS Health. I’ve also provided their 2009 and 2005 ranking (you can view the 2009 list here).

To put the percent changes below into perspective, the U.S. total population rose approximately 1.6 percent from 2009 to 2011. That suggests that anything above 1.6 percent change was driven by other factors — more people seeking treatment, more pharmaceutical advertising and marketing, or some other factor.

The biggest movers and shakers on the list were Celexa — moving up 15 spots to grab the second most-prescribed psychiatric drug in 2011 — and Wellbutrin XL, moving from 22 to 13.

Drugs used to treat attention deficit hyperactivity disorder (ADHD) — generic amphetamine salts and methylphenidate — enjoyed big gains as well.

Notes:

If no percentage change is listed, we did not track it in 2005.

NA – Rank not available for this year.

* – This is not a psychiatric medication, but is often prescribed for a mental health issue.

How This Data is Derived

Information in the National Prescription Audit (NPA) is derived from IMS Health’s Xponent service, one of the most complete, national-level prescription databases in the U.S. Xponent captures roughly 70% Market Share of all prescriptions in the U.S. IMS then uses a patented projection methodology from a stratified and geographically balanced sample to represent 100% Market Share coverage of U.S. prescription activity at retail, mail service, long-term care, and managed care outlets.

These individuals may have treatment-resistant depression or refractory depression. While there’s some debate over the precise definition, treatment-resistant depression is typically thought of as failing to achieve remission after two treatments or two antidepressants, according to George Papakostas, M.D., director of Treatment-Resistant Depression Studies in the Department of Psychiatry at Massachusetts General Hospital.

Why Some People Have Treatment-Resistant Depression

People develop treatment-resistant depression for many reasons. Some struggle with severe depression, which is difficult to treat. Medical illness and comorbid psychological disorders — such as drug or alcohol abuse or eating disorders — also complicate treatment response, according to Dr. Papakostas and Yvette Sheline, M.D., professor of psychiatry and the director for the Center for Depression Stress & Neuroimaging
 at the Washington University in St. Louis. Severe stress also can impact improvement, Dr. Sheline said.

A variety of genetic, neuroimaging and electrophysiological studies have investigated the underlying causes of treatment-resistant depression. And researchers know one thing for sure: Refractory depression is not the result of one brain region or neurotransmitter system.

Preliminary research suggests that individuals with depression may have abnormalities in the frontal and temporal regions in the brain and dysfunction in serotonin modulation. Also, the subgenual cingulate (Cg25), which is located under the cortex along the midline of the brain, may play a role. Cg25 is activated when an individual experiences sadness. It also connects to other regions involved in mood, motivation and sleep. When antidepressants are effective, this area is less active. Some researchers have hypothesized that in refractory depression, Cg25 doesn’t turn off. In general, according to Papakostas, there isn’t enough evidence to show a consistent or unifying theory.

Other individuals may not have refractory depression after all. For instance, according to Sheline, a thyroid problem may mimic depression. Individuals may have bipolar disorder — though there’s recent evidence that bipolar disorder may be overdiagnosed in patients who appear to have treatment-resistant depression — or a long-term low-grade depression called dysthymia. If a treatment isn’t working, it’s critical that your physician re-evaluate your diagnosis.

Treatment Options for Refractory Depression

According to Sheline, there’s disagreement about the number of medication trials a person needs to try before moving onto more invasive interventions. While physicians determine this on an individual basis, it’s important for patients to have an adequate dose of medication for an adequate amount of time, Sheline said. “Each antidepressant has different therapeutic dose ranges, and these also vary according to individual factors, such as age,” she said. An adequate duration of treatment is usually six weeks. If there’s partial improvement, doctors may recommend patients stay on the medication for six to 12 weeks, Papakostas said.

This is why it’s especially important to take medication as prescribed. Many patients stop taking their medication after a week if they don’t get better, Sheline said. But this isn’t enough time to see improvement. Skipping or forgetting a dose can decrease a medication’s efficacy and make it look like it’s not the right medication for you. Also critical is practicing healthy habits, such as engaging in physical activities and getting enough sleep, and managing stress. Exercise boosts mood, while stress and lack of sleep exacerbate depression.

If one antidepressant truly doesn’t work, physicians will typically prescribe an antidepressant from a different drug class. Or they’ll prescribe an augmenting agent, such as lithium or an atypical antipsychotic medication to boost the effectiveness of the antidepressant.

If medication and psychotherapy are unsuccessful, these are other options:

Electroconvulsive therapy (ECT). ECT involves placing electrodes on a patient’s scalp, which sends a specific current that induces a short seizure in the brain. In the 1950s, ECT developed a bad reputation because it was administered without anesthesia and with a high voltage, Sheline said. But today, it’s a completely different treatment, she said.

ECT is administered with general anesthesia and the voltage is carefully controlled. In fact, Sheline noted that there is ongoing work to decrease the pulses to minimize side effects. There’s also been concern that ECT is involuntary, Papakostas said. He clarified that ECT is voluntary and requires a patient’s informed consent.

ECT does have various bothersome side effects, including memory loss and headaches. It’s understandable why patients would hesitate to try it, Papakostas said. However, both Papakostas and Sheline agree that a large body of research substantiates ECT’s efficacy. When compared with medication and psychotherapy, ECT appears to work faster and has a higher chance of success, according to Papakostas. It also has the most efficacy data of all the more invasive interventions.

Transcranial magnetic stimulation (rTMS). According to Papakostas, this treatment is second to ECT in quality of data. Transcranial magnetic stimulation doesn’t require anesthesia or induce a seizure like ECT. Instead it creates a magnetic field that produces an electric current in a specific area of the brain. It’s typically used for mild to moderate depression. The Food and Drug Administration has approved one device called the NeuroStar TMS to treat depression, which may be used after one antidepressant has failed.

Vagus nerve stimulation (VNS). In 2005, the FDA approved vagus nerve stimulation for treating treatment-resistant depression. The device is surgically implanted onto the vagus nerve on the left side of the neck and delivers mild electrical impulses. Think of it as a cardiac pacemaker. According to the University of Maryland Medical Center, it sends 30-second impulses to the vagus nerve every five minutes.

For over a decade, VNS has been used to treat patients with epilepsy. Researchers began studying VNS for refractory depression when they noticed that some patients’ moods improved. Whether VNS is an effective treatment for refractory depression is unclear. It appears to help some people tremendously but not others. To date, “the data [on VNS] just isn’t on par with ECT or rTMS,” Papakostas said.

Not finding a treatment that lifts your depression can be utterly frustrating and make you feel hopeless. But while it may take more time and effort, together with your physician, you can find a treatment that works for you. Remaining optimistic is important. “Being able to maintain a positive, hopeful attitude is as critical as [getting the right treatment], Papakostas said.

While both psychotherapy and medications have been shown to be effective in the treatment of social anxiety disorder, a combination approach to treatment — utilizing both at the same time — may be the most timely and beneficial.

While some people may find relief from some social anxiety symptoms through trying simple self-help techniques, most people with a diagnosed social phobia condition will need professional treatment in order to overcome it.

Psychotherapy for Social Anxiety

Psychotherapy is a very effective method of treatment for social anxiety disorder. Specifically, cognitive behavioral treatments — which include techniques such as exposure therapy, cognitive restructuring without exposure, exposure therapy with cognitive restructuring, and social skills training — appear to be highly effective in treatment social anxiety, in a time-limited manner. Most cognitive-behavioral therapy (CBT) can be administered within 16 sessions (usually one session per week). At the end of treatment, a person’s anxiety symptoms are greatly reduced or even disappear in some cases.

In addition to CBT, other psychological treatments have also been found effective in the treatment of social anxiety. These include cognitive therapy (a form of CBT), social skills training alone, relaxation exercises, exposure therapy alone, behavioral therapy, and some other types of less-practiced forms of psychotherapy.

Exposure therapy is often a primary component of psychotherapy treatment of social anxiety disorder. Exposure therapy involves a person learning to understand the irrational basis for their fears (cognitive restructuring), teaching simple relaxation skills to practice while in the moment, and gradually being “exposed” to the situation which causes the anxiety. The exposure is done first in the safety of the psychotherapy office, imagining the scenario and walking through it with the therapist. As the patient’s confidence grows, he or she will begin to apply the skills they’ve learned in the therapy session to outside world events and environments.

Psychotherapy treatments have been shown to be highly effective in treating social anxiety disorder (Acarturk et al., 2009; Powers et al., 2008). Most people who try psychotherapy with a therapist who has experience in treating social anxiety disorder will find relief from their symptoms.

Medications for Social Anxiety

The primary class of drugs used to treat social anxiety are called selective serotonin reuptake inhibitors (SSRIs). This class of drugs was first developed to treat depression and so are often referred to as antidepressants. Since then, however, they have been found to be effective in the treatment of a wider range of disorders. Common SSRIs include Paxil (paroxetine), Zoloft (sertraline), Prozac (fluoxetine), and Luvox (fluvoxamine).

Another type of antidepressant called Effexor (venlafaxine) may also be prescribed to help with the symptoms of social phobia.

These kinds of medications generally take 6 to 8 weeks in order to start feeling the full therapeutic effects of them. While it may be frustrating to wait during that time and feel little relief, always take all medications as prescribed by your doctor. If you experience any distressing side effects, talk to your doctor immediately.

There is little specific reason to prescribe one antidepressant over another for the treatment of this disorder. Your doctor may choose your medication based upon their own experience in prescribing it, or based upon the typical side effects most people who take it experience. If you are not experiencing relief in 6 to 8 weeks from the first medication prescribed, talk to your doctor. He or she may decide to either up your dose or try a different medication altogether.

Other Medications

In addition to SSRIs, others kinds of medications are occasionally prescribed in the treatment of social anxiety disorder.

Anti-anxiety medications called benzodiazepines are rarely prescribed for social anxiety disorder, because they are extremely habit-forming and act as a sedative. However, because they act quickly in the short-term, they may be prescribed when a specific situation warrants their use — such as an unexpected public speaking engagement that can’t be avoided.

A class of drugs called beta blockers may also be used for relieving social anxiety. Beta blockers work by blocking the flow of epinephrine (more commonly known as adrenaline) that occurs when you’re anxious. This means they can help to control and block the physical symptoms that often accompany social anxiety — at least for a short while. They are primarily used for short-term situations, such as when you need to give a speech. However, like benzodiazepines, they are not generally recommended for the treatment of social anxiety and are rarely prescribed for it.

Surviving Depression traces Hamlett’s life from his early childhood until he finally received a prescription for a combination of medications that successfully keep his depression in remission.  Most of the book takes place during the Vietnam War era and shortly thereafter.  During this time, antidepressant medications were still experimental and many psychiatrists still believed that depression was solely a reaction to circumstance.  The context of the book, however, must be applied to the present day to gain any inspiration.  The hope, therefore, lies in the hands of science.  Compare the available remedies of the 1970s and 1980s to the medicines and therapies we have today, and one will find much hope that depression can be held at bay.

Throughout Surviving Depression, Hamlett emphasizes his fear of slipping into a major depressive episode and having what he calls a “meltdown.”  He writes his memories in such a way that just as the reader gets comfortable with who Hamlett is, his meltdown tears the sense of security from the reader — much like a meltdown does to its victim.  Hamlett’s first meltdown forces him to drop out of school.  Another makes him run away from life and even pushes him to the brink of suicide.  Hamlett captures his “escape to nowhere” with vivid detail:

The next morning, I shaved for the first time in several days.  I also put on the best clothes that I had brought with me.  I wanted to look like a reputable citizen.  Then, I went to a local gun shop.  I had finally convinced myself that taking my own life was the only way to end my suffering … I am not sure exactly how long I stood there staring at that weapon.  It could have been a minute or ten minutes.  I had no concept of time. Many scenes from my life crossed my mind … No, I could not kill myself … I turned and walked out of the store empty-handed.

Only after being hospitalized a second time does Hamlett break free from his depression.  His psychiatrist prescribes a combination of medications that allow Hamlett to function normally, and he remains on those antidepressants to this day.

Surviving Depression achieved its goal, but I do have reservations with the method Hamlett chose to use.  Memoir is definitely an appropriate form of writing for a topic such as this, however, focusing on the negative aspects of his life seemed a bit overwhelming.  Certain parts of the book triggered my own depression and sent me into a meltdown-like state.  I appreciate the heart behind the work, but I would have preferred that the author focus on the solution instead of the problem.  Hamlett covers every way to deal with depression that I know: ignoring it, taking medication, talking to a therapist, and a combination of medicine and therapy.  Obviously, ignoring depression will not help to relieve it.  For Hamlett, talking to a therapist and taking antidepressants in conjunction saved his life.  When his psychiatrist restricted his medications, Hamlett slipped into another meltdown.  For some, this is a real risk.  For others, only therapy helps relieve their depression.  Still others feel that antidepressants alone suffice in treating their condition.

Overall, Surviving Depression was a good book, a quick read, and inspiring enough to convince me to consider other methods of treating my own depression.  The book really does give hope for a better future, especially when one considers that science has come a long way since the events of the book.  Treatments are more effective, cheaper, and the stigma of mental illness is dissipating.  I highly recommend this book to anyone who needs that extra push to get help.  I do caution, however, that reading this book while depressed may worsen your symptoms.

Surviving Depression: My Agonizing Struggle with Sanity
By Robert L. Hamlett
Vantage Press: July 1, 2008
Paperback, 147 pages

After the first chapter, the author describes the basics of depression, such as how it’s diagnosed, where researchers think it may come from, and the usual treasure trove of information you’d expect to find in such a book. The third chapter runs through the common and not-so-common treatments of depression.

The fourth chapter gives the reader the “inside track” on everything from how to best deal with antidepressants and their negative side effects, to what really goes on in psychotherapy. It offers explanations about a variety of issues and myths many patients face in psychotherapy, such as Psychotherapy does not always make you feel better, Psychotherapy is not like talking to a friend and Psychotherapy will not work if you have unrealistic expectations. This chapter also covers the basics of drug discount cards and programs, and how to best navigate the U.S. healthcare system to ensure you get your treatment paid for. This chapter alone makes the book more than worthwhile for its no-nonsense advice and information about these important — but often overlooked — issues.

The next chapter, “Your Depression,” walks you through what to expect in the typical course of a person’s depressive episode. While no two people experience depression in exactly the same way, Dr. Serani uses this chapter to offer tips and practical advice about how to approach treatment and psychotherapy. While much of the advice comes her professional knowledge, it’s also solidly informed with her own direct experiences in dealing with her own depression. While some of the advice borders on the over-exposed (such as the advice to “avoid toxic people”), it’s always well-intentioned.

Chapter 6 walks the reader through the “5 R’s” of depression — response, remission, recovery, relapse and recurrence. Chapter 7 gives us a wealth of information about suicide — a topic often not covered very well in other self-help depression books. Why? Probably because it scares some people to talk about it, but suicidal thoughts are fairly common among people with depression (not to be confused with actual suicidal actions).

The next chapter describing the societal stigma that still exists in many parts of the country regarding depression is important. But I prefer the term “prejudice” nowadays, because it makes the issue more personal. However, this is a very good chapter because it prepares a person to better understand and deal with the various responses they may receive from family members, friends and coworkers whom with they share their diagnosis with. The responses can be all over the board, and this chapter is a great guide to not only better understand the reasons why, but provides some useful ideas on what a person can do about it too.

The last chapter is entitled “Living with Depression” and offers a nice bookend to the first chapter in the book, with the author describing her own personal battles in living with depression. She also relates her own personal discovery in gaining more insight into depression through reading other people’s personal accounts:

One of the most moving accounts of depression for me came from American author William Styron, whose descent into a “dank joylessness” is vividly worded in his 1990 memoir Darkness Visible. Truth be told, the movie adaption of Styron’s Sophie’s Choice left me so hollowed out and emotionally depleted, that I resisted reading his memoir for fear that it would weaken me further. What I found in his pages, however, was quite different. The textures of his experiences offered me consolation. Again, I wasn’t alone.

The book finishes on page 114, but carries on for another 85 pages of appendices. The first 14 pages is of a list of celebrities, authors and other famous people who’ve had a mood disorder. I suppose the author finds such a list both comforting and eye opening, but such lists don’t do much for me. Since most people grapple with depression at some point in their lives — to one degree or another, whether it’s a full-blown clinical depression or not — I would argue most anyone could go on that list.

Another 15 pages list depression resources and organizations that may benefit the reader. The remainder of the book is filled with notes — mostly research references from the chapters — as well as a helpful glossary.

Insight and perspective comes in droves in this book, but for me, the best chapters were the first one and the last one, in which Dr. Serani recounts her personal failures and successes in battling depression. In short, personal stories move me more than facts and data; but I’m a biased reader, since my depression knowledge is likely greater than the average layperson this book is targeted toward. My only wish was that there was more of this personal narrative throughout the entire book, because all too often the book felt like it was more of a textbook rather than a personal account intertwined with the kind of information one might expect from a depression self-help book.

Nonetheless, this is a thoughtful book about depression and would be recommended for anyone who has just been recently diagnosed with depression, or knows someone who has and wants to better understand this illness. It left me with a very real sense of hope. Because it is up-to-date and well-written, it will give you (or your loved one) everything you’ll need to know, understand and find a path toward recovery from depression.

Hardcover: 208 pages
Publisher: Rowman & Littlefield Publishers (May 31, 2011)
Language: English
ISBN-10: 1442210567
ISBN-13: 978-1442210561
Product Dimensions: 8.4 x 5.7 x 1 inches

Side effects are a normal part of taking virtually any prescription medication. Although the drugs are intended to treat the specific condition — in this case, depression — they also cause unwanted physical symptoms that are usually an annoyance.

You shouldn’t feel abnormal, awkward or self-conscious if you have any of these side effects. You should, however, talk to your doctor about them — especially if they make you feel worse or the side effects themselves are unbearable:

• Decreased sex drive or no sex drive at all
• Dry mouth — your mouth feels very dry and cannot produce the same amount of saliva as usual
• Mild to moderate nausea
• Insomnia — inability to get to sleep, or difficulty staying asleep
• Increased anxiousness or restlessness
• Daytime sleepiness or drowsiness
• Weight gain
• Constipation or diarrhea
• Headaches
• Increased sweating
• Dizziness

Whatever you do, do not try and manage your medication — the dose, frequency or amount you take — on your own. You need to talk to your doctor before making any changes to your medication. Do not suddenly quit taking your medication, because it could cause intense withdrawal symptoms or even a return of your depression.

Keep in mind that some side effects can also be managed in conjunction with your doctor. There are remedies for dry mouth, for instance, and additional medications for other things (such as sexual dysfunction, a common side effect of many antidepressant medications).

Helping to Manage the Common Side Effects of Antidepressants

1. Decreased sex drive or no sex drive at all

Ask your doctor whether another medication is available that doesn’t have such strong sexual side effects, or if a lower dose may help with the problem. Talk to your doctor about other options, such as taking a medication for erectile dysfunction.

2. Dry mouth

Eat more water-laden snacks, like celery sticks, and consider chewing sugarless gum, or suck often on sugarless candy. The sugarless part is important, because otherwise the sugar of constant gum chewing or candy sucking can harm your teeth and cause future cavities. You can also consider increasing your daily water intake by drinking at least 8 to 10 glasses of water a day and cutting back on some of the caffeine-laden drinks, such as coffee, tea and alcohol. As a last resort, you can also try a specially formulated rinse for your mouth that may help, such as Biotene or Orazyme.

For the bad breath that often accompanies dry mouth, consider munching on these herbs: parsley, aniseed, fennel, rosemary and cayenne pepper (individually, not all together!). See this article for more details.

The different classes of antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), norepinephrine (noradrenaline) reuptake inhibitors, atypical antidepressants, tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs). Different classes of antidepressants take different amounts of time before you will start to feel their anti-depressant effects.

The most commonly prescribed modern antidepressants include SSRIs — such as Prozac, Lexapro, Celexa and Paxil — and SNRIs — such as Pristiq, Cumbalta and Effexor. Although the claim is made that some people may be able to start to feel less depressed within 2 weeks of taking one of these kinds of antidepressants, most people won’t start experiencing the full positive effects of the medication until 6 to 8 weeks after beginning it.

In addition to feeling less depressed from antidepressant medications, people will often experience the side effects of antidepressants first. While these side effects vary from person to person and from medication to medication, the most commonly observed side effects in antidepressants are:

• Decreased sex drive or no sex drive at all
• Dry mouth — your mouth feels very dry and cannot produce the same amount of saliva as usual
• Mild to moderate nausea
• Insomnia — inability to get to sleep, or difficulty staying asleep
• Increased anxiousness or restlessness
• Sleepiness
• Weight gain
• Constipation or diarrhea
• Headaches
• Increased sweating
• Tremors or dizziness

You shouldn’t be overtly concerned if you experience any of these side effects while taking an antidepressant, but you should still tell your psychiatrist or doctor about them. Some side effects may go away on their own once your body adjusts to the medication. Others may not, and may be addressed through an adjustment of your medication dose or when you take it.

Antidepressants don’t work for everyone. Sometimes the first antidepressant a doctor prescribes may not work for you (as they don’t in 50 percent of people who try an antidepressant). Don’t get frustrated, just accept that either another medication may need to be tried, or the doctor may suggest a higher dose may be required. Talk to your doctor about adjusting your medication if you’re not feeling any positive effects of the medication after 6 to 8 weeks.

Older classes of antidepressants — MAOIs and tricyclic antidepressants — take about the same amount of time to work — anywhere from 2 to 6 weeks for most people, while most people will start to feel a benefit within 3 to 4 weeks. It is not well understood why antidepressant medications appear to take longer to work than other types of psychiatric medications.

For decades, the dominant hypothesis of depression has been that low levels of monoamines in the brain cause this debilitating disorder.

In the ‘80s, the selective serotonin reuptake inhibitor (SSRI) fluoxetine (brand name: Prozac) heralded a new era of safer drugs which also target the monoamine system. Since then, various SSRIs and serotonin-norepinephrine reuptake inhibitors (or SNRIs) have been developed as new antidepressants. While these drugs aren’t more effective than older antidepressants, they are less toxic.

But SSRIs and SNRIs don’t work for everyone, so MAOIs and TCAs still are prescribed.

Two out of three patients with depression do not fully recover on an antidepressant medication according to findings from STAR*D, the largest clinical trial study of treatments for major depressive disorder, funded by the National Institute of Mental Health. (One-third of patients do have a remission of their depression symptoms.)

These results “are important because previously it was unclear just how effective (or ineffective) antidepressant medications are in patients seeking treatment in real-world settings,” said James Murrough, M.D., board-certified psychiatrist and a research fellow at the Mount Sinai School of Medicine Mood and Anxiety Disorders Program.

As Murrough explained, depression treatment can be thought of in thirds: “for one third of patients, symptoms remit; another third don’t have as good of an outcome, experiencing residual symptoms and waxing and waning course or chronic course and are at risk for relapse whether they’re on or off medication; and then a third don’t get much benefit at all.”

He added that around “10 to 20 percent have persistent clinically significant symptoms that aren’t decreased by current treatment — these are the patients that we are the most worried about.”

So there’s a real need to find treatments that work for these patients. Since the 1950s and 1980s breakthroughs, researchers haven’t discovered drugs that target chemical systems in the brain other than the monoamine system.

“We haven’t been able to find any new systems, because we don’t understand the underlying biology of depression,” Murrough said.

But researchers are studying other mechanisms of depression and various drugs have recently been approved to treat depression. Below, you’ll learn about these drugs along with several chemical systems research is exploring.

Recently Approved Drugs for Depression

Recently approved drugs for depression are generally “me-too” drugs. A “me-too drug is a drug whose mechanism of action (what it does at the molecular level in the brain) is not meaningfully different than its predecessor,” Dr. Murrough said.

Prime examples of me-too drugs are desvenlafaxine (Pristiq), an SNRI, and escitalopram (Lexapro), an SSRI, he said. Pristiq is simply Effexor’s main metabolite. Lexapro is essentially a close relative derivative of citalopram (Celexa). Interestingly, sales still skyrocketed when Lexapro came out.

As Murrough said, there is value in some me-too drugs. Generally, all drugs within the classes SSRIs and SNRIs are me-too drugs. But the side effect profiles for each drug have slight differences, which can help patients.

For instance, Prozac tends to be more activating, so a doctor may prescribe it for patients with low energy, Murrough said. In contrast, paroxetine (Paxil) makes people more tired, so it’s prescribed to patients who have trouble sleeping, he said.

The drug Oleptro was approved this year for depression. It doesn’t target new mechanisms, and it isn’t even a me-too drug, Murrough said. It’s a reformulation of trazodone, an atypical antidepressant that’s been used as a sleeping aid by psychiatrists and other doctors. Because it’s so sedating, its earlier form would just put patients to sleep. “It is unclear if the new formulation will offer any benefit for patients over the original,” Murrough said.

These recently approved medicines “characterize the state of drugs in psychiatry,” Murrough said, and speak to “what’s wrong with antidepressant drug development today.” Novel treatments just aren’t on the market.

Augmentation of Depression Drugs

Recently, the biggest development in depression treatment has been the use of augmenting agents, said David Marks, M.D., assistant professor at the Department of Psychiatry & Behavioral Sciences at the Duke University Medical Center.

Specifically, some research has found that adding atypical antipsychotic drugs, like aripiprazole (Abilify) and quetiapine (Seroquel), to an antidepressant can boost its effectiveness.

Atypical antipsychotics are used to treat schizophrenia and bipolar disorder. “Abilify has three strong studies that show how well it works in patients that have partially responded to antidepressants,” Marks said. According to Murrough, augmentation has become a common strategy in depression treatment.

The Glutamate System and Depression

Researchers have looked at the role of the glutamate system in depression. Glutamate is abundant in the brain and is one of the most common neurotransmitters. It’s involved in memory, learning and cognition.

Some research has implicated the dysfunction of the glutamate system in medical conditions, such as Huntington’s chorea and epilepsy, and psychological disorders, such as schizophrenia and anxiety disorders.

Recent research suggests that drugs targeting a specific type of glutamate receptor in the brain — called the NMDA receptor — may have antidepressant effects.

Studies have explored ketamine, an NMDA antagonist, in treating treatment-resistant depression and acute suicidal ideation. Ketamine has a long history in analgesia and anesthesiology.

Currently, when a person is at imminent risk for attempting suicide or has attempted suicide, they’re admitted to a psychiatric hospital and closely monitored. But, as Murrough explained, medically, there’s nothing doctors can do to help with suicidal ideation or intense depressed mood. Antidepressants typically four to six weeks to work.

Ketamine appears to have fast antidepressant effects — within hours or a day. Thus, it may help protect patients from suicidal thinking or acute dysphoria when they’re in the hospital. Unfortunately, its effects only last seven to 10 days.

This research is “highly experimental, and probably less than 100 patients in the country have participated in controlled depression studies of ketamine,” Murrough said. The patients in these studies typically have treatment-resistant depression: They haven’t responded to several antidepressants and have moderate to severe symptoms of depression.

They’re admitted to the hospital and receive ketamine intravenously from an anesthesiologist, while their vital signs are closely monitored.

Ketamine is a drug of abuse, known by such street names as “Special K.” It induces trance-like or hallucination states. It also produces mild to moderate cognitive side effects, like other anesthetics. People report feeling “out of it,” intoxicated and disconnected in general.

These side effects actually “introduce a potential bias to the study design” because participants know they’re getting the treatment (when saline is given in the placebo condition), Murrough said.

To eliminate this bias, Murrough and his team are conducting the first-ever study to compare ketamine to a different anesthetic — the benzodiazepine midazolam (Versed) — which has similar transient effects as ketamine, he said. The study is currently recruiting participants.

Murrough cautioned that ketamine isn’t meant to be a treatment administrated at your doctor’s office. In a recent article in the journal Nature Medicine, he said ketamine treatment may be “akin to electroconvulsive shock treatment.”

Studying ketamine may reveal mechanisms underlying depression and help to find drugs that can be prescribed as antidepressants to a wider patient population.

Pharmaceutical companies have started exploring other NMDA receptor antagonists for treatment-resistant depression. For instance, in July 2010, the pharmaceutical company Evotec Neurosciences began testing a compound in a Phase II study, which evaluates the safety and efficacy of a drug.

The reality is that it is possible to safely discontinue any medication, including psychiatric ones.

Stop your medication for the right reasons.

“Timing is everything,” according to Dr. Michael D. Banov, medical director of Northwest Behavioral Medicine and Research Center in Atlanta, and author of the book Taking Antidepressants: Your Comprehensive Guide to Starting, Staying On, and Safely Quitting. Just because someone wants to stop taking their medicine doesn’t mean they’re actually ready, he said.

There are many reasons individuals decide to stop taking medicine. For instance, they might feel better and think they don’t need treatment anymore. Their family might be pressuring them to stop, they read something about a drug that scares them, or they’re afraid that the drug will affect their personality, Banov said. Sometimes people want to stop after making major changes in their lives, such as getting a divorce, moving or changing jobs. But, according to Dr. Banov, this is actually “the worst time” to stop.

Also, some mental health conditions require taking medicine indefinitely. Ultimately, how long a person takes a psychotropic drug depends on his or her individual illness, its responses to treatment and their personal situation, according to Dr. Ross J. Baldessarini, professor of psychiatry and neuroscience at Harvard Medical School and director of the psychopharmacology program at the McLean Division of Massachusetts General Hospital. For instance, some individuals struggling with depression may take an antidepressant for nine months to a year and get better; others may need two to five years; and still others, may be “so genetically loaded for depression, that they may need to stay on them indefinitely,” Dr. Banov said.

Don’t stop your medication abruptly.

“Stopping abruptly is especially dangerous,” Baldessarini said.

Depending on the medicine, stopping abruptly or “cold turkey” can cause a variety of distressing reactions, ranging from mild to moderate early discontinuation symptoms with antidepressants, rapid return of the illness being treated, or even potentially life-threatening seizures with a high dose of benzodiazepines.

Consult your doctor before stopping any medicine, and never attempt to do it on your own.

Consider if you’ve received a thorough assessment.

A comprehensive assessment is required prior to stopping medicine. Among other indicators, your doctor needs to consider “your current clinical condition and life circumstances, your past clinical history, reasons to consider stopping versus continuing treatment, side effects and the presence of stressors and supports, as well as the dose and the length of time you’ve been taking a medicine,” Baldessarini said. You and your doctor should talk about these indicators along with how he or she plans to discontinue the drug.

There are no firm, established rules for discontinuing psychiatric medicines. However, there is one major rule of thumb: Reduce the dosage gradually whenever possible. “We still do not know for sure how long is long enough to reduce doses safely,” Baldessarini said. Still, the “slower the dose-reduction, the greater the chances of preventing return of symptoms of the illness for which treatment was started. Very slow discontinuation is especially important when a person has been taking high doses of a medicine over a long time,” he said.

Discontinuing multiple drugs is like peeling an onion, Baldessarini said. He usually leaves the most essential medicine for last. He then reduces doses of one or more optional or supplemental drugs slowly and gradually. Stopping all medicines at once is not safe.

Dealing with small final doses is tricky when dropping from a low dose to nothing. Sometimes doctors decrease the dose to one pill a day or one every two days or split the pill in half, he said. Pill-splitting can be very helpful. You can find pill splitters at your pharmacy.

Don’t expect stopping medication to be a quick process.

Gradually and safely discontinuing a drug doesn’t happen in a few days. Some drugs, including antidepressants, don’t show benefits for several weeks when they’re started; it seems best to avoid discontinuing faster than over several weeks, Banov said.

If you’ve been taking a medicine for years, Banov recommended reducing the dose, stepwise, over at least six weeks. While this may be a conservative practice, he said that “sometimes, you might not detect a change for a few weeks, but later, problems may arise.” Discontinuation symptoms usually occur within days of stopping a medicine, but relapse of the illness being treated can be delayed for weeks after initially feeling well.

In bipolar disorder, Baldessarini and his research team found years ago that the rate of discontinuing ongoing treatment determines the risk and timing of relapse, he said. Initially, their research found that risk for relapse after discontinuing lithium was reduced by one half or more when slow dose-reduction over several weeks was compared to abrupt discontinuation (Baldessarini et al., 2006). Gradual discontinuation of antipsychotic drugs also resulted in lower risk of relapse in schizophrenia (Viguera et al., 1997). In a recent study, he and his colleagues found that stopping an antidepressant abruptly or only over several days resulted in a much greater risk for depression or panic than gradual discontinuation over two weeks or more (Baldessarini et al., 2010).

If you’re switching from one medicine to another, you can be more aggressive than when discontinuing altogether, Banov said. Usually you switch drugs because of ineffectiveness or side effects, and commonly a new drug is introduced as the previous one is gradually removed. This way, there’s little concern about either withdrawal symptoms or relapse, assuming that both drugs have similar effects or belong to the same class, he said. If you’re switching classes, it’s usual to “cross-taper” the medicines: You take both drugs for a while, and then, the doctor reduces the dose of one and ups the dose of the other.

Your doctor may prescribe another medication.

If you’re taking a relatively short-acting antidepressant, such as paroxetine (Paxil) or venlafaxine (Effexor), and you experience bothersome symptoms, “your doctor may prescribe a long-acting antidepressant such as Prozac for a time, and then gradually discontinue the long-acting drug to limit risk of discomfort of withdrawing,” Baldessarini said. “The principal byproduct of the metabolism of fluoxetine has an extraordinarily long half-life or duration of action,” he said, and can take weeks to leave your system.

This method is not well established for discontinuing other classes of psychotropic drugs, including antipsychotics and mood stabilizers, so the best option usually is to “discontinue such drugs gradually, with close clinical monitoring by your doctor,” Dr. Baldessarini said.

This common phenomenon is known as SSRI discontinuation syndrome. (It may also be known as SSRI withdrawal syndrome.)

Discontinuation symptoms typically arise within days after stopping the medication, particularly if it was stopped abruptly. Stopping a high dose of a relatively short-acting drug also can bring on symptoms. In addition to the previously-mentioned symptoms, “anxiety and depressed or irritable mood are common features that may make it hard to differentiate SSRI discontinuation syndrome from early return of symptoms of depression,” Baldessarini said.

About 20 percent of people experience discontinuation symptoms, according to Dr. Michael D. Banov, medical director of Northwest Behavioral Medicine and Research Center in Atlanta, and author of Taking Antidepressants: Your Comprehensive Guide To Starting, Staying On and Safely Quitting. About 15 percent experience mild to moderately bothersome symptoms while fewer than five percent experience more severe symptoms, he said.

However, the risk for discontinuation syndrome is generally greater with potent, short-acting SSRIs —particularly paroxetine (Paxil and others) and venlafaxine (Effexor and others), Baldessarini said.

Discontinuation symptoms can happen with any antidepressant, but seem to be more common with the following classes of drugs:

• SSRIs. These include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac and others), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft)
• Inhibitors of inactivation of both norepinephrine and serotonin (SNRIs). These include chlompramine (Anafranil), venlafaxine (Effexor) and desvenlafaxine (Pristiq). Such drugs are prescribed more often for depression or severe anxiety disorders, so the withdrawal phenomenon is more common.

Whether you experience discontinuation syndrome after stopping an SSRI depends on several factors. These include the amount of time you’ve taken the medication, your dosage level, and the pill’s half-life (how quickly it is eliminated from your body). For instance, Prozac, which has about a five-week half-life, appears to cause discontinuation much less often than drugs with shorter half-lives, such as Paxil.

If discontinuation symptoms last more than a week or two, call your doctor. You may be in the early stages of a relapse.

Preventing Discontinuation Syndrome

There are ways that you can prevent or reduce discontinuation symptoms.

• Don’t stop a psychotropic medicine abruptly. People may stop their medicine abruptly for various reasons, including feeling better or experiencing unpleasant side effects, as well as simply forgetting to refill a prescription. But stopping some medicines abruptly or “cold turkey” can cause discontinuation or withdrawal symptoms.

• Talk to your doctor. If you’d like to stop your antidepressant, first talk it over with your prescribing clinician. Voice any concerns you have, and do not attempt to stop on your own. “It’s a collaborative venture between patient and doctor,” Baldessarini said. “Don’t be afraid to ask your doctor tough questions.”
• Consider if you’ve received a thorough clinical assessment. Before stopping an antidepressant — or any medicine — your doctor should assess whether this is an appropriate time to do so. He or she should consider various factors, “including your past clinical history and current stress level,” Baldessarini said.
• Discontinue slowly. One of the best ways to minimize discontinuation syndrome is by reducing doses of medicines, including SSRIs, slowly. Together, you and your doctor should decide how to reduce, then stop, the dose. Based on his and others’ clinical research, Baldessarini said that reducing the dose of an SSRI to zero gradually over two weeks or longer is prudent. Even slower discontinuation may be required if you’ve taken high doses for a long time.
• Practice healthy habits. If you’re under a lot of stress, not sleeping well, not eating nourishing foods, or not sticking to a consistent schedule, stopping medicine successfully may be unrealistic. It can increase anxiety and depression, which can make stopping harder.

Is It Discontinuation Or Depression?

Discontinuation reactions are not dangerous. According to Banov, “the bigger concern when stopping your antidepressant is making sure your depression does not return.” Typically, “this risk follows SSRI-discontinuation reactions by considerable time (weeks to a few months), but when depression re-emerges quickly, it can be tough to tell whether you’re experiencing discontinuation symptoms or a recurrence of depression,” Baldessarini said.

If you’re experiencing these symptoms soon after stopping an antidepressant, then the reaction likely is discontinuation syndrome. However, as Banov noted, symptoms such as mood swings, anxiety and depression can make it tricky to distinguish between discontinuation reactions and depression. He suggests that patients and their clinicians consider the symptoms that led to starting the treatment. “If anxiety was initially part of your symptoms, that’s a clue that new symptoms of anxiety during discontinuation of treatment may represent depression, especially if they arise after several weeks after stopping the medicine,” he said.

Risk of discontinuation or withdrawal reactions appears to be greater after stopping prolonged treatment, especially with high doses of an antidepressant, according to Baldessarini. “Although the duration of treatment is less clearly a predictor of relapse of depression or anxiety, symptoms arising many weeks after discontinuing most likely represent relapse.”

In addition to slowly reducing the dose of an antidepressant, Baldessarini emphasized the importance of “thoughtful monitoring by yourself and your doctor, and communicating” with your doctor to limit risks of relapse after stopping an antidepressant.

Credit: JOHN GREIM / SCIENCE PHOTO LIBRARY