Perhaps you or someone you love has felt persistent low moods, feelings of worthlessness, and decreased interest in life, as well as experienced changes in sleep, appetite, concentration, and energy levels. When these low energy states persist for more than two weeks, these symptoms could be a sign of depression. Thankfully, depression can be alleviated with medication. Perhaps you’re wondering how medication can be used to improve your moods? Antidepressants are the class of drugs used to treat depression. They work by balancing chemicals called neurotransmitters in the brain which affect mood and emotions. In this post, we will explore more how antidepressant medications work to relieve symptoms of depression.
Yes, medication can help with depression. Several theories claim the main cause of depression is an imbalance in chemicals (called neurotransmitters) found in brain circuits. The main neurotransmitters involved include serotonin, epinephrine, and norepinephrine. There are several classes of antidepressants with different mechanisms of action. The key ingredient which is found across all classes is the modulation of serotonin. Dopamine and norepinephrine effects are used in some classes. These all work to regulate mood and reduce symptoms of depression
More about antidepressants (primary form of medication which helps with depression)
Depressive disorders are a group of mental disorders characterized by low mood. The most common disorder is Major Depressive Disorder (MDD) which has subtypes such as psychotic depression, peripartum and postpartum depression, and seasonal affective disorders. Treatment of depression begins after a doctor, clinical psychologist, or psychiatrist makes a diagnosis of a depressive disorder based on the Diagnostic and Statistical Manual of mental disorders (DSM-5).
DSM-5 criteria for major depressive disorders include:
At least five out of nine symptoms must be present in the same two week period and should represent a change from the person’s previous functioning. At least one of the five symptoms needs to be depressed mood or loss of interest or pleasure (anhedonia). The nine symptoms include:
- Depressed mood most of the day, nearly every day, as indicated by how the person feels (sad, empty, or hopeless). Or indicated by external observation by others (for example, they appear tearful). Irritable mood can also be seen in children and adolescents.
- Sleep changes, lack of sleep, or excessive sleep nearly every day
- Reduced interest or pleasure in all, or almost all, activities (anhedonia)
- Feelings of guilt and/or worthlessness in excess
- Decreased energy or fatigue
- Decreased concentration or indecisiveness
- Decreased or increased appetite with unintentional significant weight loss or gain
- Recurrent thoughts of death and recurrent suicidal ideation or attempts
Criterion B: The symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning.
Criterion C: The episode is not attributable to the physiological effects of a substance, drug, or another medical condition.
Following diagnosis with the above criteria, the medical professional uses the biopsychosocial model used in the treatment of mental disorders to manage the depression. Biological methods include the use of medications. These are used alongside psychological methods like therapy and social interventions at the family, home, and work levels to ensure a healthy environment.
Therapy works tremendously in helping patients with depression; however, it may not always be enough. Michael Burstein, a New York-based clinical psychologist states, “Many people benefit from the combination of the two, and antidepressants can strengthen the efficacy of therapy. Sometimes when an antidepressant turns the volume down on someone’s symptoms, they can go deeper in therapy because they’re not so preoccupied with the symptomatology.”
The following are the antidepressants used in the treatment of depression. The choice of drug depends on your symptom profile, comorbidities, tolerability and response to medication, personal preference and cost. They are divided into three main classes based on their pharmacological action:
- Monoamine reuptake inhibitors:
These are the newer antidepressants which are more commonly prescribed due to their better side effect profile. They work by blocking the reuptake of norepinephrine and/or serotonin. Reuptake is the reabsorption of neurotransmitters into nerve cells after they have been released to pass chemical signals between nerve cells. Therefore, a reuptake inhibitor will temporarily prevent the neurotransmitter from being reabsorbed and increase its stay at the nerve junction (synapse). This helps by keeping levels of the neurotransmitters (in this case, monoamines) high and subsequently improves communication between nerve cells, strengthening the brain circuits and regulating your mood.
- Tricyclic antidepressants (TCAs)
- Selective serotonin reuptake inhibitors (SSRIs)
- Selective noradrenaline (norepinephrine) and serotonin reuptake inhibitors (SNRIs)
- Selective noradrenaline (norepinephrine) reuptake inhibitors (NARIs)
- Monoamine oxidase inhibitors:
Monoamine oxidase is the enzyme that breaks down the monoamines (serotonin, dopamine, and norepinephrine). The name monoamine is derived scientifically from the chemical structure of said substances. These drugs deactivate the enzyme monoamine oxidase reversibly or irreversibly, leading to a prolonged ‘lifespan’ of the neurotransmitter at the nerve junction (synapse). This regulates the mood as described earlier.
- Serotonin receptor antagonists:
These drugs have complex effects on monoamine mechanisms, but also share the ability to block serotonin receptors and increase serotonin levels at the nerve junction
Can medication help with my depression by acting on suicidal ideation?
Ironically, some research suggests that selective serotonin and serotonin-norepinephrine reuptake inhibitors (SSRIs and SNRIs respectively) may increase the risk of events that can lead to suicide such as violent behavior, mania, or aggression, especially in pediatric and young adult age groups.
However, this should not limit the use of antidepressants if one is feeling suicidal. If adequate treatment of depression is the primary goal, it will also work to reduce feelings of worthlessness that also fuel suicidal ideation.
It is therefore important you and the doctor work together to continuously monitor for progression of suicidal thoughts and behaviors while on antidepressants, especially in the pediatric and adolescent age groups.
How long does it take for the medication to start working on depression?
The action of these drugs can be detected within hours of the start of treatment, however full antidepressant effect may be delayed for several weeks. The delay is a result of the time needed for the drug to reach a steady state in your blood, which may be reached only after five to seven days. Additional studies also suggest the delay is a consequence of slowly evolving neuroadaptive changes in the brain, which are triggered by a sudden increase in monoamine neurotransmitter function.
In the treatment of depression and other mood disorders, you may experience benefits in the first six weeks of treatment, but full benefits may not be realized until 10 to 12 weeks have elapsed. It is within this time that your doctor can adjust dosages to find what dose works best for you, to keep the blood drug levels at an optimum.
Doctors closely monitor the results of drugs over a two-week follow-up period to assess how the drug is working and whether there is a need to switch drugs, as each person reacts differently to the same drug.
Those who may not respond initially to an antidepressant would then need to switch to another class. Switching strategies depends on patient preference, antidepressant profile, patient response, and side effects. The health care provider can switch antidepressants in the following ways:
- Direct switch: Stopping the first antidepressant drug and initiating another drug immediately after
- Tapering down then switch immediately: Gradually reduce the dose of the first antidepressant, then start a new antidepressant immediately after stopping the first drug
- Taper and switch after a washout: Washout is the time allotted for a drug to be eliminated from your body. Therefore, you would gradually taper down the dose of the first antidepressant, then start the new antidepressant drug after a washout period, which is usually 7-14 days.
- Cross-tapering: The first antidepressant is tapered down over one to two weeks. Simultaneously, the new drug dose is built up over time.
Can medication (antidepressants) for depression have side effects?
Yes, it can have side effects.
Some common side effects of antidepressants include:
- Sexual dysfunction and reduced libido
- Gastrointestinal disturbances, nausea, bloating, flatulence, diarrhea
- Weight gain during longer-term treatment (especially with TCAs)
- Falls in the elderly
- Hyponatremia (low sodium blood levels)
- Initial worsening of sleep and anxiety symptoms, insomnia, daytime drowsiness, agitation, tremors, restlessness, irritability, headache, sweating
- Tipping over to mania in a person with a bipolar mood disorder
Most of these side effects will resolve within one to two weeks of treatment. However, it is important to continuously monitor this progression of side effects with follow-up visits to the doctor. If the side effects cause significant distress, a consideration of switching drug classes can be made.
As James Morrow, Assistant Professor of Psychiatry and Neuroscience and director of the Mood and Anxiety Disorders program at the Icahn School of Medicine at Mt. Sinai says, “Anytime you’re taking a medication, there’s going to be potential benefits and some side effects or risks. It is a matter of weighing those and deciding if that’s a good fit.”
If you stop taking your medication suddenly, then you may experience antidepressant withdrawal (discontinuation) syndrome. Different antidepressants will have different discontinuation side effects. They include; anxiety, agitation, crying spells, and irritability. These may sometimes be misdiagnosed as depressive relapse. Antidepressants should therefore be tapered down on a schedule and not abruptly stopped.
How long will I need to take antidepressants/medication to help my depression?
For the first episode of depression, the recommended treatment timeline is one year. For a second episode, two years are recommended. For subsequent episodes, lifetime treatment is recommended as the risk of relapse is close to 100%.
You may have fears about starting antidepressants, especially because of the length of time you may need to be on the drugs. Other fears people express include whether the antidepressants make you forget your problems instead of dealing with them. Will they change my personality and make me into a zombie? Will taking them make me look weak?
Having all these considerations in mind is important. So is working through them. Make an informed decision about whether taking medications is pivotal in your healing journey with depression. Most importantly, don’t let fear be the motivating factor behind your decision to take antidepressants or not. Seek counsel from medical professionals willing to help you. Depression isn’t a character flaw or weakness. It is a genuine health problem and a mental illness and there is a lot of help you can get now to deal with it!