Depression Treatments - Antidepressant Medication

Written by HealthyPlace.com Staff Writer

WBOK: If you've been using the same antidepressant medication for 3 years or more and have had reoccurring depression, should your medication be changed?

Dr. Cady: Quick answer: YES, or raised, or something combined with it. Medications should be pushed to the limit before they are declared a failure. Here are some doses of medications that I would go up to (absent side-effects) before I would consider the medication trial a failure:

Prozac, 80 mg per day. Zoloft - 200 mg per day. Paxil - 50 - 60 mg per day. Wellbutrin - 450 mg per day. Effexor - 375 mg per day. Celexa - 60 - 80 mg per day. Serzone - 600 mg per day. If you haven't gone all the way to the max on a medication, you can't say that the possibilities have been exhausted.

Please let me refer this audience to the "Goldilocks and the Three Bears" essay on my mastermind1.com website. There's a solid explanation of dosing issues there.

poet: Dr. Cady, my medications are no longer working. I have suicidal thoughts and constant feelings of worthlessness. Should I consider inpatient treatment for depression?

Dr. Cady: Dear poet: you actually have two choices: not only the inpatient versus outpatient option. But, logically, whether or not you can reasonably expect your medications to work at the dosages they have been prescribing. For example, if you are taking 10 mg of Prozac, or 25 mg of Zoloft per day, or some low dose, aren't any better, and are suffering, and your physician is not raising the dose, then the choice really isn't so much inpatient or outpatient, but are you going to keep plowing the same soil with the same rusty instrument - if you get my drift. Inpatient treatment for depression won't make bad medication dosages work any better. If, on the other hand your depression is severe, you have significant psychological or trauma issues to deal with, and you need the nurturing sanctuary of a protective and caring environment where you can mentally and psychologically "catch your breath" and give your medications a chance to work, then the option of inpatient treatment is certainly a reasonable one and should be considered. I hope that this answered your question logically and completely. Good luck to you.

David: Dr. Cady, if a person can't find reasonable improvement in their level of depression after 6 months, would you say it's time to find another doctor?

Dr. Cady: It depends on what's been happening in the last six months. If one dose of medication has been selected and the physician has been twiddling his/her thumbs for the last six months after it's been prescribed, I would say, yes, it's time to change. If, on the other hand, the condition is extreme and severe, creative and intellectually aggressive and coherent pharmacological strategies are being considered and implemented, the physician has expressed to you a logical PLAN and you believe in him/her, then I would stick with the program.

jakey9999: I am taking Lithium and Zyprexa. Although I get a little relief while taking them, I have no energy. I have tried every over-the-counter remedy, can you suggest anything to increase my energy levels?

Dr. Cady: Good question, jakey9999. Lithium and Zyprexa are not, per se, antidepressants. Both have a known problem with causing sedation and "loss of energy" - with the Zyprexa being a worse offender than the Lithium. Lithium has been historically used to augment antidepressant therapy but, with the advent of the new "gangbuster" antidepressant drugs (Effexor, Wellbutrin, Remeron, Serzone and the like... which can be combined with other drugs), its use as an augmenter has fallen into disuse, except in the most extreme cases. If you have bipolar disorder (and you might, given that you are on lithium), another antidepressant should be considered. Wellbutrin seems to have gotten the nod for this niche in the treatment of depression in bipolar disorder.

maddy: How about the role of ECT or electro-shock therapy? And how safe is that?

Dr. Cady: Maddy, there's a good discussion of electroconvulsive therapy on this web site, I noticed tonight. It's pretty strongly anti-ECT, but I believe both sides should be aired.

My own feeling about ECT (have done it hundreds of times with patients, many more at Mayo in my residency than in my current practice) is that it absolutely works for real, legitimate, heavy duty, biological depression. It also doesn't scramble your brains (although you might have some retroactive memory loss during your hospital stay) - but you won't forget who you are, what you are about, etc. It's pretty safe. It's currently done under total anesthesia and full body muscle paralysis, so the One Flew Over the Cuckoo's Nest scenario simply doesn't apply anymore. It works, it's effective, and it's safe. That being said, it should only be used if a strong, coherent, logical trial of medications has failed or the patient is right there on the brink of suicide and heroic measures are absolutely called for.

Turbo: If one stops responding to an SSRI, does that mean other SSRI's should not be tried?

Dr. Cady: Not necessarily, Turbo. The dosage might need to be raised. Secondarily, an augmenting agent (such as Wellbutrin - which boosts both dopamine and norepinephrine) could be added to "harmonize" with the serotonin boosting properties of the SSRI.

WhoAmI: Is it possible that antidepressant medications can make depressed people worse since medications are not tested on humans?

Dr. Cady: It is always possible that medicines can make depressed people worse. I tell my patients that the use of a medication can cause anything from seizures, to allergic reactions to death. People fall over dead every year in doctors' offices after a dose of penicillin in the you-know where.

On the other hand, your statement that antidepressants aren't tested on humans is, if I may be blunt, erroneous, and would come as a great surprise to the FDA. In fact, after they are determined to be both safe, and effective. Medicines are tested in humans in clinical trials before they are released to the market and before they are tested on humans, they're tested on animals to make sure that they

1. work;
2. are non-toxic;
3. would be reasonable and extremely safe to try in people.

But the wrong medicine, for anything, can make you worse. Hope that answers your questions.