Therapeutic use of antidepressant drugs

The antidepressants are used to relieve the symptoms of depression, which may include feelings of sadness, helplessness, loss of interest in usual activities, insomnia, loss of energy, problems concentrating, weight loss or gain, and decreased desire to socialize or communicate with others.

The three most common types of depression are major depression, dysthymia, and bipolar disorder. Major depression, which may occur once but usually occurs several times in a person’s life, will interfere with the ability to work, eat, sleep, study, and take pleasure in formerly enjoyed activities. Dysthymia is less severe than major depression but will interfere with feeling good and functioning well. Bipolar disorder (formerly called manic-depression) can be more serious than the other forms of depression. In this illness the person’s mood swings from symptoms of depression to extreme excitement with over-activity and feelings of elation. This type of depression can progress to serious mental illness if not treated.

Depression is twice as common in women than men and may occur with premenstrual syndrome or after childbirth as postpartum depression. Studies have not found any negative effects on the unborn child when the mother takes an antidepressant during the pregnancy, but this is a serious question that needs to be discussed with the physician. Antidepressants are very effective in the treatment of postpartum depression, but because they are secreted in the mother’s milk, the option of breastfeeding is another essential area for discussion and decision. Usually, women are recommended to avoid drug use during pregnancy, including the use of St. John’s wort.

Although less common than in women, about three to four million men have depression, and their rate of suicide is four times that of women. Men’s symptoms of depression may be anger and irritability and be masked by alcohol and drug use.

In addition to the treatment of depression, the Food and Drug Administration (FDA) has approved the (on-label) use of the antidepressants for treatment of panic disorders, obsessive-compulsive disorders, bulimia nervosa, social phobia, and generalized anxiety disorder. And although not the treatment of choice, the tricyclics are sometimes used for enuresis - bed wetting.

A physician may prescribe an antidepressant for an off-label use. These are a variety of problems not specifically mentioned on the drug label. Among these are pain, anxiety, attention deficit hyperactivity disorder, post traumatic stress disorder, premenstrual exaggerated feelings of depression, social phobia, and obsessive-compulsive-related disorders such as compulsive hair pulling, compulsive gambling, compulsive buying, sexual addictions, and kleptomania (compulsive stealing).

Studies show that the SSRIs may help alcoholics reduce the amount of alcohol they consume and also increase the number of days they can abstain from alcohol. Patients with anorexia nervosa may also be helped by antidepressants. No other treatment has been approved by the FDA for this eating disorder, but the antidepressants are helping patients maintain their weight and avoid relapse.

Prozac is the most commonly prescribed antidepressant in the United States. In 1999, 135 million prescriptions were written for antidepressants, with Prozac (fluoxetine) the most commonly used.

Among the newer drugs, Prozac and other serotonin reuptake inhibitors (SSRIs) are as effective as the drugs formerly used for depression, but have fewer serious side effects. Another advantage is their effectiveness with other psychiatric conditions, such as post-traumatic stress disorder, anxiety, panic disorder, and eating disorders. In 2002, the U.S. Food and Drug Administration approve Prozac for bulimia nervosa, a disorder characterized by binge eating followed by purging or other efforts to lose weight.

Prozac blocks the reuptake of the chemical serotonin, which is believed to be plentiful in the areas of the brain controlling emotion. However, the brain’s biochemical pathways, and serotonin’s effect on emotion and mood, are not quite so simply understood. Scientists do not exactly know how the serotonin works in the brain and on mood.

Some psychiatrists warn that Prozac is not the cureall for emotional problems, which are usually brought on by crisis situations and not necessarily by chemical imbalances in the brain. Although Prozac is widely used, some warn that the long-term effects on the brain are not yet known. The drug should always be used under close medical supervision.

Crisis use of antidepressants Anticipating “Y2K” (year 2000) switch-over in computers, Americans increased their purchases of drugs, along with other supplies. The recent anthrax scare in America also resulted in people stockpiling Cipro, the antibiotic effective against the disease.

The attack on the World Trade Center resulted in a similar reaction from the public in New York City. After about three weeks, pharmacies and physicians received many calls for sedatives and antidepressants, with some requesting these drugs for the first time. While it is not uncommon for some people to use a sedative or antidepressant at the time of traumatic stress and anxiety, the
demand was clearly much higher after September 11, 2001.

Two specific groups sought relief: those closely affected by the loss of a loved one, and others who became anxious with the threat to their security. As a temporary means of coping, the sedatives helped some people sleep, and the antidepressants helped in dealing with stress. However, psychotherapists cautioned that these drugs are only a temporary relief, and that people may want to get to the underlying feelings through psychotherapy.

This reaction to an extremely threatening or frightening experience is called post-traumatic stress disorder. It is characterized by general anxiety, nightmares or haunting recollections, and emotional detachment. Psychiatry has only accepted the existence of this specific disorder for the past 20 years, although it used to be known under different names. For example, during World War I, the term used for post-traumatic stress disorder was shell shock; in World War II, it was called combat fatigue; and after the Vietnam War, it was post-Vietnam syndrome.

Because each patient will respond differently to the various antidepressants, the physician may try several - or even combine them - in the search for the most effective treatment for a particular patient.

Although the tricyclic and MAOI antidepressants cause an immediate pharmacologic action (drug reaction in the body), their clinical action (observable reaction) is delayed. This delay can last weeks or even months. This makes it difficult to use these antidepressants to treat severe depression when an immediate response is desired. The more severe cases of depression and other psychiatric and emotional problems may require other treatments in addition to the drug therapy.

The antidepressants have been found effective in post-stroke patients when a positive attitude is needed for recovery. Treating post-stroke depression improves the chances of the patient regaining mental acuity.