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Medication (cont.)
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Q. If an antidepressant has produced a partial response, but has not
fully eliminated depression, what can be done about it?
There are many techniques to help an antidepressant work more
completely. The simplest is to increase the dose until relief is
experienced or side- effects are severe. If the dose can not be
increased, lithium can be added to any antidepressant to augment its
effect. With all antidepressants it is possible to add small doses of
stimulants such as pemoline (Cylert), methylphenidate (Ritalin), or
dextroamphetamine (Dexedrine) to augment the antidepressant effect.
Selective serotonin re-uptake inhibitors often work better when small
doses of desipramine (Norpramin) or nortriptyline (Aventyl and
Pamelor) are co-administered. Thyroid hormones (Synthroid or Cytomel)
may be used to augment any antidepressant. At times combinations of
these techniques may be utilized.
Electroconvulsive Therapy
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Q. What is electroconvulsive therapy (ECT) and when is it used?;
ECT is an effective form of treatment for people with depressions and
other mood disorders. ECT may be used when a severely depressed
patient has not responded to antidepressants, is unable to tolerate
the side effects of antidepressants, or must improve rapidly. Some
depressed people simply do not respond to antidepressants or mood
controlling drugs, and ECT is a way for such people to be effectively
treated. ECT is utilized in the treatment of both mania and
depression. There are some people who because of severe physical
illness are unable to tolerate the side-effects of the medications
used to treat mood disorders. Many of these people can be
successfully be treated with ECT. Pregnant women and people who have
recently had heart attacks can be safely treated with ECT. Because of
time pressure regarding occupational, social, or family events, some
people do not have the time to wait for antidepressants or mood
regulating medications to become effective. As ECT quite regularly
brings about improvement within two or three weeks, people who are
under such time pressure are also excellent candidates for ECT.
Q. Exactly what happens when someone gets ECT?
The physician must fully explain the benefits and dangers of ECT, and
the patient give consent, before ECT can be administered. The patient
should be encouraged to ask questions about the procedure and should
be told that consent for treatments can be withdrawn at any time, and
in the event that this happens, the treatments will be stopped. After
giving consent, the patient undergoes a complete physical
examination, including a chest x-ray, electrocardiogram, and blood
and urine tests. A series of ECTs usually consists of six to twelve
treatments. Treatments can be administered to either in-patients or
out-patients. Nothing should be taken by mouth for 8-hours prior to a
treatment. An intravenous drip is started and through it medications
to induce sleep, relax the muscles of the body, and reduce saliva are
given. Once these medications are fully effective, an electrical
stimulus is administered through electrodes to the head. The
electrical stimulus produces brain wave (EEG) changes that are
characteristic of a grand mal seizure. It is believed that this
seizure activity leads to the clinical improvement seen after a
series of ECT. About 30-minutes after the treatment the patient
awakens from sleep. While confused at first, the patient is soon
oriented enough to eat breakfast, and return home if the treatments
are being done in an outpatient setting.
Q. How do individuals who have had ECT feel about having had the
treatments?
In studies of people treated with ECT it has been found that 80% of
such people report that they were helped by the treatments. About 75%
say that ECT is no more frightening than going to the dentist.
Q. How long do the beneficial effects of ECT last?;
While ECT is a highly successful way of helping people come out of
depressions, it has to be followed by antidepressant therapy. If
antidepressants are not administered after a series of ECTs, there is
a 50% relapse rate within 6-months.
Q. Is it true that ECT causes brain damage?;
There is no scientific evidence that ECT causes brain damage. A woman
who had over 1,000 ECT died of natural causes, and her brain was
examined for evidence of ECT-induced brain damage. None was found.
ECT does cause memory problems. These memory problems may take a
number of months to clear. A small number of people who have received
ECT complain of longer lasting memory problems. Such problems do not
show up on psychological tests, it is not clear what causes them.
Q. Why is there so much controversy about ECT?
There is little controversy about ECT among psychiatrists. Much of
the opposition to ECT seems political in nature and originates in the
anti-psychiatry groups that oppose the use of Ritalin for the
treatment of children with attention deficit disorder, and who oppose
the use of Prozac for the treatment of depressed people.
Substance Abuse
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Q. May I drink alcohol while taking antidepressants?
There are a number of problems with the mixture of alcohol and
antidepressants. First, antidepressants may make you especially
susceptible to the intoxicating effects of alcohol. Second, if you
drink more than three or four drinks a week, the effects of alcohol
may prevent the antidepressants from working. Many people who seem
not to benefit from antidepressants, do so, if they reduce or
eliminate their intake of alcohol. Third, you may be taking along
with the antidepressant a drug such as clonazepan (Klonopin) with
which one should not drink at all.
Q. If I plan to drink alcohol while on medication, what precautions
should I take?
There is much misinformation about drinking while on anti-
depressants. Alcohol can prevent antidepressants from being
effective. This is not so much because it interferes with the
absorption of antidepressants, it is because of the effects of
alcohol upon brain chemistry. Antidepressants can also increase one's
susceptibility to the intoxicating effects of alcohol. Also, both
alcohol and some anti- depressants (especially Wellbutrin) increase
the possibility of seizures.
If you are determined to drink despite taking antidepressants you
should discuss the matter with your psychiatrist. If you get
permission you might want to determine the extent to which the
medication has made you more sensitive to the alcohol. You might
start by seeing what are the effects of half a glass of wine. You
might then experiment with a full glass. Remember, a 4 oz glass of
wine, a 12 oz bottle of beer, and 1 oz of "hard stuff" all contain
the same amount of alcohol.
Q. What's the relationship between depression and recovery from
substance abuse?
It is not unusual for people who have recently been withdrawn from
alcohol, or other abusable drugs to become depressed. These
depressions are often self-limited, and clear in about 8-weeks. If
depression has not cleared by the end of that period, anti-depressant
therapy should be started.
Q. What does the term "dual-diagnosis" mean?
Dual-diagnosis is a phrase used to indicate the combination of
substance abuse and a psychiatric disorder. A path to alcohol or
other substance abuse is an attempt to self- medicate uncomfortable
symptoms such as depression, anxiety, agitation or feelings of
emptiness. The psychiatric disorders that cause such symptoms are
often diagnosed in substance abusers.
Q. Is it safe for a person recovering from substance abuse to take
drugs?
People recovering from substance abuse can safely take many kinds of
psychiatric drugs. Most psychiatric drugs are unable to be abused.
The best evidence for this is that there are not street markets for
such drugs. On the other hand, The benzodiazepines (diazepam
[Valium], lorazepam [Ativan], alprazolam [Xanax], etc.) and the
psycho-stimulants (dextroamphetamine [Dexedrine], methamphetamine
[Desoxyn], and Ritalin [methylphenidate]) are quite abusable.
For people active in AA please read the pamphlet "The AA
Member--Medications & Other Drugs." This outlines AA's official
attitude toward medication--that it is necessary for certain
illnesses including depression. Too many depressed people who have
been talked out of taking antidepressants by members of their AA
groups have killed themselves as a result.
Q. How do you know when depression is severe enough that help should be
sought?
Professional help is needed when symptoms of depression arise without
a clear precipitating cause, when emotional reactions are out of
proportion to life events, and especially when symptoms interfere
with day-to-day functioning.. Professional help should definitely be
sought if a person is experiencing suicidal thoughts.
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