Medicating Depression

by Dr. Archibald D. Hart

Antidepressant medication can be costly, especially for those without insurance. It is important, therefore, that the treating physician carefully evaluate a depressed person for the best outcome. Here are some of the features that point to a good response to medication:

Severe depressive symptoms (usually, the more severe the depression, the better)
Recurrent episodes of depression
Presence of hallucinations or delusions
Vegetative symptoms (extreme fatigue)
Family history of depression
Extreme sadness
Prior history of positive response to medication
Incomplete response to psychotherapy alone (Usually, if psychotherapy doesn"t show some improvement within 6 weeks, medications should be seriously considered.)

Of course, the only foolproof way to know if you are a good candidate for antidepressants is to have a trial on an antidepressant. Antidepressants are not habit-forming, so you don"t need to worry about getting addicted.

Stages of treatment

Acute treatment (6 to 12 weeks) aims at reducing the depressive systems. Sometimes there is a partial response only during this phase, in which case alternative medications will be tried. It is important that you cooperate with the treatment.

During this phase, psychotherapy can help to identify stress that may be aggravating the depression and help to control the distorted thinking that accompanies depression. Just having a caring and understanding professional help you talk out problem issues and do some "damage control" can go a long way toward speeding up your recovery.

Continuation treatment (6 to 12 months) aims at maintaining freedom from depression. This means you have to maintain full dosage for at least six months, preferably for a year. While the medication may have eliminated the symptoms of your depression, the underlying disorder still remains. If you stop the treatment, the depression will return in two to four weeks. Depression episodes can last up to three years, which means that the continuation phase may need to continue for several years as well.

During this phase the actual dosage of your medication may need to be increased or lowered (this is called "titrating"). If the side effects are too bothersome you may need to step back to a lower dose until your body adjusts, or even change to another medication. If at first you respond to a given dose but stress increases, you may find that you need a higher dose to control the depression. During this phase you should continue psychotherapy and have occasional visits with the prescribing physician or psychiatrist.

Maintenance treatment. The most frequently asked question during depression treatment is, "Do I have to stay on this medication the rest of my life?" The answer is not so simple. If you have had at least one previous episode of depression or have had a lifelong tendency toward depression, then the answer is probably yes.

The reason? Maintenance treatment can prevent a repeat episode. Maintenance psychotherapy may also delay the onset of the next episode.

If this is your first and only episode of depression you may still want to consider maintenance treatment to prevent a future occurrence. You will have to rely on the treating professional for some guidance. If, however, you decide to discontinue medication, remember that if ever you become depressed again, the sooner you start treatment the better. Expect a few weeks of depression until the treatment reestablishes itself.

Do not stop and start antidepressant medications at will. There is a growing body of evidence that indicates that if you start the medication, then stop it, it may not work the next time. The body may reject the medication unexpectedly. If you want to come off your medication prematurely, discuss this with your prescribing physician.