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What Doctors Don’t know About Anti-Depressants

Monday, January 11, 2010 at 6:00 AM

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Just over 50 years ago, patients had only one medical option to treat their depression - talking to their therapist. Then anti-depressant drugs came into play, revolutionizing the treatment of depression. But as ideastream health reporter Gretchen Cuda explains, medications have their drawbacks too and there's still a lot we don't know about how and why they work.

CUDA: These days if you seek treatment for depression from a psychiatrist, or even your general practitioner, you’re likely to go home with a prescription. Anti-depressants are the single most prescribed class of drug in the United States.  Ten percent of adult women and 4 percent of men now regularly take antidepressants.

For patients like Julianne Kurdila, who has battled depression since she was a teenager, they work miracles.

KURDILA:  I felt like I was living a whole new life after the medication worked. I walked outside and the trees looked so green and everything looked brighter, and it really physically felt like a veil had been lifted from my face.  It was just amazing, it was amazing.

CUDA: Kurdila, now 46, tried three different medications before finding her first miracle pill.  She’s also switched medications a number of times when they stopped working.  Psychiatrist Donald Malone of the Cleveland Clinic, says this is not uncommon

MALONE: There are well over 20 medications at this point that are marketed for depression or have been used to treat depression in various ways. A given individual may respond much better to a medication or a class of medications versus another class - the problem is we don’t know why.

CUDA: Finding the right anti-depressant and the right dosage is a huge challenge because of the complexity of the brain- cells just millimeters apart can be involved in completely different functions - and yet they all work together in systems that come together in concert to do all the things our brains need to do. Think of it like an orchestra - each section - the violins, the cellos, the flutes, the oboes-- have their own part.  Together they make music, but when one instrument misses a note—the whole thing unravels.

//MUSIC

The source of the undoing is unique to each individual and nearly impossible to pinpoint. Anti-depressants do help keep the orchestra playing in sync for most people but exactly how they work was a medical mystery when they first came on the scene.  The very first anti-depressant drug was actually discovered by accident.  It was being used for tuberculosis - when a physician noticed that his patients seemed to be happier.  That was in the 1950’s.  Around the same time a drug for schizophrenia called imiprimine (ih-MIH-pruh-meen), also appeared to elevate patients’ moods. Soon they became a common therapy for depressed patients .  Researchers eventually learned that the drugs worked by raising the levels of two different chemical messengers in the brain that are thought to be abnormally low in depressed patients: Serotonin and Norepinephrine - and when they discovered they could manipulate the drugs to target one or the other -a whole field of anti-depressant medications was born. 

One of the biggest breakthroughs came with Prozac - a drug which only affected the brain chemical serotonin, not norepinephrine.  Increasing levels of serotonin alone maintained the antidepressant effects with far fewer side-effects than any of its predecessors.  Psychologist Michael Mckee says that changed everything.

MCKEE: Then 1987 arrived and Prozac hit the big screens.  It literally was billed as “the miracle drug”.  It was going to cure all depressions and a lot of other disorders and without any side effects.

CUDA: But Malone says the field hasn’t made as much progress as most would have liked - in fact, imiprimine …the drug used in the 1950s…is still on the market today

MALONE: What’s really interesting about anti-depressant medications is that we still haven’t found anything that’s more effective than imiprimine.

CUDA: Hold on - What about all those commercials for Wellbutrin, Zoloft and Cymbalta? They’re not any better than a drug from the 50’s?

//Music from commercial.  Where does depression hurt?  Everywhere. Who does Depression hurt? Everyone. 

MALONE: They are equally effective but they’re not more effective.  And its kind of one of the things we want to change in psychiatry - we want to get things that are more effective than what we had before.

CUDA:  Malone says the fact that today’s medications offer fewer side effects and are safer means they ARE BETTER than the early drugs - just not more EFFECTIVE in relieving depression. A recent controversial study in the Journal of the American Medical Association showed that in mild to moderately depressed patients, anti-depressants aren’t any more effective than placebo.  And additional studies have shown that regular exercise fares as well or better than drugs.  Researchers also know that anti-depressants work best when they are used in combination with psycho-therapy.  There is a solid consensus in the mental health community about that.  But over the last couple of decades talk therapy has declined markedly while the use of anti-depressants has nearly tripled.  That’s mainly because giving people a pill is a lot less expensive than lengthy sessions on the couch.  Health insurers resist paying for that.

Michael McKee, a practicing psychotherapist for more than 40 years, says it’s a disturbing trend.  He says, while depression is certainly biological, drugs aren’t the only thing that can change biological processes gone wrong in the brain - and those changes can be seen on be seen on brain scans.

MCKEE: I think the mind has tremendous power -the thoughts you have can change the brain. If you have more positive constructive thoughts, you can help light up parts of the brain, that as it were, gone dark with depression

CUDA:  Both doctors McKee, the psychologist, and Malone, the psychiatrist, emphasize that there are no true quick fixes or miracle pills when it comes to depression - psychotherapy and finding the right medications take time and hard work - but when patients stick with it, most of them eventually find relief.

MALONE: People do get well. There is no question about that.

CUDA: Yet when it comes to overcoming depression, perseverance seems to be the key. Only about a third of depressed patients respond to medication the first try - while two thirds eventually find relief if they don’t give up the search.

Gretchen Cuda, 90.3

Tags

Health, Facing Depression

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