A Methodical Process of Finding the Right Antidepressant
by eros
A Methodical Process of Finding the Right Antidepressant
I’ve been reviewing this post and want to make the following points. First, do not put treatment into your own hands. ALWAYS consult with your doctor. That doesn’t mean take a passive role in your treatment. Be active. Give your doctor honest feedback, ask questions, make requests. The more you play a part in your treatment, the less helpless you will feel.
Part 3 of 4:
This particular method of drug selection is used at our research site. It is not the only method, but one of several:
As mentioned before, the hardest part of medical treatment is finding the right medication. You may be lucky and respond to the first one tried, or you may be one of those unfortunates who go through a longer process before the right one is found. Treatment should be aggressive. The goal is to reach remission as soon as possible. It really disturbs me when taking peoples history to find they have been on a medication for months or years with no relief.
First Choice of Medication (First Wave):
The initial choice of medication should be based on how safe it is and how many side affects it may produce. The first drug class of choice would be the SSRI’s (Prozac, Zoloft, Paxil, Luvox, Celexa). It is very difficult to overdose on these meds, and they are nontoxic to the heart. Most people will have few side effects. (One word about side effects. If your side effects are tolerable, stick with the medication. Most tolerable side effects dissipate with three to eight weeks of treatment. If they are intolerable-- time to try a different med).
The first three to four weeks of AD treatment is the most difficult, because side effects will be at their highest and benefits will be at their lowest. It is hoped that side effects will go down as the benefits go up. The dose should start out at the minimal, therapeutic level, unless your sensitive to meds, then you start at a sub-therapeutic level.
People absorb and metabolize medication very differently. Some people do well at the lowest dose levels, while others require higher doses. At the initial dose level, if you have not responded in any way by the end of week two, your doctor should be the dose to the next level if side effects have been tolerable. After one week if there is NO improvement, the dose should be titrated to the next level-- side effects permitting. Each week, if there is NO response, the doctor should raise the dose another level until you reach the highest recommended dose. At the highest dose, it is wise to ask your physician to perform a blood-serum level of the drug, to see if it is being absorbed adequately. A blood draw is required.
If at any time during the dose titration phase, you start to respond; most doctors will maintain that dose level for a while. If after a couple of weeks you’re still not satisfied, the doctor may increase it another level.
Second & Third Choices:
Because a drug in one drug class doesn’t work, doesn’t mean other drugs in the same class won’t. If however, you have tried around three drugs within the same drug class, then most doctors will switch to a different drug class. The various drug classes are tri-cylices, tetra-cylices, selective serotonin re-uptake inhibitors (SSRI’s), atypical antidepressants, dual action and monoamine oxidase inhibitors (MAOI’s).
As you try each drug through trial and error, you go through the same dose titration procedure as mentioned above. When a doctor maxes out a drug, again ask him/her for a blood-serum level.
Going To A Second Drug Class (Second Wave):
The next drugs of choice would be the newer drugs that do not fall in the SSRI category (atypical and dual action antidepressants). This would include Effexor, Remeron, Serzone, and Roboxetine (not in the US yet) again using the same titration (dosing) schedule.
Going to a Third Drug Class or Using Drug Combinations (Third Wave):
If you have gone this far with no relief, you physician can try combining drugs OR choosing drugs from the Tri-cyclic or Tetra-cyclic drug classes. Some drugs of choice would be Imipramine, Desipramine, Nortriptyline, Trazodone, Ludiomil, Sinequan, Anafranil, etc. These drugs are a little riskier, they have more side effects and can be toxic to the heart . . . but they are still effective. I was on Desipramine for 15 years and it never let me down. Unfortunately, I started to have arrhythmias to the heart and had to stop.
Drug combinations can be very effective. Most GP’s won’t mess with this, but psychiatrists frequently combine medications if a single agent isn’t effective enough. Wellbutrin + Prozac, Remeron + Effexor, etc.
Going to the Fourth Drug Class (Fourth Wave):
This would be the MAOI’s (monoamine oxidase inhibitors). The following are MAOI’s Phenelizine (Nardil), Selegiline (Elerpryl), and Tranylcypromine (Parnate). This drug class works entirely different from those that block the reuptake of neurotransmitters. More people respond to MAOI’s than the other classes already mentioned. They can be very effective, but most doctors shy away from them because they interact with several medications and foods that contain tyramine. You will have food restrictions and have to be careful using over-the-counter meds and prescribed medications. If taken as directed, they are safe and effective with few side effects.
The use of ECT (Fifth Wave):
Electro Convulsive Treatment is the most effective treatment for depression, but is used as a last resort because of cost and the risk of going under anesthesia. It’s common to experience some memory loss of events that occurred around the time of treatment.
As part of my internship, I assisted in many ECT treatments. Contrary to what is shown on movies, ECT is very humane. Patients do not thrash or convulse on the table. Under anesthesia and the administration of muscles relaxants, the convulsion only consists of the patients toes curling down and up. This can be subtle enough to have someone carefully observe the toes to make sure the patient experienced a convulsion. The average patient may require eight to twelve treatments before remission. They are usually done every other day.
Well, there you have it. In brief summary, treatment should be aggressive. The goal is to achieve remission as soon as possible. If one medication doesn’t work, then you move on to the next. You keep trying until you come across the correct one. Be actively involved with your treatment.
My next posts will focus on how to prevent relapse once remission has been achieved.
I hope these posts are being helpful. It is my hope we all take an active role in our treatments. Our treatments should be dynamic and we should have a good two-way communication with our Pdocs.
Posted on Mar 12, 2002, 10:55 AM from IP address 195.174.197.93