Tim doesn’t remember when he started to feel depressed, but he remembers when he started to feel better. At first, he thought he was just “feeling down.” He was sleeping a lot, felt nobody liked him, and was tired all the time. But his parents became concerned when he didn’t get better. They knew he was depressed and arranged for him to see a psychotherapist.
After six months, Tim’s therapist suggested he try a medication called Prozac. That’s when Tim became one of a growing number of adolescents who take antidepressants. And for Tim, that’s when things started to get better.
When Prozac was first introduced in 1986, it generated a frenzy of media attention that made it sound like a miracle drug. By 1992, sales of the drug had zoomed to $1 billion. But Prozac is actually no more effective against depression than other available antidepressants, some of which have been in use for more than 30 years. Why has Prozac – and its close relatives, Zoloft and Paxil – been greeted with such enthusiasm?
One reason is that today being treated for depression carries less of a stigma. Another is that doctors are more willing to prescribe the newer antidepressants, in part because of some important differences in the way they work.
Old Drugs, New Drugs
Before Prozac was developed, tricyclic antidepressants (TCAs) were the most frequently prescribed antidepressants. TCAs work by slowing the rate at which chemicals called neurotransmitters re-enter brain cells. This increases the concentration of the neurotransmitters in the central nervous system, which relieves depression.
TCAs are effective against depression, but they also can cause distressing side effects, including dry mouth, weight gain, a feeling of being sedated, excessive drowsiness, constipation, blurred vision, memory difficulties, and rapid heartbeat. Some of these persist for as long as the drug is taken.
Prozac and the other drugs known as selective serotonin re-uptake inhibitors (SSRIs) slow down the neurotransmitters, but, as their name suggests, they do so selectively. SSRIs act only on the serotonin, whereas the TCAs also slow the re-uptake of norepinephrine and dopamine.
Because of their selectivity, SSRIs cause less severe side effects, most of which subside after a few days or weeks. These include nausea, headache, dry mouth, insomnia, nervousness or agitation, sweating, dizziness, and tremors.
Other advantages of SSRIs over TCAs are that they are less likely to be fatal in the event of an overdose and are usually taken once a day, whereas TCAs sometimes must be taken several times a day.
The chief drawback of SSRIs is their cost. One month’s treatment with generic amitriptyline, a TCA, costs about $6.50; a month’s supply of Prozac costs $60 or more.
It Takes Time
Tim didn’t experience any side effects when he began taking Prozac, and within three to four weeks, he began to feel better. More than half the people who take antidepressants notice a significant improvement within six weeks. Physical symptoms, such as appetite or sleep disturbances, usually disappear first. Changes in the way the patient thinks and feels take longer.
An antidepressant that works for one person may not work for another. The recommended length of time to take an antidepressant is usually six to nine months. It’s important to continue it until well after symptoms of depression have subsided. Studies show that once a person has experienced an episode of major depression, the chance of a recurrence is 50 percent. Taking the medication for six to nine months, or longer in some cases, helps prevent relapses.
Talk It Over
Tim has continued to see his therapist while taking Prozac. Many people find that taking an antidepressant helps them get more out of “talk therapy.” A 1995 study found that a combination of counseling and medication is the most effective way to treat depression and also less costly in the long run, since it may help prevent recurrences. Some experts, however, insist that psychotherapy is needed only when the depression is related to long-established problems, such as low self-esteem, but not when the cause is more specific, such as the death of a loved one.
The current trend is away from psychotherapy and toward treatment with medication alone. This is in part because many insurance companies will reimburse the full cost of treatment with medication but only part of the cost of psychotherapy.
Whether psychotherapy is included or not, periodic monitoring by a physician is important while taking an antidepressant, especially during the early weeks, to determine if the drug is working and whether it is causing any serious side effects.
Tim’s prescription for Prozac came from his psychiatrist, a psychotherapist who is also a medical doctor. Psychologists, clinical social workers, and other nonphysician therapists cannot prescribe drugs, but they can refer patients to doctors who can determine if medication is needed. Any licensed medical doctor – including family medicine doctors, internists, and pediatricians – can prescribe antidepressants.
Important points to discuss with the physician before taking an antidepressant include:
* What symptoms will it treat?
* How soon will effects be noticeable?
* How safe is it?
* What side effects may occur?
* What are the long-term consequences of taking it?
* How long should it be taken?
Antidepressants didn’t magically transform Tim’s life. He still feels a little down at times, but now he has more energy and enjoys activities like playing sports. For Tim, and for many young people like him, antidepressants have helped reclaim the pleasure in life that depression had stolen.
A Nation of Pill Poppers?
“Antidepressant” may be the wrong name for drugs like Prozac, Paxil, Zoloft, and other SSRIs. These medications are being prescribed not just for depression but for panic disorders, eating disorders, chronic pain syndrome, poor self-esteem, obsessive-compulsive disorder, and sleep disorders, even though their effectiveness for these conditions has not been proven.
The drugs are also being prescribed for adolescents and even children as young as 3 years old, despite the fact that they have not been approved by the Food and Drug Administration for these age groups.
Are we becoming a nation of whiners who pop a pill at the tiniest sign of stress? Or is something more positive happening here? The verdict is still out on these questions, but barring new developments, antidepressants seem here to stay.