I’ll probably start with the most important thing: in fact, there are no antidepressants. What we call “antidepressants” are a whole group of substances with different mechanisms of action and chemical structure. They get their name because they eliminate the symptoms of depression (with the first antidepressant being created as an anti-TB drug), but they can also be called “anti-anxiety” medications, as they reduce anxiety. They can also be called “analgesics”, since they effectively help with neuropathic and chronic pain. Antidepressants can also neutralize hot flashes before the onset of menopause, but I find it difficult to say how to call such an action in one word.
However, having a depressive disorder does not mean that you need to take pills. If the depression is mild, you can do with psychotherapy and only if it is ineffective go to pharmacology. In the case of a mild anxiety disorder, you can again replace antidepressants with psychotherapy or other anti-anxiety drugs. On the other hand, if the condition is more severe, or the therapy does not give the desired effect, the doctor is obliged to prescribe antidepressants. They are often combined with psychotherapy to achieve better results. I must say that the type of treatment is determined together with the doctor and only with him.
How to replace antidepressants? Some depressions can be treated with “non-antidepressants”: for example, a similar condition with hypothyroidism is treated with L-thyroxine replacement therapy (an analog of the thyroid hormone T4), and depression against the background of the onset of menopause, if not too strong, responds well to estrogen. A very promising direction is now considered to be the use of psychedelics (LSD, ayahuasca) together with psychotherapy to eliminate depressive symptoms.
Different antidepressants act by different mechanisms, such as increasing the amount of certain substances or blocking certain receptors. Some representatives may contribute to weight gain, others to weight loss, but in most cases they are quite neutral in this matter. Some drugs activate, others, on the contrary, can tend to sleep. In a word, antidepressants are like people: very different, and complete with positive qualities, there are always some disadvantages in them.
The mechanism of their work can explain their effect on the body — both good and bad. For example, many representatives of this class of drugs increase the amount of serotonin, doing this both in the nervous system and in the rest of the body. The nervous system reacts by reducing depressive symptoms. And the rest of the body? Since 90% of serotonin is located in the intestine, where it activates the contraction of the intestinal wall, blocking the capture of this substance by an antidepressant leads to excessive activity of the intestinal tract and, as a result, diarrhea. This explanation of the side effects of these drugs removes a touch of “terrible mysticism” and incomprehensibility in the ideas about their effects.
Often, antidepressants are demonized by exaggerating their harm. In fact, most side effects appear only at the beginning and quickly disappear. This includes, for example, a paradoxical short-term increase in anxiety, the already mentioned diarrhea, nausea, sleep disturbance, or drowsiness. The task of the doctor at this stage is to explain to the patient that such phenomena will pass and that his reaction to the drugs is quite normal, and also, if necessary, adjust the dose of the drug (with antidepressants, it is better to adhere to the principles of start low – start with the minimum doses, and go slow-slowly increase this dose). It is also worth saying that if the instructions indicate that there is a chance of side effects, this does not mean that they will necessarily occur. Once again, “maybe” doesn’t mean “absolutely.”
Unfortunately, there are side effects that do not go away: for example, a decrease in sexual desire. Weight gain or sweating-phenomena that are also likely to not go away, if they have already made themselves felt. The good news is that all this disappears if you cancel the current drug, change the antidepressant, or add another remedy that eliminates undesirable manifestations. Cancellation, replacement, or addition of medication must be agreed with the doctor.
Very rarely, the undesirable effects of antidepressants can be life-threatening. Such a phenomenon can be serotonin syndrome (the case when the “happiness hormone” is too much). In 99% of cases, it occurs against the background of incorrect combinations of antidepressants with other drugs, so it is better not to self-medicate and find another extreme type of pastime. In the case of elderly patients, it is very important to monitor the level of sodium, which may fall due to the use of these drugs. Some medications can affect the conduction of the heart, so always inform your doctor about blockages and arrhythmias, if any. Very rarely, they can paradoxically reinforce suicidal ideas. The risk of such phenomena is higher in adolescents. It is because of this that a good psychiatrist always monitors the patient’s condition after a week or two, and in the case of very pronounced symptoms, recommends either inpatient treatment or adds an antipsychotic.
Many of my patients and patients are interested in the compatibility of antidepressants and alcohol. Let’s just say they’re no barrier to a glass of wine on a Friday night. But at the beginning of treatment, especially if the antidepressant is sedative, it is better to first get used to the drug and only then return to”wine and bread”. Some “unlucky” people on the background of therapy may react badly to any amount of alcohol (for example, headache or dizziness). Unfortunately, in this case, it will be necessary to prioritize: treatment or Chardonnay. Or ask the doctor to replace the medicine with another one and try your luck again.How long can I take antidepressants?
Antidepressants do not act instantly (the effect typically increases gradually over 2-8 weeks) and are often taken for a long time. The latter fact is very important: they, for example, contribute to the appearance of new neurons and connections that are damaged against the background of stress (depression, by the way, can also be considered as chronic severe stress). In order for the damaged paths to resume and strengthen, they must be given time. Therefore, taking antidepressants lasts 6-12 months if this is the first or second depressive episode. In the case of an anxiety disorder, the duration may increase even by 2 years. In the case of obsessive-compulsive disorder, you can wait for the beginning of the action for 3 months, and the doses that are used are the maximum allowable.
However, in 2019, ketamine was approved in the United States for the treatment of resistant depression, which acts almost instantly and “holds” for several weeks. Despite the speed of action, doctors do not yet know all the possible consequences of long-term use of the drug, so it is left for those patients who do not help at least 2 more classic antidepressants in an adequate dosage, or for those who have very pronounced suicidal ideas.
Some people need to take antidepressants all the time, almost all their lives. This happens if the depression constantly recurs. Very often, new exacerbations of the disorder occur due to too rapid termination of the treatment course with drugs. There is a kind of paradox: a person with his hasty actions because of the fear of pills with each untreated episode, more and more binds himself to them.
A very popular myth is mental dependence (addiction) on antidepressants. First, the potential for such dependence is possessed by one or two drugs and then – in very high doses. Bupropion, which is such, is not even sold in Ukraine, and ketamine is not easy to get. Secondly, other drugs of this class are unlikely to give dependence — they do not give any euphoria. Most often, they pull a person from a state of complete decline of energy to a level where there are some forces to cope with problems. Third, a lot of people call it “addiction” because of relapses of depression or anxiety, you have to go back to taking medications. Here it is very important not to confuse the egg and the chicken: in this case, antidepressants are taken not because they want to, but because the situation forces them to do so.
To be completely honest, these drugs still provoke addiction, but not mental, but physical. After all, your body adapts to the drug, for example, at the level of receptors or chemical reactions, and also begins to better metabolize it. Once again, I emphasize that physical dependence is not mental. You may not want to take any medication, you may not be attracted to it, but you may have a physical addiction.
Why is its appearance important? First, the fact that it is sometimes necessary to increase the dose of the drug. I repeat, this is not done because you become a “drug addict”, just your body has learned to cope with the drug faster and more effectively. Secondly, there is a syndrome of withdrawal of antidepressants. Since the body is “used” to the antidepressant, and the antidepressant has changed to some extent the course of reactions and the number of receptors in the body, then an abrupt discontinuation of the drug can bring chaos to this delicate balance.
The withdrawal syndrome from antidepressants is not fatal, but extremely unpleasant: a short-term return of anxiety, insomnia, irritability and many other “bonuses”. It looks as if the depression or anxiety disorder has returned. To prevent this from happening, you should stop using these drugs slowly, by gradually reducing the dose and under the supervision of a doctor. By the way, the risk of withdrawal syndrome for most antidepressants is small, since they have a fairly long elimination from the body. But with some of their representatives (paroxetine, venlafaxine) I highly recommend that you use caution.
To sum up, I want to say the most important thing about antidepressants: they are not evil, but they are not a panacea. Like any medication, they are beneficial, but they also have side effects. They will “pull” you out of a state of depression, remove anxiety and improve your well-being, but they do not cancel proper nutrition, sleep hygiene, sports. They will not teach you to do something that brings pleasure, and they will definitely not solve problems in the relationship. In any case, I wish you all good mental health, good mood and smiles without antidepressants.