Isn’t this stuff supposed to work?
I’m amazed at how much the “real world” differs from the “research world”. It is like trying to create a glove to fit people’s hands, which in itself is unremarkable, but if you require the glove to exactly match everyone’s fingerprints, that gets closer to what I’m describing.
Finding a medication that “works” can often be like finding gloves with matching fingerprints. I was talking with a psychiatrist (pdoc) about how antidepressants were “supposed” to work based on their biochemical properties (”mechanism of action”). Our conversation was something like this:
Jane: “Since this drug does this and binds this, it would do this. What have you seen in your clinical practice?”
Pdoc: “Well, I see {something different from theory and therefore different from Jane’s expectations}.”
Jane: “But if this drug binds here, wouldn’t you theoretically see this?”
Pdoc: “Yes. Theoretically.”
I’ve come to appreciate the benefits of having many medication options for mental illnesses because one of those options or combinations would be right for someone. Even though medications within the same class can work similarly, each drug is structurally different. Therefore, each drug may not elicit the same response in every individual. This is also true for mood stabilizers and antipsychotics, although this particular article deals more with antidepressants.
Based on experience, reading, and speaking with physicians, here is what I’ve learned:
All medications on market work most of the time
I’m talking about those that are subject to FDA approval. I am not talking about herbal medicines you get in health food stores (I have not tried them for depression, therefore I don’t know). What I mean by “work” is that they all have some sort of an Effect. These effects may not always include what the drug was supposed to do - improve your depression.
Antidepressants, I’ve heard, are effective 70% of the time, although I have to find the research data that support this statistical conclusion. If you were not included in the 70% with one antidepressant, you may still respond to another antidepressant, so there will be one that will work for you.
Side Effects are unique for each person
We can make statistical predictions of what to expect based on clinical research for a drug before- and after FDA approval. When you are on a medication, you can expect certain events to happen, but don’t be surprised if you experience events that were not listed on your information brochure, or if you experience events that were opposite of your expectations.
For example, some individuals on fluoxetine (Prozac) may experience sleep disturbance and therefore they had trouble falling asleep and staying asleep through the night. These side effects are “insomnia” and “night time awakenings”. However, some people became too sleepy on Prozac (”somnolence” or “hypersomnia”), which is completely opposite of the first set of sleep side effects. Someone told me that when he took an antipsychotic drug, he became even more psychotic. Therefore, expect the unexpected as well as the expected.
You can get a “partial response” to a medication
You start feeling better, but you still don’t feel 100% or even 80%. You feel the medication is working, but you are not sure if you are experiencing the full benefit of the medication. At this point you and your doctor has a few options: increase the dosage of the medication, add another medication to help “augment” the effect of the first medication, switch the medication, or add psychotherapy. Whichever option is the best one depends very much on the communication between you and your doctor plus your doctor’s clinical judgment.
Increasing the dosage of the medication may help you gain better response to the medication and therefore help you feel better, but it may also increase the side effects that come with more medicine in your blood stream. Over time, your body should adjust to the medication so the side effects can be transient (temporary). Increasing dosage may mean additional adjustment time for your body to this medication. I’d encourage increasing dosage if you can take the side effects, just because your body had already adjusted to this particular medication. Side effects are more predictable because you have experienced these side effects before. Sometimes increase in dosage is what makes that difference between “sort-of-working” and “working”.
Adding another medication may help “kick in” the first medication. This is not unusual for psychiatric medication therapies. In this case, there is an absolute requirement to monitor for drug interactions. At this point I’m compelled to ask that you please let your doctor know if you are self-medicating with alcohol, herbal supplements, over the counter medications, or any vitamins. Don’t be embarrassed, because your doctor wouldn’t be surprised: self-medication is not unusual for patients with mental illnesses, even though self-medication is often very dangerous.
Switching to a different medication within the same class or to a different class of medication may be an option based on your unique symptoms and your doctor’s clinical judgment. Examples would be switching from one SSRI to another (like prozac to zoloft) or switching from an SSRI to a tricyclic antidepressant (like celexa - an SSRI, to imipramine - a tricyclic). If this is the option you and your doctor have agreed upon, you’d want to make sure to have the first drug out of your body as completely as possible before you start the second drug. This is called the “washout period” of a medication and depends on that medication’s half-life in your body.
If the drug is associated with a withdrawal syndrome (”crashing”), you’d want to taper off the medication very gradually. Ask your physician if the drug may interact with a new drug you’re planning to start (drug interactions). This is especially critical if your doctor has decided to start you on a second drug while you are weaning off the first drug - this again is not uncommon. This is because the physician may not want you to be without an antidepressant completely so that you will not relapse into a depressive episode.
Most medications take a few weeks to work
Some may experience an effect right away with their medication. Most of us have to wait. This may be tough to hear especially when you’ve already lived with the pain for a long time. While waiting, you may want to participate in newsgroups or support groups. Another perspective is: a person does not become depressed overnight, therefore it would not be realistic to expect to feel completely better overnight (Rome-wasn’t-built-in-a-day sort of thinking). A psychiatrist had said that even for ECT (ElectroConvulsive Therapy, which is as fast as you can go in terms of changing brain wires), the patient needed to expect about 4 or 5 treatments before noticing drastic changes in their depression. Therefore, give yourself time and don’t give up.
You have options and one will work for you
Medication therapy, psychotherapy, support groups, alternative therapies (light therapy, special diets, meditation, yoga, exercises, acupuncture, etc.) can all have a role in restoring your health. The key is education and learning as much as we can about our dis-ease state. We can then make educated decisions and help our doctors help us find solutions.
I’m not sayingthat it won’t “suck” while you go through your personal trial-and-error phase to find the gloves which best fit you. However, even during your itchiest/most nauseating/insomniac/fatigued times of drug side effects, keep in mind that these diminish in importance compared with what you will find: feeling like Your Self.
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