How to know whether antidepressants will help

It seems to be trendy these days to say we’re all overmedicated. People say we  swallow a pill to try to escape any fleeting negative feeling, or that we throw them at our kids for any bad behavior. To be honest, there are times I agree.

However, sometimes people take the anti-medication thing way, way too far. They say antidepressants are a conspiracy of the drug companies to make us all robots and make themselves rich (most antidepressants are generic, by the way, and aren’t making anyone rich).

They say psychiatric medications are evil and anyone who prescribes them irresponsible. Just the other day, I read an article in some pop online magazine that named the “10 Most Dangerous Medications” and had Prozac at #7.

Really? Are you kidding me? Not digoxin, or Coumadin, or phenytoin, or even lithium, but Prozac? Give me a break.

And some people will claim that depression isn’t a real thing, and that people should be able to “pull themselves up by the bootstraps” and “snap out of it.”

I’m guessing these people haven’t spent too long working in psychiatric hospitals. They haven’t seen people come in with dozens of fractures on and the verge of organ failure after jumping off multiple story buildings hoping to kill themselves because they’re so depressed.

They haven’t seen the look of disappointment in these people’s eyes as they wake up and realize they’re still alive. They haven’t seen people so despondent that they don’t talk, don’t eat, don’t move, and seem to waste away as the days go by.

So as you might be able to tell, I am not anti-antidepressants. I believe in the judicious use of antidepressants for people who really need them.

But let’s say, like most of us, you’re not at the extreme. You’re not happy, but you’re not about to jump off a building, either. How do you know if you’re experiencing normal sadness, or clinical depression? How do you know if antidepressant medications could help?

Here some guidelines I use to help decide whether or not to use antidepressants with my patients.

(Oh, and if you think you might be depressed, please seek out help from a professional, and don’t depend on this article as medical advice!)

1. You feel sad all day, every day, for weeks (or more) on end. Occasional sadness is a normal, inevitable part of life. However, if you’re persistently sad, with no relief, it can be a sign you’re clinically depressed.

2. You cry for no reason. Frequent, unprovoked crying is not characteristic of typical, transient sadness related to life stress.

3. You feel hopeless about the future. Even if things aren’t going great, often we can see a light at the end of the tunnel. If there’s no light for you, though, and you feel things are never going to get better, it can be a sign that your sadness is more serious.

4. You feel guilty and worthless. Feelings of very low self-esteem or self-hatred are unfortunately common, but shouldn’t be accepted as a normal part of life.

5. You wake up much earlier than you want to. Many people have sleep problems, and have trouble falling asleep, or wake up multiple times throughout the night.

However, a particular type of sleep difficulty is associated with more serious depression – waking up without an alarm clock hours earlier than you have to or want to (say 4 or 5am) and not being able to fall back asleep.

6. Your appetite is way high or way low, and you’ve been losing or gaining a lot of weight without trying to. Significant shifts in appetite leading to weight change can be a sign of depression.

7. You have thoughts of ending your life. People who are “just sad” typically don’t have thoughts of suicide. This can be anything from a passing thought of wishing you weren’t alive, to having thoughts of hurting yourself, to fantasizing about a specific plan about how you would do it, to preparing to follow through with your plan.

If you have any thoughts like this, please seek out professional help right away.

8. You have trouble functioning in everyday life. Do you have trouble doing the basic things, like getting up in the morning, showering, running errands, getting your work done? Those are signs you may be depressed.

9. You’re no longer interested in things you used to enjoy. If life feels “flat,” and you no longer experience pleasure like you used to, it can be a sign of depression.

What if there’s a reason to be sad?

But what if something really, really bad happens? Isn’t it normal to be sad? What if you get divorced, lose your lob, or a loved one dies?

Good question. In the DSM-IV (the past version of the psychiatry diagnostic manual), there was a “bereavement exclusion,” meaning that if you had all the symptoms of depression, but a loved one had recently died, it wouldn’t be called depression. This exclusion was removed in the DSM-5, which came out this past May.

I agree with the change.

So what if you have a reason to be sad? If you can’t function, you can’t eat, you can’t sleep, you hate yourself, you think about suicide, you feel hopeless about the future, and there is no relief to your persistent feelings of melancholy?

I’d still like to see you in my office so we can make an educated decision together about whether medications (or other treatments, such as therapy or alternative modalities) are warranted.

How antidepressants are used

Many people are hesitant to use antidepressants because they’re afraid this means they need to be on medication for the rest of their life. There are some people who have recurrent depressive episodes for whom I recommend long-term medication, but this is the exception rather than the rule.

I use the analogy of a cast for a broken bone. Let’s say you break your arm. You’d get a cast, right? The cast isn’t actually doing the work of healing your body – the bone remodels and repairs itself. However, the cast helps support the arm and keeps it in the right position so the bone can heal properly. When the arm is healed, you take off the cast.

I think of antidepressants the same way. The mind needs to do the work of healing itself, but medications support the mind to make this job easier.

Antidepressants can help you function, help you get up in the morning, help you have the energy to get through your day, and lift your mood enough so that life doesn’t feel so… painful. The support that medications offer can make therapy more effective, too.

I typically start an antidepressant and the lowest dose, taper up until it is effective (antidepressants can take 4-6 weeks to reach their full benefit), and then continue the medication for 9-12 months, at which point I’ll taper it off.

Continuing the medication for this period of time minimizes the risk that the depression will come back when the medication is stopped.

If in doubt, seek help

This article is meant to give you a general idea of how I (and many psychiatrists) decide whether or not to use medications. When in doubt, though, talk to a professional, and feel free to get multiple opinions.

The reality of our healthcare system is that it is cheaper and easier to take a medication than to do therapy or make significant lifestyle changes, so many doctors will recommend medications even when other treatments (especially therapy) would do just as well. Your health insurance company would certainly rather pay $5 a month for Prozac than hundreds of dollars a week for therapy.

This doesn’t mean that antidepressant medications are inherently bad, though. It is just as unwise to completely throw out a useful treatment as it is to push a pill down everyone’s throat who’s sad.

Elana Miller is a psychiatrist who blogs at Zen Psychiatry.

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