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How Antidepressants Work

Depression Treatment

There is no cure for MDD, so doctors must manage their patients with the goals of reducing the patient's symptoms, improving the quality of life and minimizing any risks of suicide. Ideally, treatment requires a combination of psychotherapy, medications and patient education. MDD treatment has been divided into three phases: acute, continuation and maintenance [source: Mann].

Kashmiri antidepressant
Arif Ali/AFP/Getty Images
A survivor of the Kashmir earthquake in 2005
receives antidepressant drops at a medical center.

Acute phase
Here, the goal is to get the patient into remission (a state with minimal symptoms). This usually involves beginning antidepressant therapy. Usually, SSRIs are the drug of choice, especially for children and older patients, because they can be used in lower dosages with the fewest side effects. It takes about four to six weeks for any antidepressant to show effects.

Augmenting Antidepressants
Sometimes MDD patients show other symptoms (changes in mood, delusions, hallucinations, changes in energy metabolism) partially due to antidepressant side effects or to other types of depression (like bipolar disorder -- periods of happiness interspersed by periods of severe depression). So, primary care providers may add other medications to antidepressant therapy.
  • Mood stabilizers: lithium, latmotriguine (LamictalTM), valproic acid (DepakeneTM, DepakoteTM)
  • Antipsychotic agents: chlorpromazine (ThorazineTM) or haloperidol (HaldolTM)
  • Thyroxine: thyroid hormone to increase metabolism

The physician and patient start by rating the severity of the untreated symptoms to establish a baseline. During the first four to six weeks on antidepressants, patients may undergo psychotherapy and side-effect monitoring. The physician reassesses the severity of the symptoms and compares them to the baseline. If, after eight weeks, the reduction in severity is less than 25 percent, that antidepressant is considered to offer no improvement. The primary care provider may choose to change the dosage or class of medication, augment the medication or combine classes of antidepressants. If successful, the acute phase of treatment may six to 10 weeks.­­

Continuation phase
After remission begins, doctors try to eliminate remaining symptoms, restore the patient to his or her level of function before the MDD episode and prevent recurrence of further MDD episodes. During this time, the levels of antidepressant therapy and psychotherapy used to achieve remission are maintained. If, after six months, there is no relapse, medication might be discontinued gradually over several weeks. The continuation phase of treatment could last six to 12 months.

Maintenance phase
This phase is most important for patients with annual episodes of depression. During this time, patients should be monitored regularly. Antidepressant therapies sometimes have to be reinitiated. Psychotherapy and patient education are especially important. The maintenance phase can last one to three years.

Special populations and depression therapy
When deciding on therapy, some clinically depressed patients require special considerations:

  • Bipolar disorder -- these patients have extreme mood swings (periods of excessive high spirits followed by severe depressive episodes). Typically, the antidepressants are augmented with mood stabilizers.
  • Children/adolescents -- The SSRI fluoxetine is the only effective (and approved) antidepressant for this age group. There have been reports that children on antidepressants are more likely to commit suicide than those who are not on antidepressants; while some data suggest that this may be true, it has not been proven conclusively. Primary care providers need to weigh the risks of antidepressant therapy versus untreated depression. Most often, treatment carries fewer risks of suicide than non-treatment.
  • Pregnant/postpartum women -- Depression can be a common symptom during pregnancy and postpartum -- it usually corrects itself, but sometimes severe depression must be treated (in about 10 percent of pregnant/postpartum women). Antidepressants can pass to the fetus and through breast milk. The effects of antidepressants on the developing fetus and newborn are not well known. Therefore, doctors should carefully consider the risks and benefits of treatment.

Treatment for depression is not a short-term process but a long-term project with specific goals of remission and maintenance. Multiple approaches of medication, psychotherapy and patient education are most effective in the treatment of MDD. Close consultation with a physician and/or psychiatrist can provide the best treatment options.

Next, we'll learn about direct-to-consumer marketing by pharmaceutical companies, which has greatly affected patient choice in the past few years.