Old Approaches To Depression Are Coming Back

Depression can be a devastating, even life-threatening, disorder. Sadness, loss of appetite, trouble sleeping, low energy and reluctance to socialize are just some of the symptoms of major depression.
Fifty years ago talking therapy was a mainstay of treatment. People confided in family, friends, pastors or health professionals like psychologists, psychiatrists and their family physician. Then along came antidepressant medicines like Elavil (amitriptyline) and Norpramin (desipramine).
Such drugs did not work for everyone, but they often enhanced the response to psychotherapy. Side effects such as dry mouth, constipation, weight gain and sexual difficulties were obstacles to treatment, but many desperate patients were willing to put up with these complications.
Then along came Prozac. In 1987 when it was introduced, this antidepressant barely made a splash. Neither physicians nor patients realized that the new class of medicines called SSRIs (selective serotonin reuptake inhibitors) would go on to change the way depression is treated. By 1990, though, Prozac had taken over the market.
Its unexpected success was due, at least in part, to the perception that it had fewer side effects than traditional antidepressants. Prozac rarely causes dry mouth, dizziness, constipation or sedation. Some patients find it energizing, a welcome effect to counteract the lethargy of depression.
It wasn’t long before other companies brought out competing drugs. Now physicians can choose between Celexa, Effexor, Lexapro, Luvox, Paxil, Serzone, Wellbutrin and Zoloft.
Such meds are being prescribed enthusiastically for a range of mental health problems, such as pre-menstrual distress, shyness or anxiety, in addition to depression.
Almost from the beginning, however, these drugs have been controversial. In the original clinical trial for Prozac, 15 percent of patients in the study dropped out because they felt worse instead of better. Anxiety, insomnia, restlessness, nausea and tremors cause some people distress. SSRIs can also cause sexual dysfunction and a variety of other complications.
Despite such side effects, many patients recover from their depression. For some, these drugs are life savers. Others, though, may not benefit.
A number of studies (some unpublished) have failed to show that such drugs are statistically superior to placebo. A recent investigation of adolescents with depression showed that treatment with Prozac alone was not very impressive (JAMA, Aug. 18, 2004).
The researchers did demonstrate, however, that Prozac combined with cognitive-behavioral therapy resulted in a substantial improvement of symptoms in these young people. That may be the most important lesson from this new research: sending patients home with a prescription for an antidepressant is not always enough.
Treatment tailored to the individual needs of the patient is essential. For some, that may mean counseling with a therapist or pastor. For others, it may mean exercise therapy, high-dose fish oil, or a light box to provide ultraviolet exposure during the winter months. Some people will need multiple interventions, including antidepressant medication, to overcome major depression.