Dealing with Depression

Introduction

Approximately 15 to 20 million Americans experience depression each year. Over a lifetime, one in five women are likely to suffer an episode of depression.

Signs of Depression

• Feeling sad or emotionally numb for more than a few weeks
• A sense of hopelessness
• Feelings of helplessness or worthlessness
• Disordered sleeping: insomnia or hypersomnia
• Low energy, fatigue
• Loss of appetite or excessive, joyless eating
• Disinterest in sex
• Restlessness or anxiety
• Trouble remembering things or concentrating
• Indecisiveness
• Physical ailments that don’t respond well to treatment
• Suicidal ideation, thoughts of death

Anyone who has ever been diagnosed with depression isn’t likely to forget what it feels like. It feels horrible, and it can wreak havoc on your life. The symptoms can seem contradictory: it may make you want to stay in bed and sleep the day away—or it may plague you with chronic insomnia. It can take away your appetite, or it can cause you to overeat, even if the food you’re consuming gives you no pleasure. If you’re prone towards one of these tendencies or another, it may exaggerate your typical behavior.

There are some symptoms of depression that are more universal: a feeling of sadness, hopelessness, or simply lack of interest in one’s surroundings. Feelings of alienation from friends, family, and coworkers. Loneliness. People suffering from depression often have a hard time motivating themselves to do even simple projects. They frequently have low energy, and may also have a difficult time remembering things. Other signs of depression include a generally pessimistic outlook on life, moodiness, and self-doubt. The most dangerous warning sign of depression is suicidal thinking.

Depression is a very serious illness and should be treated with as much urgency as any other potentially life-threatening disease. This cannot be emphasized enough. If you or anyone you care about suffer from any of the symptoms described above, please seek help from a qualified mental health specialist immediately.

Some people hold the unfortunate misconception that depression is something you can just snap out of if you try hard enough: that it’s “all in your head.” And while it’s true that there is a psychological component to depression—it is, in some ways, “in your head”—it also affects the rest of your body in serious ways. Chronic depression can increase your chance of developing heart disease, stroke, diabetes, and other very dangerous conditions. It’s not something you should try to tackle on your own.

There are other ways in which depression is similar to other serious illnesses. For one thing, it’s not always as easy to diagnose as you might think. Depression may emerge during or after difficult periods in our lives: the death of a loved one or a pet, the end of a relationship, losing a job, experiencing financial difficulties. Suffering from what appears to be a purely physical malady can also have psychological ramifications. After experiences like these, it’s understandable that people feel sad, and sometimes this sadness deepens into depression.

But other times, depression seems almost to come out of nowhere. Things at work and at home could be okay, but for whatever reason, you just feel blue. Things in your life could even be wonderful—you’ve just been promoted at work, or you’re about to get married—and instead of jumping for joy, you feel down in the dumps. Even having a baby can trigger very severe depressive episodes, known as post-partum depression.

Luckily, depression no longer carries the same social stigma that it did 40 or 50 or even ten years ago. But some people found ways to deal with their depression even before it became easier to seek mental health treatment. They sought out people to talk to—friends or neighbors, pastors or psychiatrists. They exercised. They spent time outside in the sun. And they sometimes took cod liver oil—a surprisingly effective treatment for depression, as it turns out.

Two very common perceptions by people suffering from depression are that they are alone—they’re the only ones on earth who feel the way that they do—and that their depressive feelings will never go away. Both of these perceptions are false. If you’re feeling depressed, you’re far from alone. And there are many very effective forms of treatment available for depression.

Drug Therapy

Fluoxetine (Prozac)

Fluoxetine is fairly similar to other SSRIs in terms of both benefits and side effects.

Side effects may include: headache, nausea, dizziness, diarrhea, nervousness, anxiety, insomnia, delayed ejaculation, inability to achieve orgasm, and decreased libido. Some people may also experience drowsiness, drop in appetite, indigestion, sweating, mania, dry mouth, heart palpitations, tremor, chills, constipation, blurred vision, memory problems, confusion, rash, and joint pains. SSRIs may also affect blood sugar or thyroid levels, and in a very small percentage of the population, seizures have been reported.

If you’re experiencing suicidal or violent thoughts, tell a doctor immediately.

You should also ask your pharmacist and doctor if your antidepressant will interact with your other drugs or supplements, as many are affected by SSRIs.

Bupropion (Wellbutrin)

Before Prozac, there was Wellbutrin (bupropion). It was the first of a new generation of antidepressants and was introduced in 1985, almost two years before Prozac received FDA approval.

The company started shipping Wellbutrin to pharmacies around the country, but before prescriptions could actually be filled, a problem arose. A small study involving 50 women with an eating disorder revealed an alarming statistic.

Four out of the fifty (8 percent) had suffered a seizure. This unexpected and alarming discovery created consternation at the FDA and the feds had the drug pulled off pharmacy shelves. The agency demanded additional tests, but the company resisted, maintaining that the bulimic subjects in the study were not representative of depressed patients. Prior research suggested that the seizure incidence was similar to that for other antidepressants.

For more than a year the company and the FDA argued. Eventually the company capitulated and studied an additional 3,000 patients. The results redeemed Wellbutrin: The seizure incidence turned out to be 0.4 percent, not that different from other antidepressants and nowhere near the 8 percent seen in the small bulimia study.

Finally, in August 1989, Wellbutrin returned to pharmacy shelves, but it was almost too late. Prozac, introduced in 1987, had become a shooting star. Its incredible popularity made Wellbutrin an also-ran.

Although Wellbutrin works differently from Prozac and similar drugs, doctors seemed to remember only the initial concern about seizures. Despite its initial lack of success in the marketplace, Wellbutrin is roughly comparable to Prozac-like drugs in effectiveness.

Unlike traditional antidepressants, bupropion does not cause weight gain, drowsiness, blurred vision, mental confusion, cardiovascular problems or impaired memory.

Bupropion is Different:

The drug works differently from Prozac and all other antidepressants. There are lots of tricyclic antidepressants including amitriptyline, desipramine, doxepin, imipramine, nortriptyline and protriptyline. There are so many SSRIs and SNRIs that we have lost count. They include citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine and vortioxetine.

Bupropion is unique. We’re not convinced that the experts have figured out exactly how it works. They initially categorized the drug as “atypical.” It does not affect serotonin the way Prozac and friends do. Instead, this antidepressant is thought to inhibit the reuptake of both dopamine and norepinephrine at the level of the synapse.

The Sex Pill?

Because of its different mechanism of action from other antidepressants bupropion has fewer sexual side effects. For some people, it can be helpful for treating decreased sexual desire. One reader shared this story:

“About ten years ago I began taking Wellbutrin for depression. Within two weeks I felt better than I had in decades.

“I also experienced a welcome side effect. Though I have always had a healthy libido, I did have some trouble reaching orgasm, as many women do.

“Suddenly I was able to have quick, easy, multiple orgasms. Because Wellbutrin works on dopamine rather than serotonin, my psychiatrist said it often has that effect.

“What a relief! Why don’t people know about this? When I read about antidepressants, the only ones mentioned are the SSRIs that so often produce negative sexual side effects. Wellbutrin has been a solution for my sexual difficulty.”

Wellbutrin was once called “The Sex Pill” because a controlled trial showed that the antidepressant improved libido and sexual satisfaction (Journal of Sex & Marital Therapy, Winter, 1987).

People with low sex drives were divided into two groups. Half were given bupropion and half received a placebo. The researchers reported that within two weeks the people taking bupropion reported a greater interest in sex. By three months more than 50 percent were making love more frequently.

One of the investigators stated:

“the effects we saw in several women who’d had trouble having orgasms were stunning.”

Helen Kaplan, then director of the human sexuality program at Cornell Medical Center in New York City, believed that:

“Wellbutrin is really the first sensible sexual stimulant we’ve ever had.”

Another report (Diabetes Care, Feb. 2011) noted that patients with type 2 diabetes and depression responded favorably to bupropion:

“We found a high rate (71.1%) of sexual dysfunction in patients with type 2 diabetes and MDD [major depressive disorder] despite a modest rate of neuropathy (22.2%). SF [sexual functioning] improved significantly during BU [bupropion] therapy of MDD, with 58% of subjects experiencing substantial gains in SF during this interval. This effect was more robust in those with greater improvements in depression and glycemic control, but was still observed in approximately 20% of those with persistent MDD or hyperglycemia…

“In summary, this study is the first to report on the high rate of sexual dysfunction in persons with diabetes and depression. Significant improvements in mood, glycemic control, and SF [sexual functioning] were observed during BU treatment of MDD.”

Generally, bupropion makes patients feel energized rather than lethargic.

The Slow Start of Bupropion:

Wellbutrin (bupropion) has had a checkered career as an antidepressant. It originally had to be taken three times a day. That made it a slow starter compared to drugs like Prozac (fluoxetine) and Zoloft (sertraline). People like to take one pill a day and forget about it.

Eventually a slow release (SR) form of bupropion was developed. It only had to be taken twice a day. That made it a little more convenient and sales picked up. Eventually a once-a-day formulation was introduced (XL). Wellbutrin XL 300 became very popular.

When Wellbutrin XL 300 lost its patent, generic formulations came along. There is a tale of woe and intrigue about some of those products. We were directly involved in getting the FDA to investigate this scandal. Eventually, products were removed from the market. You can read all about this debacle at this link.

We fear that the FDA has let down its guard…again. We have been hearing complaints about generic bupropion…again. Here is a link to the ongoing saga of generic bupropion.

Side effects of bupropion may include: insomnia, dry mouth, anxiety, headache, skin rash, nausea, and dizziness. Occasionally, more serious reactions can occur, like mania, seizures, irregular heart rhythms, hallucinations, paranoia, high blood pressure, and migraine.

Report any thoughts of suicide or homicide to a doctor immediately.

Bupropion can interact with a lot of other medications. Be sure you give your doctor and pharmacist a full list of other drugs and supplements you are taking.

The Crazy Cost of Wellbutrin XL 300:

Wellbutrin XL 300 lost its patent many years ago. You might think that would bring the price down. Au contraire. The last time we checked, GoodRx reports that a month’s supply could cost over $1,800. That’s more than $60 per pill.

Of course the generic formulation is much cheaper, but lots of folks claim that you cannot always trust the generic bupropion XL 300 formulations. What to do? PharmacyChecker.com reports that legitimate Canadian pharmacies charge roughly between $1.16 and $2.26 per pill. That is for the brand name Wellbutrin XL 300 formulation. That is a dramatic difference between the US price and the Canadian price. You can learn more about Canadian pharmacies by going to PharmacyChecker.com or checking out our eGuide to Saving Money on Medicine.

For many years, the main type of therapy available to those seeking professional help for depression was “talk therapy” of one form or another. During the 1960s and 1970s, researchers developed the theory that depression was more biologically based than psychologically based. Many thought the source of depression was a chemical imbalance in the brain, and that the best method for dealing with it was antidepressant medication that would correct these imbalances. Thus the era of drug therapy was born.

Early on, lots of patients were prescribed what were known as tricyclic antidepressants like amitriptyline (Elavil), desipramine (Norpramin, Pertofrane), doxepin (Adapin, Sinequan), imipramine (Janimine, Tofranil), and nortriptyline (Aventyl, Pamelor). These drugs certainly did help many people. But alas, they could also cause very unpleasant side effects— some of which were remarkably similar to symptoms of depression: drowsiness, fatigue, constipation, dry mouth, dental issues, weight gain, blurred vision, urinary problems, memory impairment, lack of concentration, dizziness, confusion, and sexual dysfunction.

Other early antidepressants were known as MAOIs (monoamine oxidase inhibitors). They often helped, but deadly interactions with foods such as aged cheese (Camembert, Cheddar, Gruyere, etc.) or meats (pepperoni, salami, etc.) limited their use.

For some people, antidepressant medications can be almost miraculous. But many experience no benefit or suffer disturbing side effects. They should consider the possibility that cognitive and behavioral therapy is effective for many people. It may end up costing far less than antidepressants in the long-term—not just financially, but also perhaps in terms of health and general well-being.

In 1987, Prozac (fluoxetine) was introduced. By 1990, this drug had taken the nation by storm. Americans spent more money on Prozac than on all other antidepressants put together.

Prozac is a SSRI, or selective serotonin reuptake inhibitor. It did so much better commercially than the older antidepressants, not necessarily because it worked better, but because it had a real crackerjack PR campaign. It also appeared to have fewer of the classic side effects.

Pretty soon, other pharmaceutical companies decided they wanted to get in on the action. Within no time, a bumper crop of Prozac competitors (SSRIs and others) had sprung up. These now include: Wellbutrin (bupropion), Celexa (citalopram), Pristiq (desvenlafaxine), Cymbalta (duloxetine), Lexapro (escitalopram), Serzone (nefazodone), Paxil (paroxetine), Zoloft (sertraline), and Effexor (venlafaxine). Doctors write prescriptions for just under 200 million of these medications annually, to the tune of more than $12 billion.

Part of the reason for the remarkable popularity of these medications is that they’re no longer prescribed just for depression. The pharmaceutical industry has pitched the case that antidepressants can be used for lots of other conditions as well, like obsessive-compulsive disorder, or OCD; anxiety and social anxiety disorder; and panic attacks.

Doctors have also been prescribing them for some other things that may surprise you: hot flashes, for one, as well as premenstrual symptoms and fibromyalgia. Surprisingly, it seems that the antidepressants that can decrease the discomfort of hot flashes, for example, do so in a way entirely separate from their psychological capabilities.

But despite the huge numbers of pills and dollars changing hands, Prozac and the others have been very controversial from the beginning. Even during trials for Prozac, 15 percent of patients dropped out because instead of making them better, the drug made them feel even worse. That is a staggering number, yet with all the hype surrounding Prozac, that statistic didn’t get much play in the media.

Also, while they don’t cause the same side effects as the tricyclics or MAOIs, SSRIs can lead to a whole slew of other problems for some people: insomnia, anxiety, restlessness, nausea, tremors, and sexual dysfunction. Some of these medicines (especially the shorter-acting ones) can be very hard to stop. The big question that has dogged these drugs the most is whether or not they may lead some people to have thoughts of suicide or homicide.

The Selegiline (Emsam) Patch

A different antidepressant treatment may hold promise. It’s a prescription skin patch that contains the medication selegiline (Emsam), and it functions in a totally different way from most other prescription antidepressants.

Emsam is fairly new, but it belongs to a class of drugs that were some of the first antidepressants developed, MAOIs, or monoamine oxidase inhibitors. MAOIs can interact in potentially lethal ways with many foods, beverages, and other drugs. This was known as the “cheese effect,” because patients taking drugs such as Marplan or Parnate could suffer a stroke if they ate an aged cheese like Cheddar due to a dangerous spike in blood pressure.

Luckily, they seem to have worked some of the kinks out, and Emsam is much less likely to cause these kinds of problems. With the lowest-dose skin patch, there’s no reason to worry about food interactions. At higher doses (9 to 12 milligrams), people should avoid foods containing tyramine: beef and chicken liver, blue cheese, bologna, Brie, broad beans, Camembert, cheddar, Chianti, draft beer, miso soup, Parmesan, pepperoni, salami, sauerkraut, and yeast extract. These foods can still cause a dangerous jump in blood pressure for those on the high dose.

Emsam can’t be taken with other antidepressants or St. John’s wort, and you should check with your doctor about other potential drug interactions. The most common side effects people report when taking Emsam are skin irritation where the patch is applied, rash, indigestion, headache, insomnia, diarrhea, dry mouth, and dizziness. Sexual side effects seem to be rare. As with any other antidepressant, those who experience thoughts of suicide should contact their doctor immediately.

Antidepressants and Suicide

FDA Public Health Advisory: July 1, 2005

• Adults being treated with antidepressant medicines, particularly those being treated for depression, should be watched closely for worsening of depression and for increased suicidal thinking or behavior.
• Close observation of adults may be especially important when antidepressant medications are started for the first time or when doses for the specific drugs prescribed have been changed.
• Adults whose symptoms worsen while being treated with antidepressants, including an increase in suicidal thinking or behavior, should be evaluated by their healthcare professional.

We heard of this tragic experience from one reader:

“Our 24-year-old daughterwas experiencing anxiety. Her doctor prescribed clonazepam (also known as Klonopin). Along with that, he gave her free samples of an antidepressant called Cymbalta. “Our daughter took these medicines beginning on Thursday, but they made her feel bad. By Sunday evening she began talking about losing a desire to live. On Monday morning, she drove her beautiful 4-year-old daughter to school and then drove to her fiance’s home. When she got there, she took a gun and killed herself. “We are at a loss as to what happened. Our daughter might still be here if not for Cymbalta.”

The Food and Drug Administration now requires this black box warning for duloxetine (Cymbalta) and other similar antidepressants:

“WARNING: SUICIDAL THOUGHTS AND BEHAVIORS

“Antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults in short-term studies. These studies did not show an increase in the risk of suicidal thoughts and behavior with antidepressant use in patients over age 24; there was a reduction in risk with antidepressant use in patients aged 65 and older.

“In patients of all ages who are started on antidepressant therapy, monitor closely for worsening, and for emergence of suicidal thoughts and behaviors. Advise families and caregivers of the need for close observation and communication with the prescriber [see Warnings and Precautions.”

What About Older People and Antidepressants?

Controversy remains over the risk of suicide in middle-aged adults. The FDA clearly warns that antidepressants can trigger suicide in children, adolescents and young adults. Magically, though, this danger disappears once people are older than 24. According to the FDA, the risk of suicidal thoughts or actions goes away after someone reaches the age of 25.

There is a great deal of confusion about the risk of suicide in older adults. One British study of people aged 24-65 reported a greater than 2-fold increased risk of suicide among people taking antidepressants (BMJ, Feb. 18, 2015).

A more recent review of reviews reveals how confused experts are about whether antidepressants can trigger suicide (PLoS One, Jan. 25, 2022):

“The results of this review of reviews find the evidence inconclusive towards use of antidepressants for the prevention of suicidal behavior in older people, thus monitoring is required prior to start, dosage change or cessation of antidepressants.”

Questions about the possibility that Prozac might lead some people to think about suicide first emerged just a few years after it came onto the market. In 1990, there was an article published in American Journal of Psychiatry that described six patients who had experienced “intense violent suicidal preoccupation after 2 to 7 weeks” of taking the medication.

Obviously, this report upset many people, but lots of psychiatrists didn’t think the connection was very strong. And the FDA and the drug company both told us that they thought these reactions were the result of the patients’ depression, not their treatment with fluoxetine.

This did not square with the horrible story that we had heard from a physician two years earlier, in 1988, whose daughter had started taking Prozac. After a month on the medication, she hanged herself. When he told us this, we, like the FDA and others, thought that the young woman’s suicide must have been linked to depression. But as her father later explained to us, his daughter had never been depressed, and certainly not suicidal—she was being medicated for an eating disorder.

Since the time of her tragic death, we have heard many, many other accounts of people who have become obsessed with thoughts of their own or others’ deaths after starting on an antidepressant. In 1997 a mother related this tragic story: “Last year my son, who had been put on Prozac by his psychiatrist, had what I would call a gigantic temper tantrum. He destroyed his computer, his car and set himself on fire, burning himself over 90 percent of his body. Most of those were third degree burns. He rushed into the bathroom and put out the fire with a shower, which probably saved his life. He had never expressed suicidal tendencies before this episode, and has fought to live throughout his treatment for burns.”

We heard from one man whose son, a graduate student teaching assistant at New Mexico State University, started taking Paxil. Within fewer than three weeks, he had shot and killed himself with a .22 rifle. A woman described having strange thoughts about bashing her car into other cars and having thoughts about killing an annoying coworker while she was taking Prozac.

We became more and more alarmed, and we tried reporting these cases to psychiatrists, the drug companies, and the FDA. But inevitably, they told us that the suicides were unrelated to the medications and were merely coincidental.

That all changed when drug regulators in the UK started to tell doctors overseas that SSRI-type medications could produce suicidal thinking and behavior in some young people. Enough concern was generated that the FDA finally had one of its staffers analyze 22 studies about the potential ties between antidepressants and suicidal tendencies. After his review, Andrew Mosholder, MD, MPH, came to the conclusion that: “Short-term pediatric trials of antidepressant drugs demonstrate an increased rate of suicidal events with active drug compared to placebo.”

As if these findings weren’t shocking and disheartening enough, he also remarked that there was not as yet enough evidence to suggest that antidepressants other than Prozac were even helpful for children. It still took some time for the FDA to issue warnings even after Dr. Mosholder had made his report. But eventually, the agency did issue warnings in line with his conclusions for adults as well as children (see sidebar on the right).

Sadly, their warnings came too late for the many people who took their lives in the 20 years before these statements were presented to the public. It was difficult for many psychiatrists, other health officials, and FDA experts to grasp this paradox: a medication designed to prevent depression and deter suicidal thoughts could in fact make things worse, driving some to kill themselves. But that has now been proven to be one horrific potential side effect of these drugs that are indeed life saving for so many others.

The FDA and the drug companies both came under harsh criticism for not adding warnings to SSRI-type antidepressants sooner. Harvard psychiatrist Joseph Glenmullen, MD, is among those who have admonished drug manufacturers. Such remonstrations have led some companies to provide clearer labeling. For example, the makers of Effexor XR included “homicidal ideation” among one of its rare side effects when it first came onto the market. A number of violent episodes have been associated with SSRI-type medications.

We are concerned that the link between SSRIs and suicide was so poorly publicized. It seems to bear an unfortunate resemblance to the Vioxx (rofecoxib) scandal of a few years ago, and suggests a dangerous coziness between the FDA and drug companies.

Questions about the possibility that Prozac might lead some people to think about suicide first emerged just a few years after it came onto the market. In 1990, there was an article published in American Journal of Psychiatry that described six patients who had experienced “intense violent suicidal preoccupation after 2 to 7 weeks” of taking the medication.

Obviously, this report upset many people, but lots of psychiatrists didn’t think the connection was very strong. And the FDA and the drug company both told us that they thought these reactions were the result of the patients’ depression, not their treatment with fluoxetine.

This did not square with the horrible story that we had heard from a physician two years earlier, in 1988, whose daughter had started taking Prozac. After a month on the medication, she hanged herself. When he told us this, we, like the FDA and others, thought that the young woman’s suicide must have been linked to depression. But as her father later explained to us, his daughter had never been depressed, and certainly not suicidal—she was being medicated for an eating disorder.

Since the time of her tragic death, we have heard many, many other accounts of people who have become obsessed with thoughts of their own or others’ deaths after starting on an antidepressant. In 1997 a mother related this tragic story: “Last year my son, who had been put on Prozac by his psychiatrist, had what I would call a gigantic temper tantrum. He destroyed his computer, his car and set himself on fire, burning himself over 90 percent of his body. Most of those were third degree burns. He rushed into the bathroom and put out the fire with a shower, which probably saved his life. He had never expressed suicidal tendencies before this episode, and has fought to live throughout his treatment for burns.”

We heard from one man whose son, a graduate student teaching assistant at New Mexico State University, started taking Paxil. Within fewer than three weeks, he had shot and killed himself with a .22 rifle. A woman described having strange thoughts about bashing her car into other cars and having thoughts about killing an annoying coworker while she was taking Prozac.

We became more and more alarmed, and we tried reporting these cases to psychiatrists, the drug companies, and the FDA. But inevitably, they told us that the suicides were unrelated to the medications and were merely coincidental.

That all changed when drug regulators in the UK started to tell doctors overseas that SSRI-type medications could produce suicidal thinking and behavior in some young people. Enough concern was generated that the FDA finally had one of its staffers analyze 22 studies about the potential ties between antidepressants and suicidal tendencies. After his review, Andrew Mosholder, MD, MPH, came to the conclusion that: “Short-term pediatric trials of antidepressant drugs demonstrate an increased rate of suicidal events with active drug compared to placebo.”

As if these findings weren’t shocking and disheartening enough, he also remarked that there was not as yet enough evidence to suggest that antidepressants other than Prozac were even helpful for children. It still took some time for the FDA to issue warnings even after Dr. Mosholder had made his report. But eventually, the agency did issue warnings in line with his conclusions for adults as well as children (see sidebar on the right).

Sadly, their warnings came too late for the many people who took their lives in the 20 years before these statements were presented to the public. It was difficult for many psychiatrists, other health officials, and FDA experts to grasp this paradox: a medication designed to prevent depression and deter suicidal thoughts could in fact make things worse, driving some to kill themselves. But that has now been proven to be one horrific potential side effect of these drugs that are indeed life saving for so many others.

The FDA and the drug companies both came under harsh criticism for not adding warnings to SSRI-type antidepressants sooner. Harvard psychiatrist Joseph Glenmullen, MD, is among those who have admonished drug manufacturers. Such remonstrations have led some companies to provide clearer labeling. For example, the makers of Effexor XR included “homicidal ideation” among one of its rare side effects when it first came onto the market. A number of violent episodes have been associated with SSRI-type medications.

We are concerned that the link between SSRIs and suicide was so poorly publicized. It seems to bear an unfortunate resemblance to the Vioxx (rofecoxib) scandal of a few years ago, and suggests a dangerous coziness between the FDA and drug companies.

Magic Pills or Sugar Pills?

Generics

Are generic antidepressants as effective as their brand name counterparts?

We used to be among the most ardent supporters of generic medications. Over the last several years, though, we have lost confidence in the FDA’s ability to oversee quality control. We have received hundreds of reports of problems with some generic drugs. Many of these anecdotes involve antidepressants.

Starting a few years ago, visitors to our Web site (www. peoplespharmacy.com) began complaining about a generic formulation of Wellbutrin XL 300 called Budeprion XL 300. They reported that shortly after switching to the generic they experience side effects such as headache, tremor, irritability, nausea or insomnia. After a few weeks many found that their depression returned with a vengeance:

“I got switched to the generic and it was one month of hell. My world crashed and suicide began to feel inevitable. Fortunately, my psychologist determined that the issue may have been the generic drug. Within 3 days of returning to Wellbutrin XL, my life was returned to me. This was a VERY scary experience!”

Others have reported problems with generic Prozac (fluoxetine) or Zoloft (sertraline). If you suspect that your antidepressant has stopped working, consider the possibility that the generic might be part of the problem.

Another bizarre fact about antidepressants— one that many people find hard to fathom—is that there is a huge discrepancy between their reputations as highly effective treatments and the facts from clinical trials. They just don’t seem to measure up.

A huge analysis of nearly 100 antidepressant trials conducted from 1979 to 1996 showed that in 52 percent of them, the antidepressant’s effect was indistinguishable from the placebo’s. That is astounding. That means more than half the time, the benefit of these antidepressants was indistinguishable, statistically, from that of a sugar pill.

Considering the number of these drugs bought, sold, and consumed each day, those figures are remarkable, especially when you think about how persistent the strength of these pills’ reputation has been. Many of us still believe that they work for nearly everyone, nearly all of the time. Not so.

Other, similar meta-analyses have been worded even more strongly. One suggested that SSRIs “have no clinically meaningful advantage over placebo. . . Antidepressants have not been convincingly shown to affect the long-term outcome of depression or suicide rates.”

One thing to keep in mind about these types of meta-analyses is that they look retroactively at a number of smaller studies and then pool their data to analyze it in various ways. A large clinical trial conducted over a long period of time is always a more accurate test.

The most impressive such study was a $35 million project paid for by the National Institutes of Health (not a pharmaceutical company). It was called STAR*D, Sequenced Treatment Alternatives to Relieve Depression, and it was intended to look at not just relief of some symptoms, but at actual recovery from depression (“remission”). That is obviously what paatients suffering from depression want and expect. There were four antidepressants included in the trial: bupropion SR (Wellbutrin SR), citalopram (Celexa), sertraline (Zoloft), and venlafaxine XR (Effexor XR).

The much-anticipated results of the study were published in the March 2006 issue of the New England Journal of Medicine, and they were remarkably disappointing. Only about one in four patients followed in the study achieved remission. In other words, 75 percent didn’t. This was especially disheartening in this particular case because these patients received exceptionally good care: they were evaluated more closely than most other patients are. The authors of the study acknowledged this and hypothesized that if the patients had received more normal care, “the remission rate probably would have been significantly lower—perhaps even in the single digits.”

There was some good news to come out of the study, though. As many people know from their own personal experience, switching medications often works wonders. STAR*D demonstrated that remission rates rose to about 33 percent when patients swapped out a medication that wasn’t working well for a different one.

We don’t want to emphasize the negative. Many people who take antidepressants benefit from them, and about 50 percent of people can actually achieve full remission of their depressive symptoms by taking the appropriate medication. That is wonderful. Unfortunately, though, it also means that about 50 percent of people taking antidepressants are experiencing no appreciable recovery while still potentially suffering from drug side effects. There also were no placebo controls in the STAR*D study, which means there’s no way to know how many people might have improved on their own without the aid of anything but sugar pills.

Naturally, people want to know whether or not to take these medications, and which might be best for them. But the reality is that it’s very hard for both patients and physicians to know whether or not an antidepressant is worth the potential side effects and risks for any given patient without trying it, which may seem a little like Russian roulette. And there’s also no good way of knowing which pills are “better” than others.

A class of drugs introduced after SSRIs affects two different neurotransmitters: not just serotonin, but also norepinephrine. (As a result, these medications are known as SNRIs, serotonin/norepinephrine reuptake inhibitors.) This double-pronged approach is supposedly more effective, but at least one head-to-head study pitting the SNRI Cymbalta against the SSRI Effexor didn’t show any statistically significant difference. There is a pretty significant cost difference, though. Cymbalta can cost upwards of $3 or $4 per pill.

The basic facts are that there isn’t really one superior medication or class of medications. They’re all about equally effective (although their individual effectiveness will vary from person to person), and they all can cause adverse side effects, some serious. Be careful.

Kicking the Habit: Withdrawal Woes

Another unpleasant surprise for many taking antidepressants doesn’t rear its ugly head until the person is ready to come off their medication. You may have kicked the blues, but then kicking your medication could be enough to give you the blues all over again. And that’s because many of these drugs can cause nasty withdrawal symptoms.

One of our readers was prescribed Cymbalta for hot flashes. Here is how she describes what happened to her when she tried to come off of the medication:

“The dosage was reduced for several months. Then I took a pill every other day for months. I have not taken any for over two weeks and my life is a living hell. I cannot turn around without falling over from dizziness. I cannot go up or down stairs without falling. Running or exercising is out of the question. No one told me that this would happen.”

Withdrawal Horror Stories

Cymbalta (duloxetine):

“I have just been through detox hell from stopping Cymbalta. After a week of dizziness, nausea, diarrhea, sweats, chills, itching, disorientation, mood swings and headaches, I am angry! My doctor did not tell me about this.

No Warning:

“I had been on Zoloft and Cymbalta for about a year. I stopped the Zoloft with no problems and then was weaned off Cymbalta by gradually dropping the dosage until stopping completely. I expected some emotional consequences, but did not expect to be a prisoner in my own home for over a week, unable to function in any way. If I had not had the Internet to confirm my suspicions that the symptoms were Cymbalta-related, I would have assumed I was dying of some strange flu!

“My point is not to rant and rave about the horrible time I had withdrawing from Cymbalta, but to question why? Why wasn’t I warned? Why couldn’t I have been told up front, before starting the drug, that the possibility of severe withdrawal existed? Why wasn’t I given suggestions to ease the withdrawal symptoms?

“I know that I am not the only one who has been blind-sided by this drug. Are doctors not allowed to tell?”

Effexor (venlafaxine):

“I tapered off [Effexor] as told, but even months later I still have feelings like electrical shocks going through the brain. I finally got relief from the other symptoms, but getting off this drug has been a nightmare. If a person had to stop suddenly, he would probably go crazy with the withdrawal. Once I forgot to take my medicine with me on a short trip and the withdrawal symptoms were excruciating.”

Another visitor to our website said this about Effexor XR:

“Effexor XR almost killed me when I reduced the lowest dose (75 mg) by half. Within 2 months, I went into extended seizures, head zaps every 2-3 seconds, uncontrollable sleeping (36 out of 48 hrs), raging diarrhea, extremely swollen eye area, and many more adverse reactions. When I questioned 8 different doctors and the company, I was given NO help. My body is permanently damaged from this pill.”

Maddie describes getting off venlafaxine VERY gradually:

“I was prescribed Effexor in the late 1990’s. No mention was made of any kind of withdrawal symptoms. My prescription was renewed year after year for over twenty years, even though, to my knowledge, there is no research to show that long-term use is safe.

“In 2014, I suspected that the venlafaxine XR 75 mg I was taking was giving me unpleasant side effects as well as debilitating withdrawal symptoms if I missed by dose by as little as four hours – brain zaps, nausea, dizziness. One night I woke up and found that when I moved my eyeballs, I heard a distinct ‘click’ with each movement – this happened over several months any time I was late taking my dose. I also didn’t think I needed an antidepressant any more.

“I decided I would open up the capsule and take one less pellet every two weeks. I did this for over a year and finally reduced my dosage to 37.5 mg. After a couple of months stabilizing myself at the lower dosage, I started back reducing it by 1 pellet a week.

“I ended up having withdrawal symptoms even with this tiny reduction. Now I’m stuck at that dosage. It makes me furious that a drug company can market a drug like this with no warning, and even with a denial that the drug is addictive. Of course it works well for them, since I’m still buying their pills!”

No Help!

Therein lies one of the biggest problems: many people aren’t properly notified before taking some antidepressants that they might experience distressing side effects as they try to come off of them. Some of the symptoms described above—dizziness, sometimes to the point of falling—is typical of what we have heard from other people. Other readers have reported nausea, insomnia, headaches, nervousness, sweating, shakiness, weakness, visual disturbances, and difficulty concentrating.

There’s also another unusual symptom we’ve heard about from many readers now. Some call it “Brain Shivers,” or “Head in a Blender,” a very uncomfortable shock-like sensation in the head. One reader wrote to us, “ I am experiencing the ’brain shivers’ of Effexor withdrawal. I reduced the dosage from 75 mg to 37.5 mg and had been on that dose for a month. I have been off for about a week and I have constant brain shivers. Is there anything that can help lessen these odd side effects?”

Kent describes his challenges with brain zaps:

“I am a 50 year old college honors grad, U.S. Marine and a retired homicide detective. I began taking Cymbalta to combat the effects of stress and depression.

“I have been taking it for about 15 years and now have symptoms I would trade for those that put me on Cymbalta in the first place. Each time the Veteran’s Healthcare Administration has failed to send my refills in the mail, it takes just 48 hours for the most terrible withdrawal symptoms to reappear.

“I experience horrible shakiness, uncontrollable, inappropriate and sudden bursts of tears, irritability and snappy moodiness, appetite problems and more. The worst of all my withdrawal symptoms, however, are the electrical shorts or zapping sensations in my brain. It literally feels like it shoots across my head and makes my brain bounce and eyeballs wobble. I find that it progressively worsens day after day while I wait for VHA to do their job and send the next bottle of capsules.

“There are symptoms that I get from taking the capsules as well, including erectile dysfunction, appetite changes, severe dry mouth, and MAJOR tinnitus [ringing in the ears]. The worst two are massive anxiety and sweating anytime I am in public or have even the slightest thought of things that are stressful for me.

“As a cop, I always thought anxiety was something people made up and used to escape work, or some other unpleasant task. Now I know it’s very real and has completely destroyed my public life. Standing in ANY store checkout line is a guaranteed shirt-soaking, sweat-filled-eyeballs experience for me.

“At one time, I was an over-achiever and a rising star in my profession with national awards and recognition, but now I live alone, have lost my family, friends, my personal belongings and even my home. I’m now stuck on a drug my brain cannot live without in a system with no reasonable means for discontinuation whatsoever.”

Slowing Down:

Unfortunately, we don’t know of any good way to reduce the discomfort of withdrawal symptoms, except to slow the process down as much as possible. The length of time until cessation of side effects depends on the rate of reduction of medication, and probably also on individual physiology. So we don’t know how long it will take for the symptoms of dizziness, shock-like sensations, nausea, or nervousness to disappear.

One of the really disheartening things about the issue of withdrawal is that no one really knows just how common it is—not patients, doctors, or even pharmacists, so good guidelines haven’t been developed for helping people with this complication. Many doctors don’t even seem to believe their patients when they report these symptoms. And drug companies of course have no great desire to help determine how best to get people safely and comfortably off of their medications. That would mean people would be going off of their medications (and also would be a tacit admission of guilt that these drugs can be difficult to discontinue).

Where is the FDA?

We consider the FDA negligent or “absent without leave” (AWOL) when it comes to antidepressant discontinuation. In fact we would go so far as to say the agency has had its head deeply buried in the sand for decades with regard to the whole issue of stopping psych drugs. That includes anti-anxiety agents such as alprazolam (Xanax), clonazepam (Klonopin) diazepam (Valium) or lorazepam (Ativan) or antidepressants like sertraline (Zoloft), trazodone (Desyrel) or duloxetine (Cymbalta).

The FDA was slow to appreciate how common and how challenging it could be for people to discontinue these kinds of head drugs. Far worse, in our opinion, is the fact that the FDA has never required drug manufacturers to come up with recommendations for gradual discontinuation. The FDA-approved Medication Guide offers this advice:

“Never stop an antidepressant medicine without first talking to a healthcare provider. Stopping an antidepressant medicine suddenly can cause other symptoms.”

The medication guide that comes with Cymbalta (duloxetine) adds this:

“discontinuation symptoms: Do not stop duloxetine delayed-release capsules without first talking to your healthcare provider. Stopping duloxetine delayed-release capsules too quickly or changing from another antidepressant too quickly may result in serious symptoms including:

anxiety
irritability
feeling tired or problems sleeping
headache
sweating
dizziness
electric shock-like sensations
vomiting or nausea
diarrhea”

Please note that there is a warning not to stop duloxetine “too quickly.” The official prescribing information for physicians doesn’t offer much help either. It warns doctors, PAs and nurse practitioners that abrupt or tapered discontinuation can cause “dizziness, headache, nausea, diarrhea, paresthesia, irritability, vomiting, insomnia, anxiety, hyperhidrosis, and fatigue.” The official advice:

“A gradual reduction in dosage rather than abrupt cessation is recommended whenever possible.”

Such a recommendation is virtually worthless. There is no attempt to define a “gradual reduction in dosage.” Is that over a week, a month, six months or a year? Do not look to either the FDA or the drug company for practical advice when it comes to stopping anti-anxiety agents or antidepressants.

Some Practical Hints:

Not long ago, however, one of our readers told us about this very inventive solution for coming off of Xanax:

“You have written about people having a hard time getting off antidepressants without awful side effects. I had a terrible time getting off Xanax, a highly addictive medication. A pill can only be cut into so many pieces. So the doctor told me I could have a local custom pharmacy make up ’gummies’ (like the kids’ candy). Each week or two they would put in a little less of the drug until it got down to a minute amount. It took weeks but it helped lessen the side effects.”

We think this is a very creative approach to a difficult and uncomfortable problem.

Switching to Prozac (Fluoxetine)?

Another approach that some doctors take is to switch their patients from a SNRI to fluoxetine and then to taper them off slowly. Prozac stays in the body longer than some other medications, and therefore may be less likely to cause withdrawal effects.

F. shared this approach for getting off Effexor:

“I got off of effexor after multiple attempts. I promised myself that if I was able to get off of it successfully I would share how for others. Here are the steps:

“I was on 75 mg and I reduced to 37.5mg – I stayed on this dose for a few months. This dose drop was the hardest and I even felt suicidal a few times and I just had to remind myself that it was not really me it was the chemical changes in my brain. Please do not do this unless you have a support system in your life – a friend, family member, counsellor, psychiatrist that knows what you are going through and that is accessible to you.

“I then had to get custom doses of Effexor made for me at a pharmacy that does titrating and compounding – the pharmacy then told me what increments I would need.

‘Before reducing the first dose – I started on 10 mg of prozac as a bridge

Schedule:
10 mg prozac for 2-3 weeks (or until you feel stabilized on the prozac)
27.5 mg effexor for one month
17.5 mg effexor for one month
12.5 mg effexor for one month
7.5 mg effexor for one month
5 mg effexor for one month
3mg effexor for one month

“Then it was just prozac – if prozac helps you then stay on it but i didn’t like how I felt on just the prozac so I slowly tapered OFF of the prozac. “

There is a liquid formulation of fluoxetine (Prozac). A physician could come up with a very gradual tapering regimen to make this somewhat easier.

How to stop duloxetine (Cymbalta) from “Hopeful” in Indiana:

“Getting off of Cymbalta was the hardest physical thing I’ve ever done in my life. Many doctors don’t realize how difficult it is or that you have to taper – mine did not.

“I found A LOT of help online — my withdrawals were so difficult, I’m not sure I would have survived if I had not found all the online resources and other people’s stories of how difficult getting off of it was and the techniques they used.

“What I did, safely and carefully, was actually open the capsules and count the beads in order to taper down. (Cold turkey is horrible and was simply not do-able for me!) This counting of the ‘beads’ was detailed in many places online.

“I went down VERY slowly and this greatly minimized the horrors of cold turkey. I think I took 3 solid months to go off of it completely. I took a LONG time to phase off this drug. Even then, I had bad side effects and my brain didn’t ‘heal’ completely for 9 months. I had bad memory problems, extreme difficulty with logical thinking, exhaustion, physical aches, and more. BUT I DID get better finally; it was just a very long, painful journey.

“Now I continue to experiment and research and have had successes with natural alternatives to a prescription antidepressant. I understand deeply how much antidepressants are needed for some people, but after my terrible experience with going off of Cymbalta, I hope to not use one again. (And the fact that the manufacturer doesn’t make a tapering dose/pack is unbelievable given the bad results of cold turkey.) I have much sympathy for you and urge you to search online regarding how to best go off Cymbalta. I wish you well. Hang in there – it can be done!”

Cindy offers a somewhat similar approach:

“I was prescribed Cymbalta over 10 years ago. My doctor told me that it would help with the chronic nerve pain that I was having. It wasn’t long before I started experiencing horrible side effects. I had anxiety, depression and suicidal thoughts. I was nauseous, dizzy and confused. I was weak and exhausted all the time. I would forget words and how to spell them. I had a hard time finishing my sentences. I had blurry vision and hearing loss. I lost a lot of my hair. I had excessive sweating. I lost interest in the things I used to enjoy. I still enjoyed making love with my husband but I couldn’t have an orgasm. I gained over 80 pounds, and I looked and felt like I was pregnant. My pain was worse than it was before I started taking Cymbalta. I was a miserable mess.

“In the summer of 2017 I went to a doctor’s appointment and told him that I couldn’t live that way anymore. He told me I had a lot of years left to live, and I just had to learn to live with it. Well, I left his office crying, and I decided right then that I had to do something on my own.

“So I started researching Cymbalta, and I found an awesome group on Facebook called Cymbalta Hurts Worse, and they have helped me tremendously. There are over 18,000 members now and it’s growing larger every day. With their help I started tapering off 60 mg (356 beads) of Cymbalta in the fall of 2017 and I am now down to 1.3 mg (8 beads). I tapered off slowly by 10% of my last dosage taken every two weeks. When I got to 10 beads I’ve had to hold 3 weeks for every bead.

“Almost every side effect is gone now and I’m feeling like myself again. The pain is completely gone. I have started to lose weight and I no longer look or feel like I’m pregnant. I’m excited to be spending time with my children and grandchildren again. There is life after Cymbalta (and other medications like it).”

In general, we think that fluoxetine might be a good choice for people considering an antidepressant, even with all of the controversy surrounding all antidepressants. Prozac has of course helped many people, and other medications haven’t really been shown to be more effective. And it’s also relatively affordable in generic form. (We’re not completely convinced that all generic manufacturers produce equally effective forms of the drug; you may need to do some research to find a company that produces a quality product.)

Then again, some other medication may turn out to work better for you. Alas, it seems to come down to a process of trial and error, and since each medication may take 4 to 6 weeks to work, this could be a long trial period. If a few drugs in one class don’t seem to work, it may be time to move on to another category.

There is one other benefit to fluoxetine. It has a long half life. That means it lasts longer within the body than many of the short-acting antidepressants. And it comes in liquid form or in capsules with delayed-release pellets. That means a compounding pharmacy could help create a gradual withdrawal program with a physician’s assistance.

The Ashton Method for Getting Off Antidepressants:

One of our heroes is Heather Ashton, DM, FRCP. She was a brilliant British physician and psychopharmacologist. Dr. Ashton taught clinical psychopharmacology at the University of Newcastle upon Tyne. What made her unique was her recognition that benzodiazepines such as diazepam (Valium), chlordiazepoxide (Librium) and temazepam (Restoril) could lead to dependence. Stopping suddenly could cause severe withdrawal symptoms.

Her book, Benzodiazepines: How They Work and How to Withdraw, was revolutionary. It was published in 1999, before many clinicians realized that there was a potential problem. It is now available for free in a Kindle Edition and is also known as “The Ashton Manual.” Here is a link to an online version.

In addition to the information about benzodiazepine withdrawal, there are also “Guidelines For Withdrawal of Antidepressant Drugs.” Dr. Ashton submitted these recommendationis in January, 2001 and were:

“guidelines intended for long-term benzodiazepine users who are also taking an antidepressant and wish to withdraw from both drugs.”

Old is New Again: Getting Rid of Depression Without Drugs

As we mentioned in the introduction to this guide, there were a number of ways that people tried to mitigate their depressive symptoms in the days before medications flooded our marketplace. They used the seemingly quaint methods of talk therapy, exercise, and even taking fish oil. But now there are some scientific data that seem to support the usefulness of these approaches.

Talk Therapy

People raise all sorts of objections to talk therapy these days: it takes too long; it costs too much; it doesn’t seem to get to the root of the problem.

Insurance companies tend to perpetuate these myths, since they’re often not willing to cover the costs of therapy, which can be upwards of $100 to $200 per hour session each week for months, and sometimes even years. It’s true that that can be a lot for an individual to pay, especially compared to $20 per month of generic fluoxetine.

But this thinking is backwards for a few reasons. For one, a relatively short course of therapy can often have far longer lasting effects than the Band-Aid® approach of medication, which generally stops working when you stop taking it. If you add up the relative costs—a whole year’s worth of therapy versus being on medication potentially for life—therapy starts to seem like a much better deal. And of course talking doesn’t come with the same kinds of side effects, both short-term and potentially long-term, that drugs can have. Not only that, if one does decide to try a pharmaceutical approach, talk therapy often makes one’s medication far more successful.

Cognitive behavioral therapy, interpersonal therapy, and problem-solving therapy are three types of psychological treatment that have been proven to be very effective for moderate and mild depression. Cognitive behavioral therapy, or CBT, first came on the scene in the 1970s, so it’s been around for as long as many modern antidepressants. The way that it works is essentially this: it takes as its premise that depression comes from dysfunctional thoughts, beliefs and habits. These can become entrenched early on, during early learning experiences, and then be triggered later in life, leading to depression, anxiety, or other psychiatric symptoms. Cognitive and behavioral therapists work with patients to identify patterns in negative thinking and behavior, and then develop a series of strategies and techniques for dealing with, and ultimately eliminating, those negative thoughts and actions.

What’s so interesting about CBT is that it works on the same areas in the brain that medication is meant to target. One study of CBT found that it “can be as effective as medications for the initial treatment of moderate to severe major depression . . . ” The authors also found, however, that “this degree of effectiveness may depend on a high level of therapist experience or expertise.” The conclusions of another study seemed to reinforce these findings: “cognitive therapy has an enduring effect that extends beyond the end of treatment. It seems to be as effective as keeping patients on medication.”

If this is an approach that you might be interested in, we suggest doing significant research in order to find a highly experienced and qualified therapist, even if this means spending a bit more money. In the end, finding a good therapist is much more cost efficient than going to just any therapist; you’re far more likely to benefit, and perhaps will require fewer sessions as well.

Finding a Cognitive Behavioral Therapist and Other Resources

Association for Behavioral and Cognitive Therapies (ABCT):
www.abct.org

National Association of Cognitive and Behavioral Therapists (NACBT):
www.nacbt.org/searchfortherapists.asp

Academy of Cognitive Therapists:
www.academyofct.org/ Library/CertifiedMembers/ Index.asp

General Information:
www.anxieties.com www.psychcentral.com

Exercise

Many of us have heard of a “runner’s high.” But maybe you’ve wondered if such a thing really exists. The answer is yes. Recent studies have scientifically proven the existence of the runner’s high, and researchers have known for decades that exercise of all kinds can boost mood and general outlook on life, and can actually alleviate depression. It obviously doesn’t hurt physical health, either, and as we know, there is an undeniable connection between mind and body.

The trick is to really work up a sweat. One study of the link between exercise and relief of depression tested men and women between the ages of 20 and 45 with mild to moderate depression. They were asked to exercise for different lengths of time, up to 30 minutes, almost every day. Low-intensity exercise was only about as effective as placebo for curbing depression, but high-intensity exercise was much more successful.

Moderation might actually be best, however. A study that assigned 61 depressed college students to no exercise (control group), high-intensity exercise and moderate, continuous training foung that high-intensity exercise reduced depression but increased stress (Biological Psychology, March 2018). Students assigned to no exercise had worse depression after six weeks. Those doing moderate training had less depression and lower stress, both subjectively and reflected in biomarkers.

The “Runner’s High” Scientifically Proven

“Researchers in Germany, using advances in neuroscience, report in the current issue of the journal Cerebral Cortex that the folk belief is true: Running does elicit a flood of endorphins in the brain. The endorphins are associated with mood changes, and the more endorphins a runner’s body pumps out, the greater the effect. “Leading endorphin researchers not associated with the study said they accepted its findings.”

—The New York Times, March 27, 2008

Light Therapy

We all know that the holidays, and the winter in general, can be a depressing time of year. One reason is the lack of sunlight. Even those without seasonal affective disorder (SAD) can get discouraged when it’s dark out for months on end.

Perhaps not surprisingly, getting extra sunlight has been proven to alleviate depression, not just during winter, but all year round. One prominent psychiatrist who was skeptical of phototherapy did a review of data on it, and he concluded that it was actually “comparable to what has been described in the clinical literature for conventional medications to treat depression.”(Am. J. Psychiatry, Apr. 2005) More recently, a meta-analysis of bright light therapy (BLT) confirmed that it is effective against SAD (Psychotherapy and Psychosomatics, Oct. 1, 2020).

Light therapy can also enhance the benefits of other approaches, including medications like citalopram (Celexa) and exercise. So when you can, go outside to get in your daily dose of movement: running, walking, hiking, biking and gardening are all good ways to do double duty fighting depression the natural way, injecting a little more exercise and sunlight into your life.

Bright light therapy can also help with ordinary non-seasonal depression. A meta-analysis of 23 clinical trials that included 1120 volunteers showed that light therapy was significantly more effective than placebo (Psychiatry Research, Sep. 2020).

Light Boxes

When you can’t get the real thing by going outside just after dawn, there are also lamps and light boxes made especially for light therapy. Some doctors’ offices have them, and other models are available for residential use. The most effective approach entails 30 to 60 minutes of white light exposure early in the morning with a dose of 10,000 lux (Praxis, Feb. 2, 2022). This is brighter than ordinary home lighting, and the light box should be equipped with UV filters to protect the eyes. The light box should sit above the eyes and shine down towards the face to prevent unpleasant glare or eye fatigue.

People whose depression includes symptoms of insomnia and weight loss don’t generally benefit from light therapy, which is especially helpful for those with daytime sleepiness, carb craving and weight gain. Some people experience headaches or nausea as side effects. The authors of this review point out that true darkness at night is as important as bright light during the day.

Therapeutic Light Manufacturers:

Light Therapy Products
www.lighttherapyproducts.com

Full Spectrum Solutions
www.fullspectrumsolutions.com

Prevention.com offers its editors’ recommendations here

Fish Oil

Parents who, in bygone days, made their unhappy children choke down spoonfuls of foul-tasting cod liver oil may actually have been onto something. There have been several randomized, placebo-controlled studies that indicate fish oil can help defeat depression.

The good news is you don’t have to hold your nose to swallow down the awful stuff anymore. Pharmaceutical-grade fish oil is now available in pill form, odorless and tasteless. And it’s not all cod liver oil, either, which has us relieved. Cod liver oil is often very high in vitamin A, and when taken in excess, vitamin A can be bad for your bones. We suggest choosing an alternate fish oil that’s not as high in this vitamin.

A meta-analysis considered the relative efficacy of DHA and EPA, the fatty acids in fish oil (Translational Psychiatry, Aug. 5, 2019). These are also termed omega-3 polyunsaturated fatty acids. The researchers found that in 26 randomized controlled trials, omega-3 fats (EPA and DHA) were helpful against depression. Specifically, however, formulations in which EPA (eicosapentaenoic acid) predominate were effective at a dose of around one gram per day. Formulations of mostly DHA don’t seem to have that benefit.

A Cochrane review applying very rigorous criteria to 35 studies was unable to determine if omega-3 fatty acids actually result in a clinical response (Cochrane Database of Systematic Reviews, Nov. 24, 2021). As with so many Cochrane reviews, it found that the studies are not adequate and called for better research to determine both benefits and potential risks of omega-3 fats. Speaking of risks, EPA is associated with a slightly increased risk of atrial fibrillation, a heart rhythm disturbance.

St. John’s Wort

The herb St. John’s wort has long been prescribed in Europe to treat depression and mood disorders. It’s been used over the counter in the US for the same purpose for quite a while now, too, but many doctors here remain skeptical of its usefulness.

The fact is that there have been dozens of clinical trials showing St. John’s wort to be as successful for treating mild to moderate depression as antidepressants. It generally has fewer side effects and is well tolerated.

Interestingly, researchers don’t know precisely why St. John’s wort seems to work, or even which components of the herb do the trick. This can make it difficult to select an appropriate extract. You should only use an extract that has been standardized and tested for effectiveness. As with other herbal medicines, we suggest you check the evaluation at ConsumerLab.com before you purchase a product.

Like any other medication or supplement, it should only be taken under the supervision of your physician, and you should be careful to avoid any potential interactions that St. John’s wort may have with other medications; some of these can be quite dangerous. Talk to your doctor and pharmacist about this.

Some potential side effects include stomach upset and possible allergic reaction. St. John’s wort can also cause photosensitization, which makes the skin and eyes vulnerable to sun damage. Hypericin, a compound in St. John’s wort, reacts with sunlight and can alter the lens of the eye, increasing the risk of cataracts. In particular, people taking St. John’s wort should avoid bright light therapy, as this could increase the potential for eye damage.

Questions & Answers on St. John’s Wort

Q. I’ve been taking St. John’s wort for the past three years for mild depression. There is absolutely no doubt in my mind that I am doing better. My mood and outlook improved without the side effects I experienced on antidepressants.

I saw a report that St. John’s wort is ineffective against depression. I don’t believe my improvement is imaginary, but now I’m beginning to question its benefit. Should I stop St. John’s wort cold turkey to see what happens?

A. The research on St. John’s wort published in the Journal of the American Medical Association (April 10, 2002) was somewhat confusing. The investigators chose to study major depression rather than the mild disorder you describe. The study based at Duke University compared a standardized extract of St. John’s wort to the antidepressant Zoloft (sertraline) and an inactive placebo.

Neither St. John’s wort nor Zoloft proved more effective than placebo on the primary outcome measure of depression. St. John’s wort is not recommended for serious psychological problems, so it is not surprising that this herb was ineffective in the study. More puzzling, however, is the finding that Zoloft also proved ineffective, which makes this study difficult to interpret. If you are doing well on St. John’s wort, we see no reason for you to discontinue.

Resistant Depression

Some people remain dangerously depressed despite every treatment they try. For such individuals, life is a daily struggle. Many cannot drag themselves out of bed, go to work or relate to family or friends. Just imagine living in the painting by Edvard Munch, “The Scream.”

For these people, there are few options. ECT or electroconvulsive therapy may be a life saver. Despite frightening depictions in movies like “One Flew Over The Cuckoo’s Nest,” ECT is an accepted therapy for treatmentresistant major depression.

Like other therapies, it does have potential side effects. Most notable is the loss of memory, especially for events in the weeks just before and after the treatment itself. Some people have reported confusion; again, this is usually most troubling soon after the treatment. Be sure to discuss the pros and cons thoroughly with the therapist if ECT is recommended for you or a loved one.

Another fascinating but still very experimental treatment for resistant depression is a drug normally used during anesthesia. In a small clinical trial, ketamine (Ketalar) was administered intravenously to severely depressed patients who had not responded to an average of six previous therapies. One injection alleviated depression within hours and the benefits persisted for up to a week (Archives of General Psychiatry, Aug. 2006). If confirmed, ketamine may offer another option for people with hard-to-treat depression.

Conclusions

As is true for many other medical conditions, no one treatment is a cure-all for everyone suffering from depression. You may need to try a variety of different approaches or use some—like vigorous exercise, light therapy, and antidepress- ant treatment—in combination with each other. You should always be carefully monitored by a physician. Report any violent or suicidal thoughts right away. If nondrug approaches work for you, great. But if Prozac or another medication is more effective, don’t hesitate to use it. Be mindful of what works for you.

• Don’t expect to pull yourself together alone: get help from friends and family.
• Antidepressants can be very effective for some people. You may need to try a few to find the best one for you.
• Suicidal thinking can occur with almost every medication prescribed for depression. Friends and loved ones should be vigilant, especially in the first few weeks of treatment, to guard against disaster.
• Some antidepressants are very difficult to stop suddenly. Get supervision from an experienced physician. Consider switching to a longer-acting drug like fluoxetine and very gradually taper your dose to conquer withdrawal symptoms. Maybe give gummies a go (p. 5).
• Some nondrug approaches may be just as effective as antidepressants: vigorous exercise, light therapy, fish oil, and St. John’s wort have all been proven to be quite successful at conquering depression in some people.
• If SSRIs like Prozac don’t work for you, Wellbutrin might. If not, you may want to see if the skin patch Emsam could be a reasonable alternative.