Subject: alt.support.depression FAQ Part 2[5]
Supersedes: <alt-support-depression/faq/part2_827711986@rtfm.mit.edu>
Date: 8 Apr 1996 18:09:47 GMT
References: <alt-support-depression/faq/part1_828986727@rtfm.mit.edu>
Summary: The following Frequently-Asked-Questions (FAQ) attempts to
     impart an understanding of depression including its causes; its
     symptoms; its medication and treatments--including professional
     treatments as well as things you can do to help yourself. In
     addition, information on where to get help, books to read, a list
     of famous people who suffer from depression, internet resources,
     instructions for posting anonymously, and a list of the many
     contributors is included.
X-Last-Updated: 1994/08/22
Xref: senator-bedfellow.mit.edu alt.support.depression:86839 alt.answers:16921 news.answers:68933

Archive-name: alt-support-depression/faq/part2
Posting-Frequency: bi-weekly
Last-modified: 1994/08/06


Part 2 of 5
===========

  **Causes** (cont.)
   - What initiates the alteration in brain chemistry?
   - Is a tendency to depression inherited?

  **Treatment**
   - What sorts of psychotherapy are effective for depression?

  **Medication**
   - Do certain drugs work best with certain depressive illnesses? What
     are the guidelines for choosing a drug?
   - How do you tell when a treatment is not working? How do you know
     when to switch treatments?
   - How do antidepressants relieve depression?
   - Are Antidepressants just "happy pills?"
   - What percentage of depressed people will respond to
     antidepressants?
   - What does it feel like to respond to an antidepressant? Will I
     feel euphoric if my depression responds to an antidepressant?
   - What are the major categories of anti-depressants?
   - What are the side-effects of some of the commonly used
     antidepressants?
   - What are some techniques that can be used by people taking
     antidepressants to make side effects more tolerable?
   - Many antidepressants seem to have sexual side effects. Can
     anything be done about those side-effects?
   - What should I do if my antidepressant does not work?


Causes (cont.)
--------------

Q. What initiates the alteration in brain chemistry?

   It can be either a psychological or a physical event. On the physical
   side, a hormonal change may provide the initial trigger: some women
   dip into depression briefly each month during their premenstrual
   phase; some find that the hormone balance created by oral
   contraceptives disposes them to depression; pregnancy, the end of
   pregnancy, and menopause have also been cited. Men's hormone levels
   fluctuate as deeply but less obviously.

   It is well known that certain chronic illnesses have depression as a
   frequent consequence: some forms of heart disease, for example, and
   Parkinsonism. This seems to be the result of a chemical effect rather
   than a purely psychological one, since other, equally traumatic and
   serious illnesses don't show the same high risk of depression.


Q. Is a tendency to depression inherited?

   It seems there are some people whose brain chemistry is predisposed
   to the depressive response, and others who are at much lower risk of
   depression even if exposed to the same physical or psychological
   triggers. The genetic relations of manic-depressives are at a higher
   risk for unipolar depression than the population at large or their
   adopted/by marriage relations. There seems to be a link between high
   creativity and the gene for manic-depression: artists and writers
   often are not manic-depressive themselves, but have a family member
   who is. Studies of families in which members of each generation
   develop manic-depressive illness found that those with the illness
   have a somewhat different genetic make-up than those who do not get
   ill. However, the reverse is not true: not everybody with the genetic
   make-up that causes vulnerability to manic-depressive illness has the
   disorder. Apparently additional factors, possibly a stressful
   environment, are involved in its onset.

   Major depression also seems to occur, generation after generation, in
   some families. However, depression can occur in people with no family
   history of any form of mental illness. And I would be reluctant to
   suggest that there is any human who is entirely immune to depression
   under all possible conditions.

   Psychological triggers: many, if not most, people with depression can
   point to some incident or condition which they believe is responsible
   for their unhappiness. Of course, people with severe depression are
   prone to astonishingly virulent and inappropriate guilt and
   self-hatred.

   The (genuine) life events that most often appear in connection with
   depression are various, but there is one distinguishing feature that
   appears in many cases, over and over: loss of self-determination, of
   empowerment, of self-confidence. More profoundly: a loss of self, of
   the abilities or activities that a person identifies with herself.
   Stereotypically: a man loses the job that had defined him to himself
   and others, whether that definition was "executive" or "breadwinner";
   a woman who had spent her whole life preparing for and living the
   role of wife, supporter, caretaker, is suddenly left alone by divorce
   or death. In general, any life change, often caused by events beyond
   one's control, which damages the structure that gave life meaning.

   The ability of a person to respond to such an event will depend on
   many factors, including genetic predisposition, support from friends,
   physical health, even the weather. It can also depend on internal
   psychological factors which may best be explored in talk therapy: why
   is the person's self-esteem so bound up in the position or state that
   has been lost? Can she find a new source of self-esteem? Therapy can
   be immensely helpful here.

   Obviously, not everyone to whom this sort of event happens becomes
   depressed, and not every person who becomes depressed has had this
   sort of catastrophe befall them. In fact, if a person suffers a loss
   and then becomes depressed, it may well be that they weathered the
   loss in fine style and then succumbed to a much less obvious trigger,
   psychological or physical.

   Some depressions may well be caused by a spontaneous aberration in
   brain chemistry, with no trigger that we can currently identify, just
   as a seizure or migraine may have an obvious trigger or be apparently
   spontaneous.

   However, once the depressive state has set in, both physical and
   psychological problems will be generated in abundance. What faster
   way to lose a job or a spouse than to be too depressed to work or to
   communicate? What worse psychological state for coping with a blow to
   identity can there be than a chemically promoted, pathological
   self-hatred? And what can be worse for self-esteem than watching
   one's appearance and household disintegrate as one loses the
   motivation to shower, straighten up, wash dishes or laundry, or
   choose attractive clothes? Health deteriorates as well: some
   depressed people can't sleep or eat, others sleep constantly (a real
   help on the job!) and eat incessantly, sometimes in order to stay
   awake, sometimes because it's the only thing that gives a little
   pleasure or comfort. (Carbohydrates induce production of serotonin,
   so there may be an element of self-medication here); almost no one
   has the impulse to exercise or get fresh air and sunshine. Most if
   not all of these effects form feedback loops, increasing in magnitude
   and becoming triggers for further depression.

   The question, "Is depression mostly physical or psychological," is
   rather beside the point. Depression may be triggered by either
   physical or psychological events. Most commonly, both seem to be
   involved, though it is often difficult to separate the two when one
   is talking about psychology and neurochemistry. But however it
   begins, depression quickly develops into a set of physical and
   psychological problems which feed on each other and grow. This is why
   a combination of physical and psychological intervention has been
   shown to give the best results for most patients, regardless of any
   classifications that doctors may have tried to impose on their
   depression and its cause. 


Treatment
---------

Q. What sorts of psychotherapy are effective for depression? 

   Two effective methods of psychotherapy for people with depressions
   are cognitive therapy and interpersonal therapy. Both psychoanalysis,
   and insight oriented psychotherapy have not been shown to be
   effective treatments for people with a depressive disorder. Cognitive
   (and cognitive-behavioral) therapists can be found in most major
   cities.

   For a referral to a properly trained cognitive therapist practicing
   close to your location, contact:

      Aaron T. Beck, MD.
      The Center for Cognitive Therapy
      3600 Market Street
      Philadelphia, PA 19101
      (215) 898-4100.

   While many therapists call themselves cognitive therapists and
   interpersonal therapists, only a few have had proper training. To
   find an interpersonal therapist with the best training, contact:

      Myrna Weissman, Ph.D.
      New Your State Psychiatric Institute
      722 West 168th Street
      New York, NY 10032
      (212) 996-6390


Medication
----------

Q. Do certain drugs work best with certain depressive illnesses? What
   are the guidelines for choosing a drug?

   There are very few kinds of depression for which there are specific
   antidepressant treatments. When it comes to people with Bipolar
   Disorder who are depressed there are some major problems. Most
   importantly, with any antidepressant, there is a possibility that the
   antidepressant treatment will cause depressed bipolar people not just
   to come out of their depressions, but to develop manic episodes. The
   possibility of an antidepressant causing mania is least when the
   antidepressant is bupropion (Wellbutrin). The possibility of mania is
   greatly reduced if depressed bipolar folks are on a mood stabilizer
   such as lithium, Tegretol or Depakote when they are started on an
   antidepressant.


Q. How do you tell when a treatment is not working? How do you know when
   to switch treatments?

   Antidepressant treatment is clearly not working when the individual
   receiving the treatment remains depressed or becomes depressed again.
   When a recently started antidepressant fails to cause improvement,
   the depressed individual often asks that the medication be stopped,
   and a new one started. It generally does not make sense to change
   antidepressants until 8-weeks at the maximum tolerated dose have
   elapsed. With some tricyclic antidepressants, it is important to
   check the blood level of the antidepressant before it is stopped. The
   blood test can tell if the amount in the blood has been adequate.
   Only after an adequate trial of one antidepressant should another be
   tried. To have been on four antidepressants in an 8-week period means
   that one has not had an adequate trial on any of them.


Q. How do antidepressants relieve depression?

   There are several classes of antidepressants, all of which seem to
   work by increasing levels of certain neurotransmitters (most commonly
   serotonin, norepinephrine, and dopamine) in the brain. It is not
   entirely clear why increasing neurotransmitter levels should reduce
   the severity of a depression. One theory holds that the increased
   concentration of neurotransmitters causes changes in the brain's
   concentration of molecules, receptors, to which these transmitters
   bind. In some unknown way it is the changes in the receptors that are
   thought responsible for improvement. 


Q. Are Antidepressants just "happy pills?"

   No matter what their exact mode of action may be, it is clear that
   antidepressants are not "happy pills." There is no street-market in
   antidepressants, for unlike "speed" which will improve the mood of
   almost everybody, antidepressants only improve the mood of depressed
   people. Also unlike the almost instant effects of speed, the
   mood-improving effects of antidepressants develop slowly over a
   number of weeks. "Speed" induces a highly artificial state,
   antidepressants cause the brain to slowly increase its production of
   naturally occurring neurotransmitters.


Q. What percentage of depressed people will respond to antidepressants? 

   Generally, about 2/3 of depressed people will respond to any given
   antidepressant. People who do not respond to the first antidepressant
   they have taken, have an excellent chance of responding to another.


Q. What does it feel like to respond to an antidepressant? Will I feel
   euphoric if my depression responds to an antidepressant?

   The most common description of the effects of antidepressants is that
   of feeling the depression gradually lift, and for the person to feel
   normal again. People who have responded to antidepressants are not
   euphoric. They are not unfeeling automatons. The are still able to
   feel sad when bad things happen, and they are able to feel very happy
   in response to happy events. The sadness they feel with
   disappointments is not depression, but is the sadness anyone feels
   when disappointed or when having experienced a loss. Antidepressants
   do not bring about happiness, they just relieve depression. Happiness
   is not something that can be had from a pill.


Q. What are the major categories of anti-depressants? 

   There are many classes of antidepressants. Two kinds of
   antidepressants have been around for over 30 years. These are the
   tricyclic antidepressants and the monoamine oxidase inhibitors. While
   there are newer antidepressants, many with fewer side-effects, none
   of the newer antidepressants has been shown to be more effective than
   these two classes of drugs. In fact, many people who have not
   responded to newer antidepressants have been successfully treated
   with one of these classes of drugs.

   The tricyclic antidepressants (TCAs) include such drugs as imipramine
   (Tofranil, amitriptyline (Elavil), desipramine (Norpramin),
   nortriptyline (Aventyl and Pamelor).

   The monoamine oxidase inhibitors (MAOIs) include tranylcypromine
   (Parnate), phenelzine (Nardil), and isocarboxazid (Marplan) which has
   recently been taken off the market in the U.S.A. for marketing rather
   than safety or efficacy reasons.

   One of the popular new classes of antidepressants are the selective
   serotonin reuptake inhibitors (SSRIs). The first of these drugs to be
   marketed in the USA was fluoxetine (Prozac). Sertraline (Zoloft), and
   paroxetine (Paxil) soon followed, and fluvoxamine (Luvox) is
   scheduled to be marketed in late 1994, or early 1995.

   Bupropion (Wellbutrin) is the only drug in its class, as is trazodone
   (Desyrel). The most recently marketed antidepressant (4/94) is
   venlafaxine (Effexor), the first drug in yet another class of drugs.


Q. What are the side-effects of some of the commonly used
   antidepressants?

   Below is a list of some of the more frequently prescribed
   antidepressants, and their most common side effects. The figure
   following each side effect is the percentage of people taking the
   medication who experience that side effect.

   Aventyl (nortriptyline): Dry mouth (15); Constipation (15);
   Weakness-fatigue (10); Tremor (10).

   Effexor (venlafaxine) Nausea (35); Headache (25); Sleepiness (25);
   Dry mouth (20); Insomnia (20); Constipation (15).

   Elavil (amitriptyline): Dry mouth (40); Drowsiness (30); Weight gain
   (30); Constipation (25); Sweating (20).

   Nardil (phenelzine): dry mouth (30); insomnia (25); Increased heart
   rate (25); Lowered blood pressure (20); Sedation (15); Over
   stimulation (10);

   Norpramin (desipramine): dry mouth (15); increased pulse (15);
   constipation (10); reduced blood pressure (10).

   Pamelor - see Aventyl

   Parnate (tranylcypromine) Dry mouth (20); Insomnia (20); Increased
   pulse rate (20); Lowered blood pressure (15); Over stimulation (15);
   Sedation (15).

   Paxil (paroxetine): Decreased sexual interest and/or problems
   achieving orgasm (30); Nausea (25); Sedation (25); Dizziness (15)
   Insomnia (15)

   Prozac (fluoxetine): Decreased sexual interest and/or problems
   achieving orgasm (30); Nausea (20); Headache (20); Nervousness (15);
   Insomnia (15); Diarrhea (15).

   Sinequan (doxepin): Dry mouth (40); Sedation (40); Weight gain (30);
   Lowered blood pressure (25); Constipation (25); Sweating (20).

   Tofranil (imipramine): Dry mouth (30), Reduced blood pressure (30),
   Constipation (20), Difficulty with urination (15).

   Wellbutrin (bupropion): Agitation (30); Weight loss (25), Dizziness
   (20); Decreased appetite (20);

   Zoloft (sertraline): Decreased sexual interest and/or problems
   achieving orgasm (30);Nausea (25); Headache (20); Diarrhea (20);
   Insomnia 15); Dry mouth (15); Sedation (15).


Q. What are some techniques that can be used by people taking
   antidepressants to make side effects more tolerable?

   Listed below are some frequent side effects of antidepressants, and
   some techniques to reduce their severity:

   Dry mouth: Drink lots of water, chew sugarless gum, clean teeth
   daily, ask the dentist to suggest a fluoride rinse to prevent
   cavities, visit the dentist more often than usual for tooth and gum
   hygiene

   Constipation: Drink at least six 8-ounce glasses of water every day,
   eat bran cereals, eat salads twice a day, exercise daily (walk for at
   least 30 minutes a day), ask your doctor about taking a bulk
   producing agent such as Metamucil, also ask about taking a stool
   softener such as Colace, be sure to avoid laxatives such as Ex-Lax.

   Bladder problems: The effects of some antidepressants, especially the
   tricyclic medications may make it difficult for you to start the
   stream of urine. There may be some hesitation between the time you
   try to urinate and the time your urine starts to flow. If it takes
   you over 5-minutes to start the stream, call your doctor.

   Blurred vision: The tricyclic antidepressants may make it difficult
   for you to read. Distant vision is usually unaffected. If reading is
   important to you the effects of the antidepressant can be compensated
   for by a change in glasses. As you may compensate for the change in
   your vision, try to postpone getting new glasses as long as possible.

   Dizziness: Dizziness when getting out of bed or when standing up from
   a chair, or when climbing stairs may be a problem when taking
   tricyclic antidepressants and monoamine oxidase inhibitors. Changing
   posture slowly may help prevent this kind of dizziness. Drinking
   adequate amounts of liquid and eating enough salt each day is
   important. Be sure to speak to your doctor if this side-effect is
   severe.

   Drowsiness: This side effect often passes as you get used to taking
   the antidepressant that has been prescribed for you. Ask your doctor
   if it is safe for you to increase your intake of caffeine, and if so,
   by how much. If you are drowsy be sure not to drive or operate
   dangerous machinery.


Q. Many antidepressants seem to have sexual side effects. Can anything
   be done about those side-effects?

   Both lowered sexual desire and difficulties having an orgasm, in both
   men and women, are particularly a problem with the selective
   serotonin re-uptake inhibitors (Prozac, Zoloft, Paxil and Luvox), and
   the monoamine oxidase inhibitors (Nardil and Parnate). There is no
   treatment for decreased sexual interest except lowering the dose or
   switching to a drug that does not have sexual side effects such as
   bupropion (Wellbutrin). Difficulty having orgasms may be treated by a
   number of medications. Among those medications are: Periactin,
   Urecholine, and Symmetrel. None of these are over-the-counter drugs
   and they must be prescribed by a physician. Unfortunately, many
   psychiatrists are not familiar with using these medications to treat
   the sexual side-effects of antidepressants.


Q. What should I do if my antidepressant does not work? 

   Many people decide that their antidepressant is not working
   prematurely. When one starts an antidepressant the hope is for rapid
   relief from depression. What must be remembered is that for an
   antidepressant to work, you must be on an adequate dose of the drug
   for an adequate length of time. A fair trial of any antidepressant is
   at least two months. Prior to a two month trial the only reason to
   abandon an antidepressant trial is if the medication is causing
   severe side effects. With many antidepressants the dose has to be
   increased at intervals far above the starting dose. Unfortunately,
   the two-month period mentioned above, refers to two months following
   the most recent increase in the dose, not the time from starting the
   particular antidepressant. 

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