Is it worth trying antidepressants yet again?
January 28, 2011 8:22 AM Subscribe
Is it worth trying antidepressants yet again, or should I give up on the idea of medicinal assistance in favour of therapy alone? (Very long special snowflake details inside)
Opening disclaimer: YANMD. I have a GP and therapist already, and you are neither of them. I'm hoping for anecdata, lay opinions and general impressions that'll help me figure out for myself what to do next.
I've had mental health issues as far back as I can remember, revolving mostly around depression and anxiety. Since my first diagnosis of depression at the age of fifteen (im now nearly thirty) I've tried a lot of antidepressants of various flavours. With varying results. Some did nothing noticeable at all, some helped my depression whilst making my anxiety worse, and some helped with both but the side effects made the drug impossible to tolerate.
My condition has fluctuated a great deal over the years, being manageable at times, but during rough times I am chronically suicidal, and have been admitted as a voluntary patient twice (both in 2004) and been threatened with being involuntarily sectioned (last November, although fortunately the assessment team changed their minds at the last minute as they had run out of space and funding).
The majority of the antidepressants I've tried were in the period 2003 - 2006. After that I came off all medications because the doctors caring for me believed that it was unlikely anything would help me. I have a therapist who I see regularly and get on well with, and a GP who is sympathetic but not willing to prescribe without explicit instructions from a psychiatrist.
I've had a variety of diagnoses. The current favourites (as far as I can tell, since my therapist thinks labels are unhelpful and to be avoided as much as possible) are depression, anxiety, avoidant personality disorder and maybe borderline personality disorder.
I went through a very rough patch at the end of last year, and feel like I'm starting to dig myself out the other side and get back to what passes for normal for me. I asked my therapist last week if he thought it was worth me trying again with an antidepressant, because I hoped it might help me remain more stable over the next six months or so, as there's going to be a lot of stressful things happening in the foreseeable future, both good and bad. (moving house, restructuring at work, the distinct possibility of needing to find a new job). Bearing in mind the pit I only just dug my way out of, it felt like a good idea to me to try and make plans now for surviving what's about to come before it happens. My therapist is willing to make arrangements for me to see a psychiatrist who could produce the instructions my GP requires in order to get out her prescription pad. However, he says that in his experience, antidepressants can often make the situation worse, because the long process of finding one that has more benefits than drawbacks means raising and dashing hopes over and over, and its too easy to fall into the trap of expecting them to become a magic wand to fix everything, or become more depressed at the apparent evidence that I'm "broken and unfixable" if none of them produce a noticeable effect. He's also wary about the thought of people ending up taking ineffective antidepressants over the long-term, because patients get convinced that even though the drugs aren't helping, everything would fall apart entirely without them. But he says that if I'm certain I want to try this, he'll do what's necessary to make it happen for me.
Just in case this wasn't long enough already - the antidepressants I've tried over the years have been...
* Prozac - in 1996, again in 2003 and 2006. No noticeable effect on 60mg
* Seroxat - in 1996. No noticeable effect on depression, but increased anxiety and irritability
* Citalopram - in 2004. 40mg. Small but noticeable improvement in depression, but nausea and headaches made it impossible to continue.
* Venlafaxine - in 2004. (varied doses at up to 225mg, I think) - my depression improved a little, but I developed postural hypotension. Coincided with a serious increase in suicidal thoughts that resulted in hospitalization. (no idea if this is causal or coincidental)
* Mirtazepine - in 2005. Made me extremely drowsy. GP took me off it again after only two weeks when I collapsed due to low blood pressure. I have no idea if it helped my depression or not - I was too sleepy and out of it to notice.
* Cymbalta - in 2005, and a brief trial again in 2007. Some improvement in depression, but anxiety got a lot worse
* Lofepramine - in 2005. I gained a lot of weight, and noticed no improvement
Tl;dr version: is it still worth asking to try antidepressants again after a long history of trying them before without finding one that worked, given that I'm going to be going through a lot of stress in the near future?
Questions and requests for clarification can be sent to this throwaway email: askmefi.anon4@gmail.com
Opening disclaimer: YANMD. I have a GP and therapist already, and you are neither of them. I'm hoping for anecdata, lay opinions and general impressions that'll help me figure out for myself what to do next.
I've had mental health issues as far back as I can remember, revolving mostly around depression and anxiety. Since my first diagnosis of depression at the age of fifteen (im now nearly thirty) I've tried a lot of antidepressants of various flavours. With varying results. Some did nothing noticeable at all, some helped my depression whilst making my anxiety worse, and some helped with both but the side effects made the drug impossible to tolerate.
My condition has fluctuated a great deal over the years, being manageable at times, but during rough times I am chronically suicidal, and have been admitted as a voluntary patient twice (both in 2004) and been threatened with being involuntarily sectioned (last November, although fortunately the assessment team changed their minds at the last minute as they had run out of space and funding).
The majority of the antidepressants I've tried were in the period 2003 - 2006. After that I came off all medications because the doctors caring for me believed that it was unlikely anything would help me. I have a therapist who I see regularly and get on well with, and a GP who is sympathetic but not willing to prescribe without explicit instructions from a psychiatrist.
I've had a variety of diagnoses. The current favourites (as far as I can tell, since my therapist thinks labels are unhelpful and to be avoided as much as possible) are depression, anxiety, avoidant personality disorder and maybe borderline personality disorder.
I went through a very rough patch at the end of last year, and feel like I'm starting to dig myself out the other side and get back to what passes for normal for me. I asked my therapist last week if he thought it was worth me trying again with an antidepressant, because I hoped it might help me remain more stable over the next six months or so, as there's going to be a lot of stressful things happening in the foreseeable future, both good and bad. (moving house, restructuring at work, the distinct possibility of needing to find a new job). Bearing in mind the pit I only just dug my way out of, it felt like a good idea to me to try and make plans now for surviving what's about to come before it happens. My therapist is willing to make arrangements for me to see a psychiatrist who could produce the instructions my GP requires in order to get out her prescription pad. However, he says that in his experience, antidepressants can often make the situation worse, because the long process of finding one that has more benefits than drawbacks means raising and dashing hopes over and over, and its too easy to fall into the trap of expecting them to become a magic wand to fix everything, or become more depressed at the apparent evidence that I'm "broken and unfixable" if none of them produce a noticeable effect. He's also wary about the thought of people ending up taking ineffective antidepressants over the long-term, because patients get convinced that even though the drugs aren't helping, everything would fall apart entirely without them. But he says that if I'm certain I want to try this, he'll do what's necessary to make it happen for me.
Just in case this wasn't long enough already - the antidepressants I've tried over the years have been...
* Prozac - in 1996, again in 2003 and 2006. No noticeable effect on 60mg
* Seroxat - in 1996. No noticeable effect on depression, but increased anxiety and irritability
* Citalopram - in 2004. 40mg. Small but noticeable improvement in depression, but nausea and headaches made it impossible to continue.
* Venlafaxine - in 2004. (varied doses at up to 225mg, I think) - my depression improved a little, but I developed postural hypotension. Coincided with a serious increase in suicidal thoughts that resulted in hospitalization. (no idea if this is causal or coincidental)
* Mirtazepine - in 2005. Made me extremely drowsy. GP took me off it again after only two weeks when I collapsed due to low blood pressure. I have no idea if it helped my depression or not - I was too sleepy and out of it to notice.
* Cymbalta - in 2005, and a brief trial again in 2007. Some improvement in depression, but anxiety got a lot worse
* Lofepramine - in 2005. I gained a lot of weight, and noticed no improvement
Tl;dr version: is it still worth asking to try antidepressants again after a long history of trying them before without finding one that worked, given that I'm going to be going through a lot of stress in the near future?
Questions and requests for clarification can be sent to this throwaway email: askmefi.anon4@gmail.com
Have they never tried you on a pair of drugs, one for depression and one for anxiety? I thought that was fairly common. Sometimes they give you a daily depression drug (such as those you mention above) and an "acute" anxiety drug that you take just when the anxiety is bad, or when you have a panic attack, such as Xanax.
Lots of anti-depressants don't touch anxiety, and the anxiety can become surprisingly crippling as the depression starts to clear up.
(On the flip side, I personally found anxiety a lot easier to attack with therapy than depression was, though I imagine it varies considerably from person to person.)
posted by Eyebrows McGee at 8:32 AM on January 28, 2011
Lots of anti-depressants don't touch anxiety, and the anxiety can become surprisingly crippling as the depression starts to clear up.
(On the flip side, I personally found anxiety a lot easier to attack with therapy than depression was, though I imagine it varies considerably from person to person.)
posted by Eyebrows McGee at 8:32 AM on January 28, 2011
Nobody knows if a new drug will help you when other ones didn't. If therapy alone is not doing it, what's the worst that could happen if you went to a psychiatrist with this medication history and said, "Tried these. What else you got?" Maybe there's something new in the past four years. And of course you need to make sure you're doing the other things to help yourself, such as exercise, nutrition, sleep, activity, and interaction. If you've got all of the bases covered that can be covered without medicine, it won't hurt to ask.
posted by Askr at 8:34 AM on January 28, 2011
posted by Askr at 8:34 AM on January 28, 2011
I know you were looking for more general advice, but I would think trying escitalopram (Lexapro) would make sense if you were going to try smething It is similar to citalopram (citalopram is a mixture of two configurations of a molecule, and escitalopram is just one configuration, supposedly the effective one) but with fewer side effects. Since citalopram helped you a noticeable amount but had side effects, it seems like a good option.
More general advice: I kind of relate to what your therapist said. The whole host of antidepressants I tried, even the ones that helped, never did as much as life changes/restructuring for me, and sometimes being on them I felt less...agency, I suppose. But I don't have suicidality at all.
posted by needs more cowbell at 8:41 AM on January 28, 2011
More general advice: I kind of relate to what your therapist said. The whole host of antidepressants I tried, even the ones that helped, never did as much as life changes/restructuring for me, and sometimes being on them I felt less...agency, I suppose. But I don't have suicidality at all.
posted by needs more cowbell at 8:41 AM on January 28, 2011
Have you tried combining medications? Citalopram alone helps me, but not enough - I felt better, but still very, very low when I first went on it. I added Provigil, which helped significantly, but I was still quite hopeless. Then, we added Abilify, and with those three together I am stable and not depressed. I had about 5 years of continuous depression (at times moderate, at times very severe), and now that I'm on the three meds together (plus therapy), I haven't been depressed at all for about a year.
posted by insectosaurus at 9:36 AM on January 28, 2011
posted by insectosaurus at 9:36 AM on January 28, 2011
Did the periods you were taking antidepressants make you feel worse/agitated? I ask because this happened to me for *years* before someone suggested that maybe I was Bipolar II and so antidepressants (particularly SSRIs) were actually making the situation worse. And of course when they made me worse, Drs would add on a bunch of other treatments (antipsychotics, antianxieties, mood stabilizers, eventually ECT) to try & even it all out - until there was a whole raft of side effects to deal with, and no results.
Once I got the Bipolar II diagnosis, I went on Lamictal (a mood stabilizer also used for nonresponsive depression) in 2003, was able to drop everything else, and have been stable & happy ever since. I'm not saying that this is your situation, but it's worth a discussion with your doc.
posted by media_itoku at 10:06 AM on January 28, 2011
Once I got the Bipolar II diagnosis, I went on Lamictal (a mood stabilizer also used for nonresponsive depression) in 2003, was able to drop everything else, and have been stable & happy ever since. I'm not saying that this is your situation, but it's worth a discussion with your doc.
posted by media_itoku at 10:06 AM on January 28, 2011
Do you ever have (mild) mania - not full-blown, but feeling very hyper, charged-up, talkative? I, too, tried every anti-depressant - at least a dozen - and nothing worked. Nobody recognized my mild mania, because I never saw it as a problem, and only sought treatment for my depression.
A gifted psychiatrist finally figured it out, and diagnosed me as Bipolar II. I went on Lamictal - which is a mood-stablizer, not an antidepressant, per se - and for me, it was miraculous. My depression, which was severe and debilitating, as yours has been, lifted to the point of manageability. I've been on Lamictal (as well as a couple of other bipolar-specific meds; the disorder generally requires more of a "cocktail") for about four years, and so far it is working well.
(Lamictal is also used off-label for depression, I believe, though results have been mixed. It could be worth a try, though, since it has - at least, as far as I've been told - a different mechanism than traditional anti-depressants.
Good luck. Please feel free to message me if you have any questions.
posted by soulbarn at 10:11 AM on January 28, 2011
A gifted psychiatrist finally figured it out, and diagnosed me as Bipolar II. I went on Lamictal - which is a mood-stablizer, not an antidepressant, per se - and for me, it was miraculous. My depression, which was severe and debilitating, as yours has been, lifted to the point of manageability. I've been on Lamictal (as well as a couple of other bipolar-specific meds; the disorder generally requires more of a "cocktail") for about four years, and so far it is working well.
(Lamictal is also used off-label for depression, I believe, though results have been mixed. It could be worth a try, though, since it has - at least, as far as I've been told - a different mechanism than traditional anti-depressants.
Good luck. Please feel free to message me if you have any questions.
posted by soulbarn at 10:11 AM on January 28, 2011
(In other words, ditto @media_itoku's answer, which he was typing almost concurrently with mine.)
posted by soulbarn at 10:13 AM on January 28, 2011 [1 favorite]
posted by soulbarn at 10:13 AM on January 28, 2011 [1 favorite]
I tried over a dozen medications over the course of a decade before I found something that worked for me. When I found it, it wasn't a magical cure that made me feel happy and fulfilled. What it did was enable me to function in a way I hadn't been able to before, and in that respect, it changed my life.
Also note that there are no effective drugs without side effects. If you find something that works for you, it will probably mean accepting some side effects you don't particularly enjoy.
Some suggestions:
Lithium, either by itself or to augment other drugs, particular if you have a problem with mood fluctuations (sudden and unexplained periods of suicidality could fall within this category).
Wellbutrin is entirely unrelated in mechanism to the drugs you mentioned, so it would at least be something new. However, it also stands a pretty good chance of increasing your anxiety.
Buspirone could help with your anxiety, and possibly your depressive symptoms as well.
Venlafaxine at a higher dose. Up around the 275mg mark, it starts to act on dopamine in addition to serotonin and norepinephrine.
Mirtazepine at a higher dose, or over a longer period of time. This drug has a reputation for being effective for refractory (that is, treatment-resistant) depression. You will definitely feel like a zombie at the beginning, but that side effect lessens over time. There is also anecdotal evidence that, paradoxically, fatigue decreases with higher doses.
MAOIs. This would be an option of last resort, as the side effects and risk profile are severe. However, some people find them effective when more contemporary drugs fail to work.
Finally, therapy: some forms are equal in efficacy to antidepressants, and people who use therapy and antidepressants simultaneously have the best statistical outcome. However, just because you get along well with your therapist doesn't mean it's helping you. Cognitive-behavioral therapy has a fair amount of evidence to support its effectiveness. Other types of therapy, not so much.
Good luck.
posted by dephlogisticated at 10:33 AM on January 28, 2011 [1 favorite]
Also note that there are no effective drugs without side effects. If you find something that works for you, it will probably mean accepting some side effects you don't particularly enjoy.
Some suggestions:
Lithium, either by itself or to augment other drugs, particular if you have a problem with mood fluctuations (sudden and unexplained periods of suicidality could fall within this category).
Wellbutrin is entirely unrelated in mechanism to the drugs you mentioned, so it would at least be something new. However, it also stands a pretty good chance of increasing your anxiety.
Buspirone could help with your anxiety, and possibly your depressive symptoms as well.
Venlafaxine at a higher dose. Up around the 275mg mark, it starts to act on dopamine in addition to serotonin and norepinephrine.
Mirtazepine at a higher dose, or over a longer period of time. This drug has a reputation for being effective for refractory (that is, treatment-resistant) depression. You will definitely feel like a zombie at the beginning, but that side effect lessens over time. There is also anecdotal evidence that, paradoxically, fatigue decreases with higher doses.
MAOIs. This would be an option of last resort, as the side effects and risk profile are severe. However, some people find them effective when more contemporary drugs fail to work.
Finally, therapy: some forms are equal in efficacy to antidepressants, and people who use therapy and antidepressants simultaneously have the best statistical outcome. However, just because you get along well with your therapist doesn't mean it's helping you. Cognitive-behavioral therapy has a fair amount of evidence to support its effectiveness. Other types of therapy, not so much.
Good luck.
posted by dephlogisticated at 10:33 AM on January 28, 2011 [1 favorite]
I have a GP and therapist already
But you do not have a psychiatrist who specializes in psychopharmacology. You should at least see someone like that and investigate medication options with them before you write off the whole idea of medication.
GPs simply can't keep up with the floods of information on medication options and results for every single ailment they treat, so that's why they send people whose conditions don't respond to the basic repertoire of treatments to specialists. You need to see a specialist.
posted by Sidhedevil at 10:54 AM on January 28, 2011
But you do not have a psychiatrist who specializes in psychopharmacology. You should at least see someone like that and investigate medication options with them before you write off the whole idea of medication.
GPs simply can't keep up with the floods of information on medication options and results for every single ailment they treat, so that's why they send people whose conditions don't respond to the basic repertoire of treatments to specialists. You need to see a specialist.
posted by Sidhedevil at 10:54 AM on January 28, 2011
I know you already have a therapist, but my advice would be to look for a Dialetical Behavior Therapy (DBT) program. I think your therapist is right about why he/she is reluctant to recommend further medication. The red flag for me when reading this post was the mention of personality disorders. Personality disorders are chronic and don't tend to respond as well to medication (plus a lot of mood symptoms can be secondary to the personality issue). DBT is specifically designed to treat Borderline Personality Disorder, but I think it teaches a lot of really useful coping skills that basically anyone could benefit from. If you're anticipating a lot of stress in the near future, the best thing you can do is arm yourself with a repertoire of effective coping skills so that you can deal with the stress without running away or being hospitalized. DBT groups are very popular, but there are also plenty of self-help books (1, 2) and online information. If I were you, I'd ask your therapist to recommend some adjunct therapy groups or books to help make your existing thearpy more effective.
posted by Mrs.Spiffy at 10:56 AM on January 28, 2011
posted by Mrs.Spiffy at 10:56 AM on January 28, 2011
Go see a psychiatrist even if you don't plan on taking any medication. A good psychiatrist will work with you to decide if medication is likely to help you. If he/she ignores your reservations, find another psychiatrist.
posted by shponglespore at 11:44 AM on January 28, 2011
posted by shponglespore at 11:44 AM on January 28, 2011
I have depression and anxiety, and went through a very long period of trying different drugs, none of which really helped. I got a therapist who believed that medication could benefit me, and then I started looking for a psychiatrist. A lot of them were too busy to take new patients. That was a blessing in disguise, because I ended up have brief converstations with a number of doctors, and each one recommended one or two other people for me to call.
I don't know if it's to your benefit to be seeing a therapist who's ambivalent about medications for you. You want your therapist and psychiatrist to have the same goal. Have you heard the term "nocebo effect"? A treatment can be less effective when someone treating you doesn't believe it's going to work. I don't know how much research there is, if any, but it stands to reason that the patient/client is affected by it, since a care-givers positive bias can promote positive results.
When you call a psychiatrist, say that some doctors told you they didn't think antidepressants could help you. See what the reaction is. A good psychiatrist is unwilling to call a patient treatment resistant, and believes that some combination of meds will at least make things better so therapy will be more beneficial. Also, they know that all SSRIs, for example, work differently from one another and that each SSRI works differently for different people. One doc told me, "Prozac stopped helping you, so there's no sense in trying another drug in that class." He was mistaken, but I didn't find that out till another MD prescribed Celexa for me.
My husband takes moderate doses of 3 drugs for his anxiety and anger. One is a mood stabilizer. I take 4 drugs. Celexa helps hugely with anxiety, but dulls my mind. So I use a little Celexa, plus two other anti-anxiety drugs in small amounts. And I take Wellbutrin to counteract side effects from Celexa. But you don't get this kind of approach from a so-so psychiatrist.
If a really good psychiatrist says he or she can't take a new patient, ask for a consultation anyway and write down what they say. You can learn a lot, plus the doctor, after talking to you, might suddenly become interested in treating you. Some of these docs love a challenge.
A relative of mine was diagnose with a personality disorder, which, as "everyone knows" is permanent. Afyer many years, a phychiatrist at a psychiatric hostpital recognized that a lot of the bad things she did were actually ways of getting relief from her own extreme anxiety and very sensitive, changeable emotions. Treating the diagnosis can really lead you down the wrong road.
posted by wryly at 2:13 PM on January 28, 2011
I don't know if it's to your benefit to be seeing a therapist who's ambivalent about medications for you. You want your therapist and psychiatrist to have the same goal. Have you heard the term "nocebo effect"? A treatment can be less effective when someone treating you doesn't believe it's going to work. I don't know how much research there is, if any, but it stands to reason that the patient/client is affected by it, since a care-givers positive bias can promote positive results.
When you call a psychiatrist, say that some doctors told you they didn't think antidepressants could help you. See what the reaction is. A good psychiatrist is unwilling to call a patient treatment resistant, and believes that some combination of meds will at least make things better so therapy will be more beneficial. Also, they know that all SSRIs, for example, work differently from one another and that each SSRI works differently for different people. One doc told me, "Prozac stopped helping you, so there's no sense in trying another drug in that class." He was mistaken, but I didn't find that out till another MD prescribed Celexa for me.
My husband takes moderate doses of 3 drugs for his anxiety and anger. One is a mood stabilizer. I take 4 drugs. Celexa helps hugely with anxiety, but dulls my mind. So I use a little Celexa, plus two other anti-anxiety drugs in small amounts. And I take Wellbutrin to counteract side effects from Celexa. But you don't get this kind of approach from a so-so psychiatrist.
If a really good psychiatrist says he or she can't take a new patient, ask for a consultation anyway and write down what they say. You can learn a lot, plus the doctor, after talking to you, might suddenly become interested in treating you. Some of these docs love a challenge.
A relative of mine was diagnose with a personality disorder, which, as "everyone knows" is permanent. Afyer many years, a phychiatrist at a psychiatric hostpital recognized that a lot of the bad things she did were actually ways of getting relief from her own extreme anxiety and very sensitive, changeable emotions. Treating the diagnosis can really lead you down the wrong road.
posted by wryly at 2:13 PM on January 28, 2011
If you want to try drug therapy again, definitely look into welbutrin or MAOIs. Ask your docs whether they could be good choices for you. MAOI's bad reputation is often overblown.
posted by DarkForest at 3:24 PM on January 28, 2011
posted by DarkForest at 3:24 PM on January 28, 2011
2nding DBT. It was a lifesaver for me.
Nthing combining meds. My current cocktail includes Lexapro plus one of the tricyclic ADs plus Valium. Works a treat for me.
Previously, when in a period of severe depression (like 6 months inpatient severe) I was on a combo of 2 ADs, a mood stabilizer, an antianxiety, an antipysychotic and Cytolmel which is actually a thyroid med. There was nothing wrong with my thyroid, but it seems it can boost the affects of ADs.
posted by kathrynm at 7:11 AM on January 29, 2011
Nthing combining meds. My current cocktail includes Lexapro plus one of the tricyclic ADs plus Valium. Works a treat for me.
Previously, when in a period of severe depression (like 6 months inpatient severe) I was on a combo of 2 ADs, a mood stabilizer, an antianxiety, an antipysychotic and Cytolmel which is actually a thyroid med. There was nothing wrong with my thyroid, but it seems it can boost the affects of ADs.
posted by kathrynm at 7:11 AM on January 29, 2011
This thread is closed to new comments.
posted by mareli at 8:26 AM on January 28, 2011 [1 favorite]