Posted by: thealienist | June 18, 2010

Treatment with Antidepressants for Depression: General Issues

Antidepressant medications come in many forms.  There are some that primarily increase serotonin levels in the brain, such as the serotonin specific reuptake inhibitors (SSRI’s).  Some elevate norepinephrine levels, such as desipramine and atomoxetine.  Some do both, for example venlafaxine and duloxetine.  Others are more unique in their mechanisms of action.  Bupropion increases dopamine levels, and mirtazepine blocks certain serotonin and norepinephrine receptors.  In short, antidepressants can produce their effects in a bewildering number of ways, some of which may be helpful to some people and some of which may be helpful to others.  Still, there are some practical things to know about how to take your medications and get the most out of them.

First, it is important to realize that antidepressants are simply tools that you and your doctor use to achieve your goals.  Just like owning and using a hammer does not necessarily get a house built, buying and swallowing an antidepressant does not necessarily make you happy.  I recommend discussing with your doctor what your goals are for treatment and what your concerns are about medications and therapy.  Consider how you want medications to fit into your life and where you want them to have little impact.  Find out what the medications are capable of and what they are not expected to change.

Antidepressants are often most effective on the neurovegetative symptoms (i.e. physical symptoms) of depression such as changes in sleep and appetite, decreased energy, poor motivation, problems with concentration and memory, and feeling that thoughts and motions are slower than normal.  It is not unusual for patients to find that the medications do not work as well on issues of depressed mood, anhedonia (decreased ability to enjoy activities), guilt, and self-esteem.  It is not that antidepressants cannot help these issues, but that sometimes other things are needed.

Second, antidepressants do not work in a vacuum.  They will not help you sleep if you do not go to bed.  They will not help you eat properly if you do not buy food.  They will not increase your energy if you don’t get out of the recliner.  They won’t improve your concentration and memory if all you do is stare at the walls all day.  Finally (and often most importantly to my patients), antidepressants will not make you happy if you don’t have anything to be happy about.  For example, I once had a patient who came to me on antidepressants and told me that he was very disappointed that he didn’t feel happy.  I asked him what he had to feel happy about, and he replied, “Nothing.”  “Well,” I said, ” then not feeling happy seems to be pretty normal.”  Antidepressants will not make you happy, but they will let you be happy. They won’t make you enjoy activities, but they will let you enjoy activities you would normally enjoy.  They will not make you feel less guilty about yourself, but they will let you feel less guilty if you have activities you are content with or proud of.

For some people, this is the hardest part of taking antidepressant medications.  They have relied on their emotions to push them and motivate them to engage in enjoyable activities, but now that their emotions have failed them, they find it very difficult to do the things that bring joy, happiness, and self-esteem into their lives.  They may find that their energy, concentration, sleep, and appetite are improved but that they simply do not have the joy of living they had before they became depressed.  I strongly believe that in these cases, the psychiatrist or a psychologist should provide therapy to help enable patient to set and achieve goals for meaningful and enjoyable activities.

Third (and finally), antidepressants work slowly.  Patients need patience when they start their treatment.  Antidepressants take weeks to begin working.  I tell my patients that it will take 4-6 weeks on a therapeutic dose of medication before most people will feel the medication start working.  After that, it can take several more weeks (and sometimes changes in medication dosing) before the medication has its maximum effect.  In truth, there are some people who can detect the positive effects of antidepressants after only 2 weeks of treatment, but most are not this fortunate.

In summary, remember that the antidepressant is simply a tool.  Learn to use it wisely and with skill.  Use it not as a substitute for the activities and genuine emotions you once had, but as a means of reclaiming these activities and genuine emotions.  And finally, be patient.  One of the most common causes of people not recovering from depression is that they gave up too soon on treatment.



  1. I think you have arrived at the point! Diagnosed in the early ’90s, I recall a lecture in New York where the MD declared, “psychotherapy may work, I just have never seen it work without medication.”

    Thank you.


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