Most prescriptions for SSRIs are written by general practitioners and other nonpsychiatric MDs, and indeed that’s how the drugs have been marketed, both to consumers and to the medical community. Many doctors were glad to have something to give their stressed-out patients who really had no physical complaints. But I strongly recommend to most patients that they consult a psychiatrist for depression. (An APRN, Advanced Practice Registered Nurse, who has training in psychiatry may be an alternative to a psychiatrist, since there are so few of them in parts of the country.) Prescribing for depression is as much an art as it is a science, and good psychiatrists or APRNs often have an educated guess about which medication will be most effective for you. It can save you months of frustration, trying one pill after another. Psychiatrists and APRNs know much more about appropriate dosing and auxiliary medications. They specialize in this stuff, and they can see things that you can’t and your GP doesn’t have the training for, including the ability to track you over time to get a better idea about what’s working and what isn’t. I know that psychiatrists are in short supply, and there are some bad ones out there. If you’re working with a therapist who is pretty up-to-date about meds, he or she may be able to collaborate with your GP to find something that works for you right off the bat, but if that first try doesn’t work, please find a psychiatrist.
Another reason I make this recommendation is that if your first try at meds doesn’t work, your depression—and the idea that there is no help for you—is reinforced. Remember that most patients don’t complete the first three months of a medication trial, and even fewer will go back for a second; so try to get it right the first time.
If you’re seriously depressed and you don’t respond to the first antidepressant you try, you should definitely try another. Each medication helps about 50-60 percent of the people who try it, but it’s a different group for each drug. If A doesn’t work for you, there’s still a better-than-average chance that B will.
If you don’t reach an optimal response (close to cured) within six months or so on a medication that is working somewhat, it’s likely that your psychiatrist will want to add something as a secondary medication. Maybe not another SSRI, but perhaps Wellbutrin, or a mood stabilizer, or something to help you relax, or energize you. Even a tricyclic. Although this is increasingly common practice, and makes intuitive sense, your psychiatrist is experimenting with you. I actually endorse this if a medication has helped only so much, but you should be aware. Because drug companies sponsor almost all research in the U.S. now, and because the cost of research is so high, research on the effects of two medications at the same time is still relatively rare. The drug companies don’t want to know; finding a pattern might give a lead to their competition.
As for “polypharmacy,” your doctor trying you out on multiple different drugs, it depends. If your doctor is connected to a big research hospital and is really up on the latest developments, you might want to give her more rope than someone in a private practice who rarely takes the trouble to educate himself. If you feel that your doctor has stopped caring and is essentially throwing darts at you, find another doctor.
Some doctors may not want to tell you that medications are doing all they can for you; they may follow your lead if you want to keep trying the latest drug or drug combo. But you may reach the point where you don’t want to experiment any more, and that can be a wise decision. You may decide that your current medication regime is doing a reasonable job, and that you have to stop hoping for a magic bullet and start trying to change the way you live.
You may need to be on a medication a long time. With major depression, the more episodes you have, the more likely you are to have more; the sooner you stop your medication, the more likely you are to relapse. The general guideline is to stay on your medication at least six months after you feel symptom-free. Some people who have had many episodes should consider staying on a maintenance dose even longer than that, even for the indefinite future, if the side effects aren’t too troublesome. I say this despite my warning in the next section that SSRIs may be artificially insulating you from life. In the studies that follow people beyond an initial three-month treatment period, most patients relapse. But the chances of relapse go down if you don’t quit your meds too soon. That's why treatment has to go beyond the standard paradigm, be longer, more intensive, use medications as long as necessary, and include a strong component of education, self-help, and aftercare. In one study that followed people over 5 years, only half of patients with dysthymia reached full recovery, and of those half relapsed. Many developed major depression. It's now generally recognized that if you have one episode of major depression, your odds of having another are 50 percent; if you have three episodes, your odds of having more are 90 percent. But if you stay in psychotherapy, take a maintenance dose of medication, and really work on your own recovery, you can beat these odds.
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