Depression Not Getting Better, But Not Out Of Options

Over the past 2.5 years I have been on and off 7 different antidepressants (5 SSRIs, one SNRI) but my doctor has not been satisfied that the benefits outweigh the risks/side effects. He says he is out of drug options and is looking to my psychologist to help me. For about the past year and a half I have consistently struggled with a heightened sensitivity to trauma, TV news, movies, sudden noises (jumpy) that significantly limit my lifestyle. I recall after one antidepressant telling my doctor I now know what anxiety is. Could antidepressants cause these problems – longterm? I have been off the last antidepressant (Trazodone) for about a month.

You raise a number of interesting points with your letter.  Let’s jump to the last issue first . . . can antidepressants cause long-term anxiety issues?  As I have noted in other entries, one of the side effects of antidepressants can be heightened anxiety.  This is typically an early onset side effect caused, presumably, by the rapid increase in the amount of neurotransmitter present between nerve cells.  Remember, the “RI” in “SSRI” stands for “re-uptake inhibitor” . . . a blocking of the recycling channel nerve cells use.  When the recycling is blocked, levels of neurotransmitter between cells goes up.  This provides for the clinical benefit from the medicine, but can also lead to the side effects.  If the anxiety side effect is not too much and you can wait it out, it will often decrease over time.  This does not always happen tho, and sometimes, the anxiety is just too much.  Some people benefit from really, really low starting doses of a medicine that is titrated up very, very slowly.  This can allow your body to get used to it gradually over time.  It may take a longer time to get to the dose that is effective, but it can work.  Some people are just sensitive to the medicine.  

Can the anxiety that is “caused” by the medicine continue when the medicine is stopped?  Not likely.  Once the medicine is gone, the medicine is gone.  We are all changed by our life experience, however.  If you had a particularly traumatic experience from a medicine . . . or a car crash . . . or a soured relationship . . . it can hang with you.  Therapy is absolutely important through the process of treatment, and can help limit the progression of symptoms.  It is difficult (if not impossible) to know if significant anxiety symptoms might have come out over time anyway.  People with significant depression often develop significant anxiety at some point in the illness.  

So, where do you go from here????

I agree with the therapy.  Get yourself a good therapist.

I have no information about your SSRI trials.  Remember, a good trial consists of enough meds for long enough.  If you did not tolerate or were not prescribed medicine with these guidelines in place, then you must start all over (with someone new).  I have several concerns about your brief description of your medicine.  There is little reason to give trials of five SSRI’s.  Generally speaking, if one of my patients does not tolerate or benefit from two SSRI trials, I move on.  I am glad that you had an SNRI trial (again, no idea if it was a complete trial).  But, if that does not work, there is still a huge list of options available for your potential benefit.  That would include use of Wellbutrin to augment the SSRI or SNRI, use of mood stabilizers like Lithium or Abilify, addition of thyroid hormone, stimulants, Provigil, nutritional supplements . . . LOTS OF OPTIONS.  

My point is, don’t despair.  Get yourself a therapist that will work with you on addressing the behavioral and emotional experiences that you are having.  But get yourself in with a psychiatrist who will be thinking creatively (and systematically) with you.  It appears to me (from your brief description) that you have many options left and no reason to think pessimistically.

–Dan Hartman, MD

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