Re-occuring depression . . . an attack of tachyphylaxis

Laurie writes in with the following observation . . . 

A few years ago, it would make me sad knowing I might be on anti-depressants and/or mood stabilizers for the rest of my life. (I have been diagnosed with major depression, but several psychiatrists, including my current one, have suspected bipolar II disorder.) Because I had previously had several recurrent episodes of depression for years before I sought medical help, it seemed likely that I wouldn’t just “wake up” one day and be free from depression or bipolar disorder forever as I had always hoped. I think it’s a hard thing to be in your early 20s and realize you’ll be taking pills everyday for possibly the rest of your life.

Right now, though not thrilled with taking pills daily, what worries me more is not that I’ll be taking a pill for the rest of my life, but instead that I might have to try new medications every few years when my current medication stops working. It is the fear that my worst depression will come back despite being on drugs and trying to take care of myself. I can deal with being on the same medication for the rest of my life; it is having to experiment with different kinds that is the worst. I experienced this in the spring of 2007 after several years of taking a medication that had been effective, and my psychiatrist and I are still working on finding the right medication for me.

The observation that you make is not uncommon.  Tachyphylaxis is the fancy term used to describe the waning of benefit that some people experience from antidepressants or other medication.  While not the typical experience, it does occur and, when it is a recurrent phenomenon, it is puzzling and troubling.  There are a number of ways to help minimize the risk of this occurring and there are strategies to address it once it does occur.  To minimize the risk, patients should do all those healthy things we have talked about before–take the medicine as prescribed, eating right, getting proper amounts of sleep, taking nutritional supplements, exercise, etc., (sounds like a list of New Year’s resolutions!!!).  Despite your best efforts, you may still experience a lessening of benefit from the medicine.  What do you do then???

If you are on a medicine that has been effective, the dose of that medicine should be maximized to either the maximum recommended dose or to where side effects become prohibitive.  If that does not work, a change of medicine is in order.  This can be to one of the other agents in this class (for example, switching from Prozac to Zoloft).  If you have already tried two agents in the same class, a trial of a medication with a different mechanism of action should be considered.  There are other strategies as well, including combining various antidepressants (usually this involves adding Wellbutrin to another agent), and use of augmenting strategies such as Lithium or thyroid supplementation.  If you do have a diagnosis of Bipolar II, the picture becomes more complicated because of the risk of precipitating mania with the antidepressants.  Lamictal can be used either alone or in combination with low doses of standard antidepressants to address depressive symptoms in patients with Bipolar Disorder.  Mood stabilizers may need to be utilized to help blunt the stimulating effects of antidepressants. 

This obviously becomes very complicated.  As always, it is important that you have a relationship with your psychiatrist that allows for good communication.  It is also important to have family and/or friends who are there to help you during this difficult time.  It is often a waiting game . . . relief from the symptoms can take weeks or even months to occur.  It is hard not to feel like a failure or feel like you just want to give up.  Despite the difficulty of these re-occurring episodes of depression, they do tend to resolve over time with therapy, support and medication assistance. 

–Dan Hartman, MD