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Ask the Mental Health Expert Archives 2001-2004

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Dysthymia and Depression

Q. In addition to psychotherapy, which antidepressants are best used to treat dysthymia and depression? (First line medications.) Which symptoms will it treat? In other words, what sort of relief can a patient expect by taking these drugs? What are the side effects that each drug possess?

A. As your question implies, medication is only part of the approach to depression--psychotherapy is also very important, and there is good evidence that the two together work better than either treatment alone. Indeed, there is some evidence that each kind of treatment may benefit certain symptoms of depression more than others. As a general rule, antidepressants are more likely to help with the somatic aspects of depression, such as insomnia, low energy, impaired concentration, decreased sex drive, etc. (As I'll mention below, some antidepressants can provoke sexual side effects).

Psychotherapy tends to be more useful for the psychological aspects of depression, such as low self-esteem; guilt or feelings of unworthiness; catastrophic thinking; and various interpersonal problems that often complicate depression. Sometimes, medication provides the jump start necessary before a severely depressed individual has the energy to really work in psychotherapy. However, for mild-to-moderate, non-bipolar depression without psychotic features, psychotherapy may suffice for many patients.

Regarding specific antidepressants: in current practice, the so-called SSRIs and their close cousins are usually considered the medications of first choice. These agents include fluoxetine [Prozac], sertraline [Zoloft], paroxetine [Paxil], citalopram [Celexa], and related agents, such as nefazodone [Serzone] and venlafaxine [Effexor]. However, this does not necessarily mean that these agents are always the most effective. Some clinicians continue to believe that for very severe depression, especially in elderly patients, the old standby tricyclic agents are still the most effective. However, owing to the potential toxicity (e.g., in overdose) and numerous side effects of the tricyclics, these are generally regarded as second line agents for most patients.

Common side effects from the SSRIs [Prozac, Zoloft, Paxil, Celexa, Luvox] include gastrointestinal complaints, headache, and (unfortunately) sexual dysfunction. Some patients may complain, initially, of agitation or tremor. The SSRIs may provoke either insomnia or drowsiness in about 1 in 5 patients. Sexual side effects may occur in as many as 60% of patients taking an SSRI (which stands for selective serotonin reuptake inhibitor). Nefazodone is much less likely to provoke this problem. Another non-tricyclic, bupropion [Wellbutrin], is also considered a first-line agent for most depressed patients-not those with a seizure history or an eating disorder, however-and has very little tendency to cause sexual problems.

With the older tricyclics, the typical side effects are dry mouth, blurry vision, constipation, sedation, and lightheadedness or dizziness. The tricyclics can also have some negative effects on the heart. For much more details on specific drugs and their side effects, you can take a look at my book, "Handbook of Essential Psychopharmacology", or "Prozac and the New Antidepressants", by Dr. William S. Appleton. Another excellent source of information on depression is Dr. John Medina's book, "Depression: How it Happens, How It's Healed."

January, 2001

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