mental health mondays :: as nature intended

it's really, really easy to hate drug companies. they kill hundreds of thousands of lab animals, use the poor as guinea pigs for their concoctions, occasionally fake studies or slant information in order to make their products appear better, they bribe doctors to recommend their product rather than the competition's and they occasionally release poisons that harm or kill innocent people. not warm and cuddly stuff, that.

as a reaction to the harshness of medications and the questionable ethics of pharmaceutical providers, the last few decades has seen the rise of alternative medicine. their credo is simple: nature provides many nutrients that can ease the pain of a wide variety of diseases without incurring the problems of harmful side effects, addiction or difficult withdrawal, or the risks of long-term use of medications.

the downside, which most reasonable naturopaths will admit, is that they are less effective on the whole than pharmaceuticals and they often take a lot longer to reach therapeutic levels. that makes them chancy, but a lot of people would still start with an herbal option rather than jumping into the murky waters of chemical madness (or madness management, as the case may be). after all, if you want to seek treatment, you don't start at the extreme end, because then you'd have no place to go, right?

right. and wrong. maybe. or not. you see, the cases for and against herbal remedies are more complicated than most of us want to imagine. to start with, there is the problem of regulation. in most countries, herbal medicine is unregulated, meaning that the manufacturers can fill their packaging with very nebulous claims and unless they make a specific statement as to the benefits and improvement that can be expected, they don't need any backup whatsoever. i don't mean just that they don't have to have any backup they've done themselves, they don't need any at all. so many herbal medicines are marketed purely on the basis that people have been taking them to help with the same condition for a number of years. it doesn't ever necessarily need to have worked, it just has to have been taken.

that isn't to say that there aren't studies that have been done on natural remedies. there have been some that are extremely well structured and that have important implications for the long-term management of conditions like chronic anxiety, depression and panic disorder. more on that a little later.



although i'd been intending to write about this subject for a while, i got inspired to do so this week by this piece on the always engaging neuroskeptic blog. there are a couple of salient points in there, at least one of which is something that most advocates of homeopathy don't want to admit- their wares are poisons and the reactions they cause are a form of toxic shock. still feel good about taking those green capsules before bed every night?

the other point that i found intriguing there was that many of the pharmaceuticals we now take are actually refined from natural ingredients in order to capture their analgesic, anxiolytic or anti-depressant qualities, while actually stripping away some of the stuff that's going to make you sick or kill you in other ways. the more one investigates it, the harder it becomes to draw a solid line between what constitutes a natural remedy versus a pharmaceutical one. that said, here's a little bit of information on some of the most popular herbs recommended for dealing with mental disorders.

nepeta cataria :: catnip to you

catnip :: it's not just for watching fluffy get all crazy happy anymore! most people are aware that you can make a nice and fairly tasty tea [the plant itself is a member of the mint family, so that's not surprising]. many, however, also insist that it is an effective anxiolytic at the same time. in fact, there's precious little research that would indicate anything of the sort.

what is known is that nepetalactone, the ingredient in catnip that gives it its mojo, is a weak sedative and anti-spasmolytic, meaning that it is capable of calming you if you're in the throes of a panic attack. its sedative properties also make it appropriate for use as a sleep aid for insomnia resulting from depression or anxiety disorders.

in larger doses, catnip produces effects much like those of marijuana. taken to an extreme, it can cause hallucinations, euphoria, panic and anxiety. kind of a bugger those last two, no? fortunately, the toxic side effects clear pretty quickly once the drug is out of your system. and since it also has emetic properties [i.e., makes you vomit], it's likely to get out of your system in a hurry.

other members of the lamiaceae family [such as lavender and skullcap] have similar properties and uses. like catnip, none of them have been shown effective in the management of depression or other mood disorders. like benzodiapines, they are most effective if taken in response to a panic attack.

valerian :: this is an interesting and quixotic little plant. unlike many other herbal supplements and remedies, the mechanism of action of valerian is reasonably well understood. you can certainly understand why it would be of interest to people studying mental disorders when you look at it.

it's been widely known for many years that valerian is effective in combating insomnia and other sleep disorders, but what is interesting for students of mental health is that its sedative effect appears to be the result of its affinity for a particular gaba receptor. huh? ok, we're falling into medical talk here, but the important thing about that, is that it is the same way that benzodiazepines work on the brain. so you'd think that there might be some potential for it as an anti-depressant or anxiolytic.

that sounds great, except that this is one of the drugs that people have been trying to study in a clinical setting and the tests have come back with squat. some show that it can be used as an alternative therapy to benzos. other tests show it's completely ineffective. everyone thinks that it should work, but no one can come up with a clear answer one way or another and no one can replicate anyone else's findings. even worse, some of the studies have even called into question its sedative properties.

it seems like the only thing more confusing than having no information on these remedies is actually getting information on them.

in the end, there is more data supporting valerian's effectiveness at combating anxiety in the short term, more effectively than catnip and its cousins, for that matter. it does not have the risk of overdose that catnip has, although, as with any sedative, you shouldn't plan on driving or mowing the lawn if you've taken it. two things you'll want to keep in mind, however: 1. valerian doesn't get along with other depressants meaning alcohol, opiates or other herbs [like catnip]; and 2. valerian can start to cause side effects similar to benzodiazepines when taken regularly, even over a relatively short term.


kava :: brought to us from the south sea islands, kava is a relative newcomer to the herbal anti-depressant scene. traditionally, it is consumed as a beverage that, after about half an hour, makes you feel relaxed, social, slightly numb and happy. at first glance, this might seem like treating depression with beer, but the science is a little more complicated. kava also works on gaba receptors, meaning that it works in a similar method as benzodiazepines and valerian.

the difference is that kava, while not extensively studied, has yielded more consistent results, indicating that it outperforms a placebo and that it can function quite well as an anxiolytic. it's even being investigated for its potential in helping fight certain forms of cancer [nothing confirmed yet, but initial results seem positive].

there being no good news without bad news, the bad news is that there is a lot of controversy surrounding kava and not just because there are some obvious parallels with alcohol.

kava

first, kava is known to cause problems with basically all other drugs you might take for a mental disorder- anti-depressants, anti-convulsants, mood stabilisers, the works.

second, sustained use of kava is associated with rashes, particularly skin that turns scaly and yellow. this goes away once one stops taking the herb, but nothing else seems to help.

third, if you are going to take kava, be very, very, very careful. kava was banned in many countries in the early 2000s and is still illegal in many places. the european union has only recently listed its outright ban, in light of kava's potential use as an anti-cancer agent. in canada, its legal status is confusing at best- retailers were ordered to stop selling it in 2002, but this is not the same as its being declared a banned substance. good luck figuring that out.

the story behind this relates to all the same horrors that are normally associated with the pharmaceutical trade. in the late 90s and early 00s, kava became something of a darling amongst those interested in exploiting the various properties of plants. as a result, demand for kava shot through the roof. suppliers could never get their hands on enough of it to process into pills and elixirs to be sold to the public. as a result, manufacturers ended up using parts of the plant that were normally discarded in traditional preparations. turns out they were discarded for a reason. the natives of the south pacific islands, it seems, have evolved a perfect system for preparing kava and that when you prepare it in other ways, it becomes a fairly virulent toxin capable of causing moderate to severe liver damage. oops.

in the subsequent ten years, kava has been exonerated from many of the charges leveled against it, largely because australia was careful to point out that its manufacturers followed the traditional method of preparation and no one got sick. still, there are always unscrupulous vendors out there [don't kid yourself- there is a lot of money in herbal supplements, as a quick perusal of your junk mail folder will reveal] and with something that can cause liver damage when it's made wrong, you want to make sure what you're getting is premium.

st. john's wort :: this is probably the herb that most people have heard of when it comes to alleviating depression. it's actually been used as an anti-depressant for years and it's even prescribed in some countries as a first-line treatment, particularly for children.

and there's a reason for that. it does work. that isn't a surprise, because its active ingredients [hypericin and hyperforin if you're interested] inhibit the reuptake of neurotransmitters serotonin and norepinephrine. that's right, st. john's wort is an herbal version of the pills your doctor would prescribe. not only that, but st. john's wort is also a monoamine oxidase inhibitor. what does that mean in english? it means that this weed is like every anti-depressant on the market all rolled into one perfect little package.

st. john's wort

studies have established that it is more effective than a placebo and comparably effective to tricyclic anti-depressants and ssri's at managing mild depression, or incidental [non-chronic] depression. even better, it won't make your skin fall off, turn your eyes inside out or anything else scary. it has a lower side effect profile and was generally better tolerated than its pharmaceutical counterparts. its effectiveness on major or chronic depression is a lot sketchier, but put it this way: if you're feeling low and you're not sure what you have constitutes a severe depressive episode, st. john's wort is a pretty solid alternative treatment to start with.

let me stress something there: alternative. the biggest problem with st. john's wort is that, because it works in the same way as other anti-depressants,  it can't be taken with any other anti-depressants. doing so can result in something called serotonin syndrome, which can be fatal. so you really do have to choose one line of treatment at a time. don't ever cross the streams.

omega-3 :: is there anything these nifty little acids can't do? omega-3 is the new kava, that thing that needs to be consumed in foods, taken in supplements and added to everything. the good news is, there's lots of research that's been done that shows that omega-3s absolutely do have an effect on the brain. even better news, you can take omega-3 supplements at the same time as other psychiatric medications and it won't make you die or turn crazier.

one of the most interesting aspects of omega-3 supplements is the way they work. i'm not medically competent enough to describe this in detail, but, in a nutshell, it seems that the active components of omega-3s are actually able to replenish parts of the brain [which is approximately 8% omega-3 anyway]. that's pretty remarkable and completely different than the mechanism of action of any current psychiatric medications.

and more news keeps on coming. a study conducted by the université de montréal, the largest of its kind to date, established that omega-3 fatty acids are effective on their own at treating unipolar major depressive disorder. that's a pretty substantial result and the clearest-cut evidence to date that these little miracle-workers are capable of doing as much on their own as pharmaceuticals.

still being studied are the potential for fatty acids to treatment of complex disorders like bipolar and schizophrenia. there are interesting links because the propensity for omega-3s to, as i mentioned, "replenish" the brain may dovetail with evidence suggesting that those suffering from bipolar disorder and schizophrenia may have less brain density in their pre-frontal cortex.

although omega-3s are found in a variety of foods, particularly oily fish, trying to eat yourself sane at the sushi buffet is likely to give you mercury poisoning before it cures you. the components that the body needs to get the benefits of omega-3s are extracted with only about 5% efficiency [women are slightly more efficient than men in this regard], meaning that you'd have to eat a lot of tuna to get a therapeutic dose. chances are, supplements are your only bet and the future of supplements is likely to be controlled by the sort of companies you were trying to escape by turning to natural medicine in the first place.

and there you have a brief outline of nature versus depression and anxiety. there are many, many natural or naturally-derived treatments on the market and i can't hope to deal with all of them. if you have any questions about specific ones, please feel free to leave me a note in the comments section and i'll see what i can do.

you might remember during previous pieces on psychiatric drugs that i mentioned an interesting study that indicated that when people who were only mildly depressed took heavier anti-depressants, they generally didn't work. sadly, i don't think that that gives most doctors any hesitation in prescribing drugs, but it really should. rather than handing out benzos and ssri's like some kind of lab-coated pez dispenser, it would be nice if doctors started off [and some of them do] by trying to deal with the depression and anxiety through other channels. there are proven links between depression and inactivity, between mental disorders and bad sleep habits, well, between anxiety, depression and a lot of things really. psychiatric meds are fairly harsh things and, in my opinion, they should be reserved for use on the people who aren't going to get better any other way.

just my opinion, of course. but it generally seems like there's a paucity of hard facts in this area anyway.

mental health mondays :: big fat deal

well, the last few weeks have been kind of heavy in terms of all the information i've been throwing around on different mental disorders and the medications we can take to control them. so this week, i thought i'd focus a little more on one issue: psychiatric meds and weight gain.

as discussed in the last few posts, one of the things that worries people the most about taking medication for any mental disorder is the common understanding that these drugs will make you gain weight. in fact, a lot of patients stop taking their medications for exactly that reason- they simply can't handle the fact that dealing with depression, panic attacks or generalised anxiety involves the equally depressing spectacle of your body ballooning in size. ironically, weight gain as a side effect is likely to be mentioned in passing by a doctor if at all, when prescribing an anti-depressant. so if this is one of the most common reasons for discontinuing medications, why wouldn't it be part of the discussion on whether or not to take them to begin with? that has to do with prevailing attitudes about weight gain in general.


weight gain is not taken seriously as a side effect of medications, because, in this instance, it is largely seen as a question of vanity. and for many, that's exactly what it is. on the other hand, even if the concern is that one will be perceived as less attractive, or as becoming overweight, there are reasons to believe that others, whether they mean to or not, do judge people who are heavier more harshly than those who appear fit. there are also negative associations with sudden or ongoing weight gain- that one is lazy, indulgent, greedy, etc. the fact is that when most people see someone they know gaining weight, their first instinct is not to think that they may be on medications that are causing them to pack on pounds.

but weight gain is more than a problem of self-image and perception. everywhere, we are bombarded by messages that obesity is rampant, particularly in north america, but increasingly over europe as well. the dangers of being even moderately overweight are drilled into our heads in the same way that the dangers of nicotine were for decades. a billion-dollar industry thrives on our fears of weight gain, vaunting the benefits of "magic" foods to aid weight loss, low-calorie meals to control weight and restrictive diets of various sorts. and yet, when doctors are handing out medications, the topic of weight gain is treated as if it's frivolous. a bit of a mixed message to say the least.

as with all drugs, there is a benefit- liability analysis that should be done. if you're really depressed, medications may be your best option, but there are things that you should prepare yourself for, so that you can deal with them if they happen and weight gain is absolutely one of those. so here's a little primer on weight gain and mental meds. again, i'll specify that i'm not a doctor and, although i've made every attempt to draw my information from reputable sources, this shouldn't be taken as a medical opinion. consider it food for thought- that won't make you gain weight.



first off, there's the obvious question: will psychiatric meds make you gain weight?

yes- and no. many are known for their tendency to make you put on weight, but others show no significant evidence of weight gain compared to a placebo, while a few others actually tend to make you lose weight. whatever drug you've been prescribed, it's worth looking up the prescribing information sheet on line. these can get a bit dense in their language, but the information you need is in there- often with convenient charts to illustrate what the prevalence of side effects (including weight gain) were in clinical trials of the drug. this should at least tell you what you're up against.

which drugs are known to cause the most weight gain?

again, it varies from one med to another, but the worst offenders as a category are tricyclic anti-depressants and anti-psychotic drugs. modern anti-depressants, despite their reputation, are less prone to causing weight gain than tca's or other older anti-depressants like maoi's. even known offenders like paxil are less prone to causing spikes in weight than their older cousins. anti-psychotics and mood stabilisers, including anti-seizure meds used to control bipolar disorder, are very prone to causing weight gain, although the problems are often dosage-dependent (the more you take, the more you gain). there are no drugs that cause everyone to gain weight. it may happen, it may not. this is just a guide to which ones are most likely to cause this problem.

why do these drugs cause weight gain?

oh lots of reasons, some of which haven't been figured out yet. anti-depressants slow the body's metabolism, so that you're actually processing food less efficiently. in practice, that means that without changing a single thing about your eating and exercise habits, you'll be more likely to put on weight. studies indicate that tricyclics (which, again, have a worse profile than more modern drugs) can depress the metabolic rate by up to 10%. that means that your body will gain an extra pound every 7-10 days using exactly the same routines that have allowed you to maintain a consistent weight previous to starting anti-depressant medication. think about that and do the math. a pound every ten days spread over 365 days in a year.[note: the average weight gain on newer anti-depressants is far less.]

exacerbating this is the tendency of anti-depressants to make you lethargic, especially when first taking them. so not only are you more likely to gain weight from the food that you're eating, you're less likely to feel up to exercising at the same level you were. the lethargy tends to pass after a few weeks, but it can still cause problems over time.

the good news is that you can combat this with simple arithmetic. (your teachers told you it would be good for something.) weight maintenance is a ratio of calories consumed relative to calories burned. equalise the two and your weight will be consistent. anti-depressants are lowering your body's ability to burn calories, so in order to prevent weight gain, you need to proportionally lower your caloric intake. unfortunately, there's no magic way of telling how many calories your body is burning, so you might have to play around with it a little until you get it right. remember the 10% figure: this is really the maximum effect that any anti-depressant is going to have on your metabolism, so you shouldn't need to have more than a 10% reduction in calories in order to maintain your weight. not so intimidating when you look at it that way, is it?

powers your weight gain

as for anti-psychotics and mood stabilisers, the picture is a little trickier. the problem is that no one has quite figured out why these medications make you gain weight, even though it's widely accepted that almost all of them do. and for the ones that are weight neutral, no one can figure out why they don't make you gain weight, when they do basically the same thing as the drugs that do.

one obvious part of the tendency for these drugs to cause weight gain is that they are highly sedative. remember, these drugs are meant to curb mania, so they have a pretty strong calming effect that will generally make you a lot less likely to want to go for a jog. this is not simple lethargy. if these meds are working, you'll have less energy than you did before you started taking them. however, if you're manic enough to warrant being on an anti-psychotic, chances are the benefits of the drug well outweigh (no pun intended) the liabilities.

the problem is that even people who exercise and eat well can have problems with these sorts of drugs and no one seems to be able to figure it out. that's partly because the medications themselves are poorly understood. lithium has been around forever and doctors still aren't quite sure how or why it works- just that it does work. this is true of many psychiatric medications. the mechanism of action is known, but the reasons why this causes certain changes in mood and behaviour are basically just educated guesses. i'm sure that makes you feel much better.

with lithium, part of the "weight gain" can be fluid retention, since the drug is administered in its salt form. mineral salts have the exact same effect on your body as table salt- they make you thirsty and they make you retain the liquids you have or put in you. this will make you feel and, to some extent, look bloated, but it's not weight gain in the classic sense, since your body has not gained any mass.

serotonin, the neurotransmitter targeted by most anti-depressants, also has a link to appetite, so any drug that plays with the serotonin levels in your brain can also cause you to crave food more(or, in some cases, less). there's nothing you can do to change that, but it helps to be aware that when you think you want food, it's worth pausing to think about whether it's your stomach or your brain that's making the request. anti-depressants can't make your stomach empty- they can only make your brain think it is.

there are lots of theories on why these drugs make you gain weight, but hard facts are decidedly lacking. as a result, there aren't really any brilliant theories as to how you can avoid the weight gain. eat healthy, watch your sugar and fat intake (especially with beverages, since these drugs also tend to leave your mouth dry), get exercise (which helps depression anyway), get adequate amounts of sleep... you've heard all this before.

can i take dietary supplements to help combat the effects of anti-depressants on my metabolism?

unless you get an ok from your doctor and/ or pharmacist, absolutely not. we have this idea that "natural" equates to safe. arsenic and cyanide come from natural sources, but i don't want to sprinkle any on my breakfast. natural supplements can play with your internal chemistry the same as pharmaceuticals and their interactions can be very scary. if you're taking any prescriptions drugs- any- you need to tell your doctor what natural supplements you take and to determine if the combination is safe.

how much weight am i likely to gain?

too complicated to answer. as much testing that is done and continues to be done on all these drugs, there is an equivalent mass of contradictory anecdotal evidence. effexor, for instance, is widely perceived to cause weight gain, but testing has shown that subjects actually experience weight loss more often than gain (to the point where the drug was being investigated as a possible anorectic, until someone pointed out that giving people an extremely harsh drug so that they could lose a few pounds might not be the best idea). research indicates that the average weight gain for people on ssri's is minimal (when averaged out over all test subjects, including those who did not gain weight). even for known offenders like paxil and remeron (a combination anti-depressant and anti-psychotic), the average gain is only a few pounds. just be aware that only about 25% of patients experience weight gain as a side effect, so to make the average 3-4lbs, those 25% put on more like 15lbs to bring the total average up.

with side effects in general, predicting them is fiendishly difficult. it's a good idea to watch what you eat a little if you're starting with a psychiatric med, just in case. i don't mean starving yourself- that can mess with your neurotransmitters as well (didn't i tell you this was complicated?) and affect how the meds work.

will i lose the weight i've gained if i switch or discontinue medications?

yes. i hate saying that, because it's encouraging people to stop taking medication they may need, but studies show that, if you remove the problem drug, the extra weight goes with it. that's not such a big problem if you're on anti-depressants only- it's easy enough to substitute one with another until you find one you can live with and that works (keep in mind that you may end up in a situation where effective treatment means being on a drug that promotes weight gain).

if you're bipolar or on any other psychiatric meds, your options are limited. lamotrigine is weight neutral, but doesn't work on everyone. lithium and valproates are effective even on extreme cases of bipolar disorder, but they're among the worst offenders for weight gain and it can be very difficult to get the weight off while you're still on the drug. again, try to monitor what you eat, try to keep active and report any weight issues to your doctor.

there are not a lot of good answers to this problem, but the usual suspects- diet and exercise- do help, even if they don't help quite as much as they did before you started taking drugs. as for what happens if you do gain weight, keep it in perspective. a small gain shouldn't send you into hysterics. if it does, chances are you need the medication more than you think. keep track of it, but 5 or 6lbs is a pretty low price to pay for literal peace of mind. evaluate weight gain as a proportion of your total body weight. my fiance is 6'5". ten pounds on him is unnoticeable. i'm 5'2". ten pounds on me is the equivalent of adding a leg. as with most things, moderation and balance are key.

finally, here are a few articles that may help you learn more about how everything works:

the lesser known "depakote" mona lisa

a huffington post article by judith wurtzman, outlining the case for taking weight gain seriously as a side effect of anti-depressants.[thanks to dom for the link.]

a really interesting chart from a web site about eating disorders that outlines the effects of common anti-depressants specifically on weight and appetite. the chart was last updated in 2007, but it is incredibly well annotated, which allows for some follow up.

a piece from nbc that serves as a decent outline on drugs that cause weight gain, including both anti-depressants and anti-psychotics.


the bipolar forum and the anti-depressant forum from mytherapy.com. there are hundreds of discussion forums on these topics scattered throughout the internet and they're a good place to supplement your understanding of these medications and find out how other people have coped.

mental health mondays :: when to say when, part 2

so you've decided to take drugs. congratulations, you've made a big step in dealing with your depression/ anxiety and hopefully one that you've thought a lot about. if you haven't. maybe you want to hit the pause button and go back to read part one of this post.

myself, i'm kind of ambivalent on depression meds. i think they're grossly over-prescribed and i think some people need them. i think some types of depression are better treated with chemicals and some aren't. what i have very little patience for are people who know they have problems and who have categorically decided that they will not take medication because "they can handle it themselves" without bothering to learn anything about depression or about the drugs used to fight it. these reactions hearken back to those same old prejudices about mental illness being somehow less serious than other forms of illness, something that shouldn't require actual treatment. i also find that "taking care of it themselves" is usually code for ignoring the problem and assuming it'll go away on its own, or finding ways to convince oneself that the problem can be dealt with by blaming it on other people, or by simply getting drunk/ high a lot. some people can deal with their depression and anxiety themselves, no question. and they're easily distinguished because they're the people who can articulate how they do it without resorting to sarcasm.

think of depression/ anxiety meds the way you would pain medication: if you take something for every little ache, you're not allowing yourself to deal with the fact that pain is real and that sometimes, you just have to work through it. when it gets a bit more serious, you might want to think about something to take the edge off and so on. and, as with pain medications, it's important to remember that drugs aren't correcting the underlying problem, ever. they're just easing the symptoms so that they aren't screwing up your life.

i am a big fan of knowing what you're getting yourself into and depression meds are serious chemicals that play with how your brain works. you should understand what the dangers and potential benefits are and you do that by collecting information. get on line and find information from the manufacturer, from current and former users, from medical professionals. look for case studies and, again, ask your doctor, counselor, therapist or whoever is helping you where you can find case studies and testimonials from sources not funded by the proponents of that drug. take the opportunity to get to know your brain and how it responds to various stimuli.


to get you started, here is some very basic information on the types of anti-depressants your doctor or psychiatrist is likely to prescribe. virtually everything about these meds is in a constant state of dispute, so i've tried to stick to claims that have been broadly accepted, or that have significant statistical data to back them up. i am not a medical profession. my medical training is limited to a few first aid and cpr classes back in the 1920s some time. this is only intended to tell you what's out there and what's being said. if you want more specific details, you need to ask a professional.

selective serotonin reuptake inhibitors :: by far the most common type of anti-depressant and normally the first line of therapy for those who opt for anti-depressant medication. prozac, paxil, celexa and zoloft are better known than the names of major constellations; they've been around long enough that they're well understood, safe and, when used correctly, effective. [note: correct usage means that you actually need drugs. it's a neat little trick that the effectiveness of anti-depressants and the seriousness of the depression are directly proportional. so if you're mildly depressed, you might as well be taking tictacs.]

the name is actually descriptive of what they do, which is to more or less regulate the flow of the neurotransmitter serotonin in the brain, allowing it access to serotonin for longer, which is what's supposed to be happening naturally. unlike earlier anxiolytics and anti-depressants, these medications do not have an immediate effect (although you may feel certain effects immediately). your brain needs time to change how it processes serotonin and so it takes at least a few weeks, if not a month or two, to get the full benefit. so unless there's a serious negative reaction, give your meds at least a few months before saying categorically that they're not working. 

just as well-known as the drugs themselves are their side effects. what isn't well-known is that the popular understanding of their side effects is often grossly exaggerated and that those effects can vary in intensity from person to person and drug to drug. no one is going to be able to tell you what side effects you will experience from these drugs. you'll just have to see for yourself. keep in mind that some of the side effects (lethargy, insomnia, agitation, dry mouth, upset stomach, bloating and others) pass within a couple of weeks of starting the drug. sure, you might feel like you have a mild but persistent case of the flu, but give it time and chances are, it'll go away.

but if you're worried about side effects, chances are it isn't dry mouth that's on your mind anyway. chances are, you're worried about the "big two": weight gain and sexual dysfunction. it's fear of these two things that probably keeps a lot of people off meds to begin with and not without reason; ssri's as a group do tend to make you pack on pounds and they do have sexual side effects both mental (loss of libido) and physical (loss of sensation and, for men, loss of... you know). sometimes you get those side effects... sometimes you don't... sometimes they go away over time... sometimes they don't... the likelihood and severity of these side effects varies by drug, although it's hard to find hard science that says one is better or worse than another and almost nothing that compares all players in the same study. anecdotally, paxil is the worst for both weight gain and sexual dysfunction, prozac is more likely to make you lose weight than gain it, cipralex generally has the greatest balance between tolerability (i.e., incidence of side effects) and effectiveness, followed by zoloft. take that for what it's worth, which isn't very much. chances are that you're only going to find out how a specific drug effects you when you start taking it.

multiple reuptake inhibitors :: related to ssri's but more complex are the multiple reuptake inhibitors. there are three that are widely prescribed- effexor, cymbalta and wellbutrin- two of which (effexor, cymbalta) are similar. these first two drugs regulate serotonin, norepinephrine and sometimes dopamine, which means they hit all the major neurotransmitters generally thought to be responsible for the vast majority of depression/ anxiety disorders. 

some side effects are more noticeable than others

these still aren't generally used as first-line therapy because the side effects are reportedly significantly harsher than those of ssri's (cymbalta is supposed to be better than effexor) and because of something called "discontinuation syndrome". that term is the drug company's way of telling you that getting off these drugs is akin to getting off crack. it usually takes time and pain and can mess you up in ways you've only dreamed of.

the third and least-known multiple reuptake inhibitor is wellbutrin. wellbutrin works solely on the dopamine and norepinephrine. its side effects are generally the opposite of all other anti-depressants and as a bonus, it's marketed under another name as a drug that can help you quit smoking. all that sounds great until you get to the part about it potentially causing epileptic-style seizures in higher doses. there is no perfect solution.

tricyclic antidepressants :: these are an older type of anti-depressant which has largely been supplanted by the two categories listed above. although the chemical structure is quite different, tca's also work by regulating serotonin and norepinephrine in the brain. they were actually developed from antihistamines back in the 1940s and their potential as a psychiatric medication was first noticed in the early 50s. although still used in cases where other anti-depressants have failed, chances are you're not going to be getting a prescription for these any time soon.

for starters, these are the anti-depressants that give psychiatric meds a bad name. although there are a small number who claim their side effect profile is no worse than ssri's, these drugs are most likely to produce the "zombie" effect that most people fear awaits them if they go down the path of anti-depressants.

second, these drugs are prone to "abuse". i don't mean recreational use. i mean that, taken in quantities larger than prescribed, they're far more likely to kill you than more modern drugs. strange how doctors have grown hesitant to supply suicide aids to depressed people.

if you're looking at having to take these, chances are you know more about the world of psychiatric meds than i do and i feel for you. it might still be worth getting an outside opinion on whether or not you have other options. if you have a doctor who has prescribed one of these as a first time medication, leave immediately and get another doctor.

it's what's for dinner

monoamine oxidase inhibitors :: by the time you've reached these, chances are you're running out of options. because of the side effect profile, they're pretty much never prescribed until depression has proved resistant to at least a few other drugs. on the positive side, these have been around a long time, they're well understood and generally pretty effective. there are tons of them (they're even found naturally in some forms) and the newer ones aren't quite as tricky to deal with (although there are some studies which suggest that they aren't as effective either.

if your doctor has prescribed one of these, my advice is to go to your refrigerator, open the door and wave goodbye to a lot of foods you love. unlike other anti-depressants, where mixing them with certain foods, beverages or drugs (usually alcohol, caffeine and sedatives) is discouraged but up to the individual, the maoi diet restrictions are serious business. maoi's react with a variety of foods (notably almost every form of cheese, but you'll need to be very careful about finding an exhaustive list) and a lot of medications (particularly cold medications), as well as natural supplements and remedies. the potential reactions can be fatal, which is why these drugs are going to run your life once you've started taking them. they can't be taken while any other psychiatric meds are still in your system, so you're potentially looking at a few weeks of unmedicated fun before and after you take these.

chances are, no doctor is going to recommend an maoi unless things are pretty serious and many doctors avoid them entirely. it's a toss-up in terms of what you'd prefer to deal with, but personally, i think i'd still choose one of the modern maoi drugs over a tca.

benzodiazepines :: i think we covered this pretty well last week.

there. now you know everything.

well, you probably know enough to get started, at least, but because there's no such thing as too much information, here are a few tips gleaned from my experience and that of others close to me:

- don't expect that you're not going to get depressed again. you will. that's life.
- remember that drug companies often court doctors to get them to recommend their product over a competitor's. it's a dirty little secret and it happens with every type of drug. doctors are also prone to recommending drugs they've grown comfortable with. keep those things in mind when you're given a prescription. just because your doctor likes it doesn't mean it's the right one for you.
- try to keep a detailed written record of your reactions to the meds you're on. don't worry about figuring out what's related to the meds and what isn't. just keep notes and talk to your doctor about them.
- getting an initial anti-depressant prescription from your general practitioner is fine, but insist on seeing a psychiatrist as soon as possible to get a specialist's evaluation. your family doctor does not have an in-depth knowledge of mental disorders and may miss telltale signs that depression isn't your only problem. giving anti-depressants to people who aren't "simply" depressed can have serious consequences.
- remember that none of these drugs are addressing the root problem. unless you're comfortable spending the rest of your life on anti-depressants, taxing your liver for no reason, start looking into different types of therapy to find one you think will help you and try it out.

whew! that's a lot to take in for something that's no more than a cursory glance at the subject. the fact that this post is "bare bones" at this length should give you an idea of how complicated this business of brains can get. and what's more, brains are big business, so there are further developments happening all the time.

there are so many resources for information on the internet that i'd require a staff of thousands to vet all of them in order to find which ones to recommend. so i'll start with just two:

jerod poore's phenomenal crazy meds site. clever, accessible and incredibly well-researched, this is the best site on the internet for finding out what various sorts of psychiatric drugs will actually do to you. his site covers far more than anti-depression meds and, while his information is focused on the u.s. market, 95% of it is universally relevant.

neuroskeptic, a comparatively new discovery for me, this is a blog maintained by a professional in the field who isn't afraid to take his peers to task. it can get pretty dense, but there's a lot of fascinating information here that helps remind us that there are a lot of aspects to psychiatric meds and treatment that slip from view if we're not vigilant.

hopefully this helps you feel a little more empowered when it comes to anti-depressants. next week, we'll look at the flip side: mania- what happens when your mental stock market won't stop rising?