Many people seek out treatment for their depression from general practitioners and psychiatrists. If you have a serious mental illness that requires pharmaceutical treatment, it is generally best to work with a quality psychiatrist. Regardless of whether you seek the help of a psychiatrist or simply go to your family doctor, finding the right antidepressant that works for you can be a bit of a challenge.
For a significant percentage of people, their depression is actually classified as “refractory” meaning they have been unable to find relief from all logical treatment options. In other cases, there are individuals that find some relief from an antidepressant, but it eventually stops working. When the medication stops working, a person typically trusts a psychiatrist to come up with a treatment that will work.
This ends up creating essentially a game of “antidepressant roulette” meaning we are essentially taking a gamble on a new treatment. A new treatment could help improve symptoms, but there is also a significant chance that it could provide no relief or even worse, possibly increase depressive symptoms. Unfortunately most people place full trust in their psychiatrist to figure something out when in reality, switching from drug to drug (to drug to drug) may be doing more harm than good.
How psychiatrists prescribe medications
Psychiatrists typically follow a general protocol for prescribing antidepressants. They first consider the “first-line” treatment options or the safest medications with the highest efficacy. They then will prescribe one in hopes that it works. If it doesn’t work, they will try several others. They will eventually keep throwing meds at you until something works (even if it only provides minor relief). It is important to understand their thought process so that you know how you will be treated.
1. Try the most logical option: The first step psychiatrists take is prescribing a first-line treatment option. These are the antidepressants that are considered safe over the long-term and generally do a good job at providing relief from depression. Unfortunately for many people, the most logical options don’t always work.
2. Experiment with other medications: The second step involves trying another medication. The moment you try another medication after already subjecting yourself to a trial of the initial medication, you are playing “antidepressant roulette.” Although the first drug will be cleared from your body by the time the second drug is introduced, the lingering effects of the initial drug will still be present throughout the brain and nervous system.
Unfortunately most doctors do not understand this concept and firmly believe that short trials of several weeks do not produce a strong enough response to make significant changes. In reality we know that significant changes are made just 3 hours after taking an antidepressant.
3. Finding an antidepressant that works: If you are able to find an antidepressant that works to ease your symptoms of depression, you are ahead of the game. This generally takes a little luck and a good interaction between the particular medication and a person’s genes. It sometimes takes many trials for a person to find a drug that actually works, but assuming it works well, the trials were likely worth the upfront experimentation and neurochemical alterations.
4. Stay on the one that works: Most people that are able to find a drug that actually works stay on it as long as possible. They aren’t generally aware of how to use antidepressants properly, so they often rely on the drug as a “crutch” rather than using it proactively as a “tool.” If the drug works for a long period of time, relying on it as a “crutch” may not be a bad thing. The problem is that certain people often build up a tolerance and the medication stops working.
5. Antidepressant stops working: A treatment that may have initially worked quite well has now worn off. The person isn’t getting the same antidepressant response from the drug that may have initially changed their life for the better. Now that a tolerance has been established, a person is left feeling overwhelmed because they never expected their depression and anxiety to return while medicated; their reality is inevitably shattered. This leads the person to check back in with their psychiatrist to come up with other treatment options.
6. Antidepressant roulette / Psychotropic roulette: Inevitably they reach the point of antidepressant and/or psychotropic drug roulette. This involves rapid transitioning between various medications, often with no understanding of neurochemical changes even from short-term trials. What’s worse is that some psychiatrists may prescribe antidepressant augmentation strategies with new medications, essentially introducing 2 new substances to the nervous system simultaneously.
- Rapid switching of medications
- Testing combinations of medications
This is not a good strategy because the psychiatrist won’t really know whether one medication is helping more than the other. Additionally if only one drug is providing the antidepressant response, we won’t know because the person may have never tried each individual medication on a separate basis. A person can get trapped in an unwanted situation when they are transitioning from medication to medication and/or combination to combination with minimal or no recovery time between transitions.
Antidepressant Roulette: Why Switching Medications Is Often Problematic
There are several problems associated with the rapid transitioning between antidepressants a.k.a. psychotropic roulette. While these are not typically known or addressed by the psychiatric community, they are very common and make logical sense.
1. Transitioning too rapidly
Many people take a medication for 6 to 8 weeks, and find out that it doesn’t work. It may be making them feel worse, and it clearly isn’t helping alleviate any symptoms of depression. In this case, a psychiatrist may tell a patient to quit their current medication cold turkey. While this alone can lead to major withdrawal symptoms, many psychiatrists assume that it can be done since a new medication will immediately be introduced.
In other cases, a psychiatrist may conduct a gradual taper (which should be done), but may not allow for enough of a transitioning period. In other words, a person may not fully have time for their neurotransmitters to revert back to homeostatic levels. The fact that the brain isn’t often given adequate adjustment time creates further neurochemical chaos.
Other psychiatrists may follow a tapering protocol and make a slower transition to the new medication. A very smart psychiatrist will wait until all withdrawal symptoms from the previous medication have subsided before starting the newer medication. By awaiting withdrawal symptoms to subside, you are increasing the chances that a person will not experience lingering effects from the previous medication – which could influence the outcome of the newer treatment.
- Cold turkey: Many people quit one medication cold turkey and immediately start a new medication. While this can work with certain medications (e.g. transitioning to Prozac), for many medications it is not a good strategy.
- Rapid transition: Sometimes a psychiatrist may have a person transfer to a new medication without giving a person time to readjust from the effects of the previous drug. Without adequate adjustment time, the person’s brain is still in chaos from stopping the previous medication. The influence from the drug that they had taken is still prevalent throughout the brain and nervous system
- Lingering effects: In many cases, effects of a previous medication will linger long after a person has stopped the drug. In some cases these effects linger for such an extensive period, a person isn’t able to distinguish whether they are experiencing withdrawal symptoms or side effects from a new medication.
2. “Snowball effect” / Cumulative effects
At one point or another, let’s say after several medication trials, your brain and physiology may experience a “snowball effect” or cumulative effect of the several past drugs on your nervous system. Let’s say you were just taking Prozac, it stopped working, so you try another medication like Paxil. You try it for 30 days and may start to feel worse than usual. So you go to your psychiatrist and he throws a new medication Cymbalta at you.
In this case, you may still not only be feeling the effects of the Prozac withdrawal, but you may also be enduring minor changes that were made to your brain from the Paxil in your 30 day stint as well as changes from the new medication Cymbalta. In many cases the patient doesn’t get any better in part because there are lingering effects from the previous couple medications. If the Cymbalta also doesn’t work, you could potentially have a snowball effect accumulating from four medications.
For some people withdrawal even after a 30 day trial on antidepressants can last much longer than the 30 days for which they took the drug. A cumulative effect from all the changes that the antidepressants have made to a person’s nervous system leaves them essentially helpless and often they feel significantly worse than before.
If you are jumping from medication to medication, just know that there are likely a lot of changes occurring throughout your brain and nervous system after just one medication trial. Even if a medication doesn’t “work” doesn’t mean that it hasn’t made significant changes to your overall brain functioning; this is a concept that many people fail to understand. Most people that are experiencing cumulative effects don’t even know it because they just assume it’s their depression organically becoming more severe.
3. Psychiatric “hamster wheel”
Unfortunately after several failed attempts of antidepressant trials, a psychiatrist will start using adjunct strategies. This may involve prescribing an antipsychotic medication along with an antidepressant. It may also involve prescribing multiple medications along with an antidepressant. Many people fail to realize that they are still in neurochemical chaos from previous medication trials, but they are compounding the chaos with their augmentation options.
In other words, instead of transitioning to one new drug, a person is now taking 2 or 3 (or 4) medications at once. If that combination doesn’t work, further tweaks will be made, but the concept remains the same. Not only is the patient likely over-drugged at this point, they are officially veterans of the psychiatric hamster wheel. In other words, they are taking all of these new medications, but aren’t really getting anywhere in terms of relief.
This essentially sets a person up to become dependent on psychiatry for the rest of their lives. New problems “develop” seemingly out of thin air – a person that originally came in with depression, may now have new (generally) misdiagnoses bipolar disorder, ADHD, etc. In reality these new diagnoses may have never come about had a person simply allowed their nervous system to reset itself and their neurochemicals to rebound to physiological homeostasis.
These individuals are so into their treatment at this point, that even though logic would suggest psychiatric treatments haven’t helped, they assume it’s their only option. They are willing to put up with any side effects and blindly accept any new diagnoses given to them. Their brain chemistry, nervous system functioning, and genetic expression has been heavily influenced by medications.
Psychiatry does help a lot of people, but in many cases a person who initially only had major depression, may now have multiple diagnoses as a result of neurochemical changes from psychotropic treatments. This takes a major toll on the person over the years and they now are dependent, trapped, and stuck relying on a barrage of non-targeted treatment options for the rest of their life unless they see the light and realize what has occurred.
What is the solution to the “antidepressant roulette” problem?
The solution to the antidepressant roulette problem is to accept the initial fact that psychiatry isn’t capable of helping everybody. Additionally, it should be widely known that treatments for depression and other mental illnesses help, but aren’t targeted. Meaning, they alter functioning of certain neurotransmitters, but don’t directly treat the problem.
A person’s depression typically isn’t caused by a “chemical imbalance,” but raising certain neurotransmitters helps alleviate depressive symptoms. Too many people assume that they are deficient in serotonin or other neurotransmitters because they were helped by a psychiatric medication – this is not true. That’s like a person taking cocaine and assuming they are deficient in dopamine because taking cocaine raised dopamine levels; it’s a poor argument. Additionally taking antidepressants may cause a chemical imbalance that wasn’t originally there.
The most obvious solution to antidepressant roulette and psychiatry is to first identify the problem, and develop targeted pharmacological and non-pharmacological treatments that are tailored to an individual. Even coming up with superior new medications like ALKS 5461 would be of some benefit because these drugs would likely work for more people and for a longer duration than present day SSRIs.
It is also important to inform users of antidepressants that they should never expect their treatment to be a panacea nor should they expect their medication to help forever. In many cases antidepressants can help by providing sufficient relief relief from depressive symptoms for months (or years), but will not likely be a life-long treatment.