Many individuals who feel depressed believe that the smartest, most efficient way to deal with their depression is via pharmaceutical antidepressants. Pharmaceutical antidepressants take effect quickly, altering neural connectivity within 3 hours of ingestion and manipulate neurotransmission to facilitate a mood boost. Though antidepressants can take several weeks to fully work or “kick in,” some individuals notice an improvement much sooner (within days).
Although there’s no shame in taking an antidepressant to ameliorate depressive symptoms, most people fail to understand the complicated nature of treatment. Even if a medication works well initially, it may not yield sustainable relief over the long-term. For this reason, it is important to know how to use antidepressants properly (something most people don’t know how to do) so that you get the most out of treatment.
It is also of vital importance to understand various phases of antidepressant treatment and how you can effectively navigate your way through possible complications. Even if you seem to have found a drug (or combination) that works well to elevate your mood, you cannot expect eternal relief without any setbacks. As setbacks emerge throughout treatment, you’ll want to be prepared to know why they emerge and know how to cope with them.
6 Phases of Antidepressant Treatment
It’s relatively easy to get prescribed an antidepressant these days: simply go to your doctor, tell him you feel uncontrollably sad all the time, and voila – you’ve got a prescription for a potent, mind-altering pharmaceutical. Once you’ve left the office and fill the prescription, you start popping a pill per day to make you feel happier. If you don’t respond to your first treatment, you’ll keep trying another (and another) until something works.
Eventually you start to feel happier on a medication, but how long will this happiness last? Hint: It may last months (or even years), but it won’t last forever. Most people are duped into thinking that they’ll be able to stay on the same drug, at the same dose, and reap the same benefits for the rest of their lives. What they don’t know is that the initial phase of the drug working is like the “honeymoon phase” of a relationship; the initial euphoric overtones subside in time.
When the happiness subsides and the drug stops working, what are you left to do? Talk to your doctor and end up on a higher dosage? Add another drug to the mix? Quit cold turkey? These are all questions that you’ll likely need to ponder. For the sake of simplicity, I’ve highlighted 6 phases of treatment that you’ll likely end up facing if you opt to take an antidepressant.
Phase #1: Preliminary Benefits (Months to Years)
Assuming you are able to find an antidepressant that “works” you may end up feeling less depressed, and possibly even “better than normal.” Feeling better than normal stems from the fact that the neurotransmission in your brain is being altered to facilitate a happier mood. Those that are taking SSRIs will experience an increase in serotonin as a result of the drug’s ability to inhibit its reuptake.
The therapeutic effect of serotonergic alterations gradually improve over the first 4 to 6 weeks of starting a drug. You may start to laugh more, feel relaxed, less socially inhibited, and may become more outspoken. In fact, you may start to notice that you feel happier than you’ve ever felt in your entire life and more energy than ever before.
At this point you’re wondering why you hadn’t thought of the brilliant idea to take medication even sooner. After all, you had been suffering for awhile and while taking the drug you feel as if you’ve finally cracked the enigma. These benefits will likely persist for awhile and lead you to believe that you’ve made a smart decision taking an antidepressant.
You understand that you feel good now and suspect that as long as you keep taking the drug you’ve been prescribed, life will be eternally blissful. For months (or possibly years), you will ride out these mood-boosting benefits. If you are lucky enough, you’ll even be able to maintain the same initial dose for awhile with no signs of functional (or mood) decline.
Phase #2: Initial signs of antidepressant trouble (side effects / efficacy)
Antidepressants are engineered in such a way that they aren’t considered addictive and take awhile to reach their full effect (usually about a month). Following a month or so of usage, an individual may experience a substantial mood boost. Although this mood boost can be maintained for months or years without any problems, eventually the first sign of trouble will emerge.
For some people, this initial sign of trouble will manifest in the form of antidepressant side effects (e.g. heart rate changes, weight gain, sexual dysfunction). For another subset of users, this trouble will manifest in the form of reduced antidepressant efficacy; your mood will start to slide. Certain people may even notice a combination of side effects and a decline in mood.
The troubles don’t usually randomly appear overnight, they usually surface gradually. For example, you may start to notice that you don’t feel quite as good as during the first few months of taking your antidepressant. You don’t think much of it initially, until the mood decline gradually becomes more prominent.
Eventually you reach a point where you may feel as if the drug has lost nearly all of its effect. When this occurs, most users have a major problem – they feel depressed and their treatment is no longer working. This is when users generally schedule another appointment with their doctor (or psychiatrist) and ask why their “miracle cure” is no longer cutting it.
Phase #3: Antidepressant dosage increase and/or adjunct prescriptions
Several more months pass since the initial signs of trouble and you notice that your side effects are becoming more severe, plus the drug doesn’t seem to be working. In other words, you are still taking the drug, but no longer get that initial kick of “happiness” that you once experienced. You seem to feel somewhat average on the drug and no longer are in full control of your emotions.
Upon telling this information to your doctor, he recommends something logical: let’s increase the dose. Increasing the dosage is likely to provide more significant antidepressant benefit – the same “happiness” you experienced when you first started the drug. At this point, most individuals fail to understand that they merely became neurophysioloigcally tolerant to the effects of their antidepressant.
Though a medical professional will not admit that antidepressants stop working because of tolerance – that is exactly why they stop working; your neurophysiology has completely adapted to the effects of the drug. Many professionals will now assume that an individual’s depression is becoming more severe; what was once a one-headed monster is now a three-headed monster. To cope with this, they increase the dosage and may even tack on a potent adjunct (e.g. an antipsychotic).
At this point the individual is likely to experience symptomatic relief – but they are drowning in chemicals that trigger side effects. The new side effects that emerge are due to the fact that you’re ingesting a greater quantity of an exogenous chemical. These side effects may be more noticeable (of greater intensity) and more plentiful (of greater quantity).
It is also important to consider that you’ll eventually build up a tolerance to your new dose (even if it takes awhile). In some cases, an increase in dose may not work (or could make you feel worse). The addition of an adjunct could have similar unwanted effects in regards to side effects and may facilitate greater future neurotransmitter “debt” via downregulating certain processes.
Phase #4: Long-term effects and/or renewed tolerance
As a result of the dosage increase and/or adjunct added for a nice little medication “cocktail” – you may notice side effects become more overwhelming. For example: Random body parts are prone to twitching, your vision feels distorted, you’ve ballooned in weight, and there’s zero percent chance you are capable of orgasm. You were once an in-shape, orgasm-capable, non-twitching individual, yet as a result of your pharmacological interventions – things have taken a turn for the worst.
These side effects emerge because there’s no biological free lunch – the greater the dose of a drug that you ingest; the greater the extent of neurophysiological changes being made. In other words, the higher the dose – the greater the shift away from homeostasis. At this point you’ve now realized you could accept these side effects or talk to your doctor about other options.
If you don’t experience any unwanted long-term effects, you may once again experience a dwindling of drug efficacy. Your new “higher” dose along with the adjunct are no longer working and you need to go in for another adjustment. At this point both the antidepressant and adjunct doses are doubled.
Upon doubling of the doses, you may feel better, but the side effects are now extremely noticeable. Although most people like when they’re in a good mood, most people hate extreme side effects. No matter how good of mood a person is in, extreme weight gain (hundreds of pounds), sweating, twitching, tinnitus, etc. will trump the mood.
Phase #5: Crossroads (Switch medications, Discontinuation, Stay the Course)
To deal with these side effects, your doctor can come up with some logical options: switch medications (after all – he’s got a sexy new antidepressant that was just approved in sampler packs), discontinue the drug (and deal with new symptoms that will make you want to scream, kick, and punch something), or stay the course of treatment (and accept the side effects). None of these options sound too appealing. Regardless of the choice you decide to make, there are inevitable consequences.
Choice 1: Switching medications
If you were lucky enough to respond to the first antidepressant that you tried, you may assume that a new drug will fix all of your woes. You tried one drug and it worked, why wouldn’t switching to a new drug work just as well as the first? At this point you may even think that the new medication could work even better than the first.
The problem with switching medications is that it’s difficult to do without any sort of backlash. Assuming you switch, your psychiatrist may have you go cold turkey from one drug, while starting up another. Since a different medication will not have the same pharmacological targets as the first drug, you may go through a rocky transition.
If the first drug was inhibiting reuptake of serotonin, and the second is inhibiting reuptake of norepinephrine – cessation of the first drug is likely to bring forth withdrawals. At this point it will be difficult to comprehend whether you’re experiencing withdrawals from the first drug or side effects from the new drug. At the very best, you once again experience some degree of symptomatic relief.
At the very worst, you may find that the new drug is actually making you feel more depressed than before; it may be targeting the wrong set of neurotransmitters. Unfortunately, if the new drug is facilitating neurotransmission that makes you feel worse and you’re simultaneously withdrawing from the old drug – your depression may be exacerbated. Those who don’t respond to the new drug will be put through “antidepressant roulette” – trying all sorts of options for 6 to 8 weeks in hope that they respond.
At this point, many people fail to respond to any new interventions because they are chemically imbalanced from the initial drug that they stopped, and their neurotransmission is amiss as a result of multiple consecutive 6 to 8 week trials. The back-to-back trials with no lag time simply serves to further jumble neurotransmitters – reducing likelihood of responding to new interventions. A major problem with switching drugs is that even if a new chemical works, you can expect to go through the same cycle of: short-term benefit, first sign of trouble, dose increase, more trouble, etc.
Choice 2: Discontinuation
Another option you have besides merely switching to a new medication is discontinuation of your current drug. One problem associated with discontinuation is that many professionals fail to understand the toll of withdrawal symptoms on the patient. They are clueless as to how long withdrawals are likely to last, suggesting that they take a few days.
Others may imply that the drug an individual has been taking isn’t associated with any withdrawal symptoms. The patient then expects their withdrawals to be over within a week or two and to fully return to normal a.k.a. how they felt pre-treatment. To their surprise, not only do they not feel how they felt pre-treatment, they actually feel worse than ever.
This may be due to quitting “cold turkey” or tapering too quickly from a particular drug – but could also simply be due to the significant neurophysiological adjustment taking place from being “medicated” to “non-medicated.” Individuals may notice symptoms emerge that they never previously endured such as: brain zaps, suicidal thoughts, dizziness, headaches, heart palpitations, hypersensitivity to sensory stimuli, mood swings, etc. Unfortunately, many of these symptoms persist for extended durations (e.g. months) following cessation of a medication.
When a patient tells their doctor of these symptoms, the doctor regards this as a medical impossibility and suggests that they are likely nothing more than a worsening of the underlying condition. It can take a long time before withdrawal symptoms subside and even longer before homeostasis (pre-treatment neurotransmission) is reestablished. The major benefit associated with discontinuation is that after awhile, the body loses tolerance to the medication that it had received on a daily basis.
Losing tolerance means that individuals can often start up their medications in the future at a low dose for therapeutic benefit. The lower dose is advantageous in that mood elevation can occur with a reduced likelihood of side effects. However, if a person doesn’t remain off of their antidepressants for long enough as to reset their homeostatic neurotransmission – tolerance to the low dose will quickly be reestablished.
Choice 3: Stay the course
The third option is to stay the course of treatment and merely put up with whatever side effects come your way. For some this may mean sacrificing the ability to orgasm and the ability to maintain a physically healthy body (or appearance) due to weight gain. Others may experience more debilitating side effects such as tinnitus (ringing in the ears) or ongoing fatigue.
In some cases, professionals may add more drugs to the mix in effort to treat troubling side effects with new chemicals. For example, something like Buspar could be added to an SSRI (as an antidepressant augmentation strategy) to combat sexual dysfunction as a side effect. Unfortunately, staying the course will eventually result in tolerance to your entire pharmacological cocktail of medications.
Fortunately, this tolerance does not usually occur overnight; it may take years before tolerability issues manifest. For some individuals staying the course is clearly the best option – especially if they’ve found an antidepressant (or combination) that keeps them functional. Those staying the course often hope that if they can hold out a few more years, new antidepressants will emerge with greater efficacy.
Phase #6: Assessment (Cost-Benefit Analysis)
Throughout your treatment with an antidepressant there may be times when you feel thankful that such an awesome, mood-boosting drug exists. However, during other phases of treatment (e.g. when the drug stops working), you may perceive an antidepressant as being pure evil. Perceptions of antidepressants change based on how a person is feeling in the current moment.
Someone who is currently feeling happier than ever before as a result of treatment is likely to view antidepressants as a godsend. For those who are feeling crappier than ever before upon discontinuation from treatment may view antidepressants as the devil. In any regard, people will end up conducting a cost-benefit analysis of their decision to take an antidepressant.
- Pros outweighed the cons: For a subset of individuals, the “pros” (therapeutic benefits) associated with their treatment will have significantly outweighed the “cons” (drawbacks). Someone on the verge of suicide that found symptomatic relief from an antidepressant will have derived much more benefit from treatment than drawbacks. Even among those who end up quitting antidepressants often consider the benefits to have outweighed the drawbacks.
- Cons outweighed the pros: For many individuals, the “cons” (drawbacks) will have significantly outweighed the “pros” (benefits) associated with antidepressant treatment. Some people may find that the drugs made them even more depressed or prompted suicidal ideation. Furthermore, some people are unable to derive any symptomatic relief from treatment. To make things worse, when these individuals stop taking the drug that wasn’t working, they are still hit hard with discontinuation symptoms.
- Balanced pros and cons: Another group of people will find that the treatment had a relatively equal “trade off” between benefits and drawbacks. Those who derive significant benefit from a drug, yet end up dealing with some wicked side effects may feel as if the treatment is both a gift and a curse. Others may feel as if the initial benefits attained during the first year of treatment were profound, but the next couple years may be difficult to deal with; indicating a mix of upside and downside.
Does everyone experience all six phases of treatment?
Those that have discontinued antidepressants after a substantial term and remained off them have likely passed through all six phases of treatment. They’ve likely reaped preliminary benefits of an antidepressant for awhile, ended up sensing some initial problems with the drug, and later realized that the effects of the drug had faded (as a result of tolerance). They may have then tinkered with dosing and/or adjunct prescriptions only to derive temporary benefit – possibly for several more months (or years).
However, the long-term effects, side effects, or dwindling efficacy inevitably prompted them to discontinue treatment. They went through withdrawal and realized that the initial benefits of the may not have been worth the hellacious protracted discontinuation symptoms. Following treatment and discontinuation, they likely reflected upon whether opting to take antidepressants was beneficial, detrimental, or a relatively even blending of both.
Other individuals are likely stuck somewhere in one of the middle phases. Those with debilitating mental illnesses that require prescription are likely under the influence of a “cocktail” of drugs at relatively high doses. For these individuals, it is relatively difficult to stop treatment because even after forcing their way through withdrawal symptoms, an underlying severe endogenous depression lingers.
Individuals that are relatively new to antidepressants may still be in the honeymoon phase – the future seems bright. Or they may have increased their dosage to derive additional benefit after they’ve noticed the drug dwindled in efficacy. Others may still be working their way through crazy withdrawal symptoms, hoping to restore neurophysiological homeostasis.
If you could go back in time, would you have still taken an antidepressant?
If you’ve taken an antidepressant to treat depression, do you wish you could go back and time and warn yourself about certain phases of treatment? For those who wish they would’ve never taken an antidepressant, explain why you wish you had avoided antidepressants in the comments section below. For those who are glad that they’ve taken an antidepressant, explain why you’re satisfied with your decision in the comments section below.
When answering this question, do your best to avoid being prisoner of the moment. Individuals in withdrawal may associate their current psychological pain with antidepressants as being the “devil,” yet fail to understand the functional benefit that they attained throughout treatment. On the other hand, individuals that are currently responding well to an antidepressant may want to consider the trials and tribulations (side effects, tolerance, withdrawals) they’ve experienced with previous medications.