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.
7 thoughts on “6 Common Phases Of Antidepressant Treatment”
I think I’m in Phase 4. Have been on a lamotrigine/bupropion/escitalopram/aripiprazole cocktail for seizures, anxiety and depression for about 2 years, and the weight gain has been very gradual, but significant enough. Doc and I have decided Abilify is the culprit, and I DID lose some weight after halving the dose.
But guess what? Anxiety returned with a vengeance. So I went back up for a while, then back down, now back up. And it works. Psychosomatic? Maybe, but my doc has compassionately stated that the effect is there; the symptoms exist, so they should be addressed. It may just be situational anxiety, however, exacerbated by my condition.
Abilify was my wonder drug that brought me back from the brink of suicide, so I can’t curse it in good conscience. I suppose I should be grateful I’m at a small dose (5mg), although the maximum adjunct dose. Lexapro has killed my libido, but I could probably stand to take less (at 20mg). I tried Zoloft and Cymbalta first but anorgasmia and fatigue, respectively, were too strong to tolerate.
I’ve loved Lamictal since I started taking it nearly 15 years ago for seizures/mood. The previous anticonvulsant (Trileptal) left me depressed, and Lamictal both controls the seizures and slightly elevated my mood at the time. Otherwise, I feel more alert and focused when I take it, so I guess that’s a positive side effect.
Finally, I don’t think the Wellbutrin is doing a damn thing; we initially added it as an adjunct and just left it there after it didn’t work. One change at a time, you know. No side effects, though, unless it’s giving me some energy I wouldn’t normally have. Great article, BTW! Very insightful and resonant.
I have suffered untreated and then treated and medicated with bipolar for 12 years. I can say without a doubt that taking the medication helped with the immediate problem. Helped me gain stability. One stable I would start a mission to get off of the meds bc I knew it was hell getting off the longer you’ve been on.
So, this started my life long journey of trying to control my illness with diet, prayer, self awareness. Eventually, I would have an episode and start taking the meds again to bring me up to stable. My point in all of this is that there are times in my life when the drugs helped immensely. There were also times I’m my life when I couldn’t leave my house bc the withdrawal had me bat sh-t crazy.
I think that, for me, taking the medication was necessary when it was necessary but it was very important to wean off the ASAP. I know now what drugs will work immediately and have not worked up a tolerance bc I stop them in time. It’s a hard way to live but it’s better then destroying every one and everything thing in my life.
For those who wish they would’ve never taken an antidepressant, explain why you wish you had avoided antidepressants in the comments section below.
Where do I begin? The weight gain. The damaged relationships. The money spent on frivolities, during my endless obsessive spending. The arrogance of my stances. Originally I was prescribed Zoloft- to help with my sleep. It helped, a bit. But as it turned out, years down the road- that a CPAP would’ve worked much better.
As to the Zoloft. The pooped out eventually, and as with all mission creep, I started another- after upping the dosage: Lexapro. Celexa. A couple week bouts of Paxil and Wellbutrin. I reinstated on Celexa and eventually got off of that. During my far too rapid taper of Celexa (Cold Turkey actually, first time)- I ended up tolerant on Ativan.
And that was hell getting off of that. After a proper taper. Apparently I still managed to not taper ‘properly’ off of the Celexa. I did it in a mere 3 months. And now – 8 months later, I’m still dealing with the effects. Effects of Hell. Not getting sufficient sleep due to every time I dream, I get a Cortisol Surge that wakes me up, and leaves my heart pounding. Every. Single. Dream. Wake up every hour on the hour.
I’ve learned to deal with the anxiety to some extent. But the lack of restful sleep- is devastating. And yet somehow try to manage to hold onto a full time job. So no- I would not have gone onto an anti-depressant. It’s a tiny little pill, that you will eventually pay – with your soul.
Should never have decided to go antidepressants. They won’t take me off them now. I want to come off them. Have twitches, have had brain zaps, suicidal thoughts. Have tried to come off them and I was a real mess. Got a bit a problem now. And now the initial happy feeling is wearing off… What do I do? And they have been making me take antipsychotics for over ten years too.
I’m scared a bit now. What do I do? I have to come off the antidepressants at least. It’s screwed. I don’t understand why they’re doing this to people… To me… I requested going on the antidepressants in the first place because I was depressed and had suicidal thoughts. Now I wish I hadn’t. What am I supposed to do now?
Very well-written and right” on point.” Since 1982, starting at age 25, have been on tricyclics, MAOI’s, anticonvulsants, minor tranquilizers, SSRI’s, stimulants and have unsuccessfully tried SNRI’s, Wellbutrin and a few other drugs I don’t remember at the moment. For the last 15 years, have been on 30 mg. of Paxil a day – doesn’t boost my mood much any more but still controls panic/social anxiety to the point that I can carry out daily activities and is still the best choice I’ve found to date.
I add a little Ritalin for energy at times – but it can get me depressed so I have to be careful with it. Have also tried eight weeks of TMS treatment – didn’t do anything but drain my bank account. Have experimented with Ketamine injections – seem to help a little – doesn’t last -may try Ketamine infusions next. Like everyone else with these “problems”, I keep waiting for the next great miracle drug or treatment, but at age 58, I can’t help but assume this illness is a “life sentence.”
I live alone, family’s all gone now. I have no friends. I don’t enjoy much – no “joyous mental energy” – “kinda’ go through the motions” – but I’m stubborn and have a deep sense of obligation to live the life I’ve been given – can’t kill myself – too “f’ing” easy – refuse to “give up.” I anger easily but have learned to control my temper fairly well and can “put on the mask” and “act happy” for a short time when I have to interact with people.
Too much “social stress” though and I have to withdraw again and regain my emotional balance. I depend heavily on exercise these days – regular running and lifting – really helps – but doesn’t last. Still better than self-medicating with booze and drugs as I did through my 20’s and 30’s. Try not to feel sorry for myself – everyone’s got problems – but I sure wish I could get back that resilient, easy going sense of “everything just being ok” again – always felt like that until about age 15 or 16 when my emotions slowly started going haywire.
The “shrinks” are clueless with their checklists, “talk therapy”, pills and useless DSM categorization. I imagine neuroscience will finally discover effective treatments for these stigmatizing brain illnesses in 100 years or so when we’re all long gone. Just have to “soldier on” for now I guess and be grateful for what I have. Take care and thanks for your writings.
Very well written article full of honest information that isn’t available anywhere else. This information is certainly not even touched upon by the Doctors who write all of the prescriptions. In hindsight, I have to say that going on anti-depressants and then other medications to “boost” them overall made me a lot sicker. Nothing offered me any real relief yet everything caused unwanted side effects.
Many of the medication combinations caused terrible side effects including severe mood instability. Once I stopped the med the side effect or mood instability also stopped. I have suffered with so many medication induced problems that my family has become extremely frustrated, hardened and now even distanced themselves from me.
I wish so much that I could go back and stand up for myself and refuse everything that was shoved at me over the years. I genuinely feel that my brain has been permanently altered due to all of the different medications I was put on.
Fantastic article – and dead-on accurate. If someone had told me about these 6 phases 20 years ago, when I started taking my first antidepressant, I wouldn’t have believed them….and I was so desperate to get some relief from the unavoidable feelings I was trying to escape. There were times when I thought the antidepressants were a godsend, and times when I wanted to die on them.
Of course, I didn’t report any of those thoughts to my doctor – I was terrified I’d be labeled as psychotic and suicidal or crazy. So I stayed quiet and tried as hard as I could to act like everything was ok. I know there are thousands of patients who don’t report these side effects to their doctor – they don’t even make the connection that the brain zaps, inner restlessness, and hypersensitivity to stimuli are caused by the SSRI/SNRI.
And they certainly don’t want their doctor to interpret those complaints as signs of a mental illness that’s even more stigmatized than depression. But depression turns into anxiety, and anxiety turns into ADHD, many, many times because of the drugs. This is why the side effects are so under-reported: patients either don’t make the connection, don’t want to to risk having their doctor misinterpret the side effects as psychosis, or the HCP doesn’t have time/energy to make the connection.
It’s been a roller coaster ride over the last 20 decades. Bottom line: you’ve got to feel and process what’s causing the depression. Antidepressants can “freeze” the cause, but not forever. As the marketing-savvy Big Pharma execs have eloquently stated, depression hurts. Antidepressants can help with the hurt, but over the long term, they’re hurting more than the original symptom. I wish I’d understood this. I wish doctors understood this. But we’re too distracted to do the work it takes to understand.