Choosing the Right Antidepressants

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Major depression affects millions of Americans, bringing symptoms including low mood and tearfulness, decreased self-esteem, lack of interest in activities that used to bring pleasure, decreased concentration, hopelessness, suicidal thinking, impaired sleep, anxiety and changes in appetite. The bad news: It ruins lives and it takes lives. The good news: It is very, very treatable, with psychotherapy or psychotherapy combined with one or more medications.

I hope you will notice I did not suggest that depression can be treated with medications alone. I don’t believe that it can be—not effectively or permanently. In order to rid oneself of depression, the psychological sources of it must be uncovered and resolved.

This is my belief and judgment after two decades practicing psychiatry with people young and old, rich and poor, from all over the world.

I do find that medications can enhance the treatment effects of psychotherapy—sometimes dramatically. And choosing the right antidepressant(s) is critical.

I hope you’ll also notice that I added that parenthetical “s” to antidepressant. Very often, patients benefit when antidepressants are combined, or used with other psychiatric medications, like anti-anxiety medicines or sleep medicines. That’s one reason why studies that look at whether a single antidepressant is better than placebo are inherently flawed. Treating depression is like going to war in this way: a general should never limit his choice of weapons. It is different from going to war in this way: There is never a reason to surrender—ever. Clinical commitment and creativity must never wane.

A psychiatrist should first decide whether a patient has anxiety as a significant component of depression or only pervasive sadness and low energy. Some antidepressants are considered more calming and others are considered more activating.

Next, after a trial period of a few weeks (even though), a decision has to be made about whether the medicine is being well-tolerated and has begun to show any effect. If it has, the dosage may still need to be increased to achieve maximum effect. If no benefit has been achieved after, say, three to four weeks (clinical judgment here is imperative) and if symptoms are severe, a different antidepressant is probably warranted, or the addition of a second antidepressant with a different mechanism of action, or an “enhancing” medication. Such “enhancing” medications include stimulants and mood stabilizing medicines.

Here are a few guidelines about being treated:
1) Go to a psychiatrist. Other clinicians may want to treat depression, but if I were depressed, I’d want to be seen by someone who can use medicines, if necessary. And I wouldn’t let my family doctor be the one responsible for treating my depression—not any more than I would suggest you rely on me to treat your high blood pressure (I might be able to do it, but I would worry I might not do it expertly.)

2) Go to a psychiatrist who also performs psychotherapy. As I said, medicine alone is only a temporary solution (if that) to depression.

3) Go to a psychiatrist who is certain he or she will join you in your battle against depression to win it, hands down, not just to improve your situation. Getting a little better isn’t the goal. Getting “all better” is the goal. Period. A timid or pessimistic psychiatrist isn’t the one you want when you’re battling depression.

4) If you aren’t very substantially better in three or four months, go to another psychiatrist. This is an arbitrary rule of mine, of course, but I think it’s a pretty good one. For some reason, some folks tend to stick with psychiatrists for years, while noting no substantial improvement in their symptoms and assuming that their illnesses must be especially severe. Don’t assume that. Switch doctors.

If it sounds like treating depression is as much art as science, that’s because it is. It requires “sensing” which medicine might be effective, given the complexities of a patient’s particular symptoms, judging when to increase dosage, judiciously (but decisively) deciding when to add a second medicine and never losing sight of the fact that depression is an emotional crisis, requiring a psychiatrist’s ability to hone in on the underlying reasons a person got depressed, to begin with.

Please keep in mind that the use of antidepressants has been associated with an increased risk of suicidal thinking and suicide attempts in young people who take them. Between two and three percent of those under the age of 24 (but not over that age) can experience suicidal thinking or behavior that is believed to be due to the medicines themselves. This may be because the medicines are creating more anxiety in some people, who then feel more uncomfortable and desperate. Always, always, always tell your family and your clinician right away if you experience suicidal thinking (whether you are on one of these medicines or not).

Should the potential increased risk of suicidal thinking stop you from taking antidepressants when they are recommended by a doctor (and used in combination with psychotherapy)? No. By that reasoning, no one would ever get surgery, because of the risks of anesthesia. No one would ever take antibiotics because of the risk of a more severe, secondary infection caused by them.

The best strategy to defeat depression is to choose a clinician wisely, always share all the information with that person you can, make certain that person is focused on a complete victory and be willing to move on if you aren’t getting results.

Depression can be vanquished. It is among the most treatable of all human diseases. If you are afflicted with it, please take heart from that and take the necessary steps to defeat it.

Dr. Keith Ablow is a psychiatrist and member of the Fox News Medical A-Team. He is a New York Times best-selling author, and co-author, with Glenn Beck, of the book "The 7: Seven Wonders That Will Change Your Life". Dr. Ablow can be reached at