“I don’t want to go on medication!” my patient Sarah said to me, almost in tears. “I’ve seen what it’s done to my mother. She went on antidepressants ten years ago, and it’s always the same—they work great for a few months, then they don’t, and then she’s worse. Then the doctor puts her on some new medication, and the whole thing starts all over again.”
Sarah was unusual among my patients, many of whom come to me eager for the antidepressants about which they’ve heard so much. Both physicians and psychiatrists have come to view such medications as Paxil, Zoloft, and Wellbutrin as true “wonder drugs,” medicines that have succeeded where traditional talk therapy and other approaches have failed. Even Prozac, despite the rash of bad publicity that it got for a while, continues to enjoy a reputation as a cure-all for anxiety and depression.
But Sarah’s mother’s predicament—a long-term reliance on medications that often work best only in the short term—is all too common, even if these more mundane problems of antidepressants don’t get the public attention of the notorious suicides and psychotic episodes that were associated with Prozac in the early 1990s. Although I do prescribe antidepressants to my patients who need them, I also feel concerned about what I see as the overreliance on medication among psychiatrists, primary-care doctors, and other health professionals. For some people, antidepressants may indeed be a kind of wonder drug, balancing their brain chemistry and enabling them to take a new approach to their lives. But in many cases, these patients might benefit from alternatives to medication that will work just as well or better, with longer-term benefits and fewer side effects. And people who do need medications, whether temporarily or for a longer time, also need to support their brain chemistry in other ways, such as with nutrition, supplements, exercise, and breathing—approaches that all too many doctors and psychiatrists fail to recommend.
So in this chapter, I’ll walk you through the promise and the perils of medication. I’ll show you how these medications work and why they need to be supported with the right nutrition, exercise, and lifestyle. I’ll tell you about alternatives to medication and help you evaluate whether they might be right for you. And if you’re currently taking or about to take medications, I’ll show you how you can work with your doctor or psychiatrist toward either getting off your antidepressants or making the best possible use of them over the long term.
When I was first learning to practice psychiatry, the pharmacological repertory was fairly limited. The standard treatment for depression was to prescribe one of two classes of drugs, MAO inhibitors and tricyclic antidepressants. Although both were somewhat effective in relieving the symptoms of depression, each brought with it such severe and uncomfortable side effects that for many patients, the cure was often worse than the disease.
Then came the new class of antidepressants, and it seemed like a miracle. These new medications were significantly more specific in rebalancing only those aspects of brain chemistry whose imbalance was causing depression.
The new effectiveness of antidepressants meant that many people who had been suffering from low-grade depression—perhaps without even realizing it—were suddenly taking these medications and feeling better. Today’s antidepressants have even fewer side effects than that first generation of “miracle drugs,” and the newest medicines are safer still. People take them and feel better almost immediately, which is a powerful reinforcer to keep taking them. And of course, the alternative—ongoing depression—is both upsetting to the patient and disturbing to the therapist, who is only too aware that suicide is a possible outcome of depression. “Better safe than sorry” becomes the slogan, and medications are almost generally viewed by my profession as entailing few shortcomings while delivering a significant number of benefits.
Today, tens of millions of Americans are now on antidepressants, and the number goes up each year. The cost of these prescriptions—at least five hundred dollars per person per year—is straining the health-insurance industry and is one of the reasons for health care’s annual double-digit inflation.
This remarkable increase in the use of antidepressants is largely the result of a major educational effort of the past ten years, in which both medical schools and pharmaceutical companies have endeavored to train physicians to better recognize depression and to treat the condition with medication. When this effort began, I thought of it as a noble undertaking, even though much of it was funded by an industry that stood to make a handsome profit from these newly enlightened physicians. After all, when most people experience the first symptoms of depression, they start by going to their doctor, seeking advice on why they’re so tired all the time or perhaps asking for medication to help them sleep. In fact, the vast majority of antidepressants are now prescribed by primary-care providers such as family physicians and nurse practitioners, and getting a prescription for an antidepressant is even easier than obtaining a flu shot. People who report symptoms of sleeplessness, agitation, or loss of energy to their family doctors—symptoms like the ones Dave presented to me—are likely to find their doctor suggesting a course of Paxil or Zoloft.
In some cases, this may be the right solution. Some people need the extra support that medication can provide to make it through a rough time or to combat what may be a lifelong tendency to depression. As we saw in Chapter 2, depression corresponds to an imbalance in brain chemistry, whether that imbalance results from a long-term pattern, childhood experience, genetic inheritance, or a specific situation. Whatever the cause, sometimes you just need medication to help restore your chemical balance.
But even when we focus entirely on the brain’s chemistry, ignoring the many mental, emotional, and spiritual aspects of depression, medications often aren’t the best way of rebalancing our hormones and biochemicals. Sometimes a change in diet and exercise habits can be equally effective, with no risk of side effects and with lifelong benefits to physical and mental health. Likewise, the approaches I describe in Step Three of this book have helped many of my patients overcome depression, both in response to specific causes or as part of a lifetime of unhappiness.
But even when medications are called for, doctors are often remiss in not prescribing the diet and lifestyle that would enable the meds to do their best work. As we saw in Chapter 1, practitioners who in other circumstances would not think of prescribing drugs without some lifestyle supports seem to consider antidepressants to be an end in themselves. Although no responsible physician would prescribe Lipitor without instructing the patient to cut back on fried foods, most doctors think nothing of prescribing Zoloft without an admonition to eat more complex carbs, cut out the sugar and caffeine, and get some vigorous exercise.
Sarah was a young woman who had grown up in a small town and was now in college. She’d always struggled with a lack of confidence, she told me, and often felt insecure and anxious. Although Sarah was easily overwhelmed by stress, she actually had more difficulty with the times when she was less busy, when her chronic, low-grade sadness seemed to become more intense. Frequently, Sarah told me, she’d experience a day or two of inordinate sadness before her mood seemed to lift.
Sarah’s mother had also suffered from depression, so Sarah was well aware that her symptoms were the classic ones for the condition. In the two weeks before she came to see me, Sarah’s depression seemed to get worse, as she found herself crying frequently for no apparent reason. Sarah was also suffering from mild insomnia, feeling physically restless, and having trouble concentrating. Although she’d once loved her courses in history and art, she found herself losing interest in these favorite subjects, and it was becoming increasingly harder to motivate herself to study or even to attend class.
Sarah was used to struggling with periodic feelings of anxiety, hopelessness, and worthlessness. But now these emotions had intensified as well. Luckily, she was not suicidal. But she was experiencing virtually every other symptom of serotonin imbalance.
From having observed her mother’s encounters with doctors over the years, Sarah was well aware that most mental-health professionals would diagnose her with major depression and prescribe an antidepressant. I was able to confirm that Sarah’s family history of depression, her long-standing struggles with energy and mood, and her classic symptoms indicated a genetic tendency to low resilience. I agreed, too, that most doctors would very likely prescribe an antidepressant, most likely one of the class known as selective serotonin reuptake inhibitors, or SSRIs— Prozac, Zoloft, or Paxil. Indeed, someone with Sarah’s symptoms would probably respond very well to that type of medication and feel much better almost immediately. So why not just prescribe it and give her some relief?
“If you were feeling suicidal,” I told Sarah frankly, “or if you’d been feeling this low for a longer period—say, several weeks—I would almost certainly suggest that you consider medications. But in this case, you’re absolutely right—there are lots of reasons not to rush to that step.”
While the new medications are a vast improvement over the older class of antidepressants, I told her, even they can cause some side effects. In the early stages of treatment, patients often experience nausea, headaches, muscle tension, jitteriness, and insomnia, although these symptoms tend to improve over time, and they can be lessened if the dose is kept low and the medications are taken with food. Likewise, some patients—including, apparently, Sarah’s mother—complain of feeling “flat,” apathetic, or listless, though I consider those responses, too, a sign that the dosage is too high and needs to be adjusted.
Even if a medication is administered in the proper dosage, however, many patients experience long-term side effects such as weight gain, fatigue, and loss of libido—problems made worse by the fact that doctors often don’t recognize these symptoms as side effects. Sometimes they’re even considered evidence of lingering depression, with the result that the doctor increases the dosage of antidepressant and makes the problem worse.
Sarah’s mother had also experienced the opposite problem—becoming more angry or agitated while on medications. Because of her mother’s experience, Sarah was particularly anxious about recent newspaper accounts of people acting impulsively, behaving out of character, or even becoming suicidal while on antidepressants. There’s still a lot of controversy over these reports, but I personally believe that some people, at least, are at risk for increased stimulation or “overactivation,” particularly if there is a family history of bipolar illness or if the patient is prone to mood cycle or irritability.
The risk of such side effects was disturbing enough. But, I told Sarah, medication posed even more troubling concerns, particularly for a young person like her, who would most likely be facing a tendency to depression for the rest of her life.
My concern was rooted in the very nature of antidepressants. Let’s start with a closer look at SSRIs, the most commonly prescribed class of anti-depressants, and the type of medication that would have been appropriate for Sarah.
Like most antidepressants, SSRIs work in a way that tends to be self-limiting. They’re often very effective in the short term while frequently losing their effectiveness in the long term. In fact, if patients don’t change their diet and lifestyle while taking SSRIs, this medication can in some cases leave them even worse off than they were before.
Sarah had observed this very phenomenon with her mother. Like so many patients who are given medications with no nutritional or lifestyle support, Sarah’s mother had gotten into a downward spiral in which medications both worsened her problem and grew less effective in treating it.
The problem with SSRIs lies in the way they operate to improve mood and energy. As the name implies, these selective serotonin reuptake inhibitors selectively inhibit the reuptake of serotonin; in plain English, they block the reuse of serotonin within the brain. As we saw in Chapter 2, serotonin is a brain chemical that is basic to our sense of calm, self-confidence, and well-being. It circulates through our brain as it is released from one nerve cell, moves across the synapse, and fits into the receptor of the next neuron. That moment of reception triggers a response in the neuron, and if the response is repeated often enough, we start to feel good. That’s why higher levels of serotonin floating in the synaptic fluid—the fluid between nerve cells—are a sure-fire antidote to depression, listlessness, low self-esteem, and anxiety. As our neurons begin to respond to the serotonin, our mood improves, we become energized, and we even start feeling better about ourselves.
As we also saw in Chapter 2, the luckiest people among us are born with naturally high levels of serotonin. For some reason, these happy people seem to be able to manufacture enough serotonin to keep their synapses flooded with the chemical, and so “their tank is always full”— that is, their neurons have a constant supply of this “feel-good” chemical.
On the other hand, people who have undergone significant amounts of stress, had stressful childhoods, or possess a genetic tendency to depression all struggle with short- or long-term serotonin shortages. Their neurons aren’t getting the serotonin they need—and depression is the result.
What happens to serotonin after the neuron receives it? As soon as the initial connection is made—producing the happy response I just described—the cell releases its serotonin molecule back into the synapse. And if the serotonin remains in the synaptic fluid, various brain chemicals break it down and eliminate it from the body. Eventually, the body has to make more serotonin, or depression will recur.
There’s an intermediate step, though, between using serotonin the first time and expelling it from our brains. To avoid having to continually manufacture new serotonin, our efficient brains have found a way to recycle that vital chemical. A “reuptake pump” captures the serotonin molecule as soon as it is released from the receiving neuron and brings the chemical right back into the cell that just released it. There it is stored, and eventually, released again.
SSRIs work by blocking that pump, preventing the reuptake and recycling of serotonin molecules. As a result, serotonin stays in our synapses longer. For people with low serotonin levels, whose receptor neurons are used to chasing every scarce molecule of the “feel-good fluid,” SSRIs create a whole new experience. Suddenly it seems as though the receptor neurons are being flooded with this soothing chemical. Instead of scrambling for a few serotonin molecules, they can luxuriate in what seems like a new abundance.
As a result, people on SSRIs often feel terrific when they first start taking the meds. Their sense of well-being improves, their mood lifts, and their depression seems to dissipate. Many people describe this experience as a veil or a cloud being lifted from their brains. People who have been depressed for years say that they finally know how “normal” people feel. These once-depressed patients may still have ups and downs, but they feel that their moods are within bounds. Instead of creeping along the edge of an abyss, they’re merely strolling along a somewhat uneven path—sometimes uphill, sometimes downhill, but never with the sense of dread and doom they used to experience every day.
For the first few weeks or even months, these newly medicated patients continue to improve. Now that they feel more resilient, they’re better able to handle the curveballs that life throws their way. A minor setback—like Jennifer’s lonely feeling when her roommate went off without her—seems truly minor instead of a trigger for overwhelming sorrow. “I finally get what people mean by ‘don’t sweat the small stuff,’” one of my patients once told me. “Before, I never even knew there was small stuff.”
As I observe patients who begin taking SSRIs, I’m always struck by how many areas of their lives improve. They tend to feel better about themselves, less worthless, more hopeful and confident. The negative self-talk (“I never do anything right,” “Who’d want to be my friend?,” “No wonder no one likes me”) diminishes, often to be replaced by the tentative beginnings of positive self-talk (“I’m learning every day,” “I’d make a great friend,” “Actually, a lot of people do like me”). They can enjoy themselves more, are better able to concentrate, and can be more productive. I’ve seen many of my patients become more extroverted, better able to put themselves out into the world. They also become braver, more able to take chances—and to pick themselves up and start over again when their chances don’t work out.
Who wouldn’t want to feel that way? If there were indeed a pill that could produce that effect, why shouldn’t I prescribe it to Sarah?
As you may have guessed from my description, the problem with SSRIs is that often their effect is only temporary. By preventing the reuptake pump from recycling serotonin, the brain experiences the temporary high of an increased serotonin level. But remember: The body isn’t actually producing more serotonin. It’s only retaining the existing serotonin in the synapses for a longer time. Sooner or later, a new stressor is likely to come along and deplete the brain’s already low supply of serotonin. Or perhaps you live such a stressful life that your serotonin stores are being gradually depleted all the time. Medication doesn’t replenish your serotonin levels—it only manipulates them. So if you haven’t done anything to boost your serotonin levels, either ongoing stress or some new problem will most likely drive your serotonin stores down to depressive levels once again.
Of course some people take SSRIs only to counter a temporary setback—a particularly stressful period or sorrowful event. People who are normally free from depression can use the temporary uplift of the SSRIs to overcome a short-term crisis. So if you haven’t suffered from depression before, or if you’re only prone to it in response to acute stress, you can probably go on to live without your medication, confident that your body is once again prepared to make all the serotonin you need.
But if, like Sarah and her mother, you have spent a lifetime struggling with depression, you’ve probably never been an efficient producer or manager of this soothing chemical. So unless you’ve done something to boost your serotonin production—starting a serotonin-friendly diet (Chapter 4), taking nutritional supplements (Chapter 5), undertaking healthy exercise and daily routines (Chapter 6), and practicing mindfulness (Step Three)—your serotonin levels are likely to remain low, and your risk of depression will remain high.
Unfortunately, most doctors and psychiatrists are unaware of the need to support serotonin production through these supplementary means. So usually, when a patient reports the return of depression, the doctor simply increases the dosage. The patient feels good—until once again, the brain exhausts the new supply. The cycle continues with the period of relief becoming shorter and shorter, until finally the dose becomes too high for the patient to tolerate or the medication simply becomes ineffective. Then the physician is likely to prescribe a new medication, or to combine two medications, and the cycle begins all over again. This was the pattern Sarah had observed with her mother. No wonder it scared her.
It’s bad enough when SSRIs provide only short-term relief for depression, leaving patients right back where they started. But in some cases, SSRIs can make a patient’s condition even worse.
Sarah, for example, had spent a lifetime struggling with low levels of serotonin. As a result, her brain had become very efficient at using any serotonin that was available. To compensate for the scarcity of serotonin molecules in the synaptic fluid, each of Sarah’s nerve cells had developed numerous serotonin receptors—the portion of the cell designed to receive serotonin—and those receptors had become highly sensitive and adept. It was as though, if even a single serotonin molecule floated by, a thousand receptive hands immediately reached out to snatch it. This process of heightening one’s sensitivity is known as “up-regulation.”
So far, so good. Although Sarah isn’t as happy and energetic as she would like, she has at least adapted to her condition. She has achieved what biologists call a state of homeostasis, in which an organism has become used to the way things are and resists any effort to change.
If Sarah were to start taking SSRIs, though, her situation would change dramatically. Although her serotonin levels wouldn’t be any higher than they ever were, her receiving neurons would feel as if they are. So as the nerve cells happily soak up the new serotonin, they gradually reduce the number and sensitivity of their receptors. After all, with so much serotonin around, why work so hard at capturing and using it? Instead of a thousand eager hands snatching at a single scarce molecule, it’s as though only a few hands reach out lazily to scoop up the new abundance. This process of decreasing sensitivity is known as “down-regulation.”
Remember, Sarah’s serotonin levels are still fairly low—but now her nerve cells have lost their heightened ability to make use of the scarce substance. So what happens if her serotonin levels drop even further, in response to a new stress? Those few lazy hands reaching out for serotonin will discover a new scarcity that they’re not equipped to deal with. Sarah will be even less able to respond to stress than she was before—and even more in need of medication.
Likewise, if Sarah tries to stop her medication without having done anything to raise her serotonin levels, what is likely to happen? Once again, she’s struggling with low levels of the crucial chemical, but without the increased sensitivity and efficiency she had developed before she started taking the meds. Those thousand eager hands—the increased number of sensitive neuron receptors—have disappeared, replaced by fewer and less sensitive receptors. So Sarah’s ability to withstand stressors will markedly decrease, her resiliency will drop to an even lower degree than before, and her vulnerability to depression will become even greater. As a result, she’s likely to feel that she needs the medication. In effect, even though antidepressants are not technically habit-forming, Sarah—like her mother—could become dependent on them, unable to function without them despite their decreasing effectiveness and painful side effects.
I explained this basic biochemistry to Sarah, who found it comforting to finally understand the cycle of serotonin depletion that had plagued her mother. I also pointed out that if Sarah didn’t take immediate steps to respond to her own depression, it was likely to get worse. At this point, she still had a choice. In a few months, her symptoms might have worsened to the point where medication would indeed be her best option.
“Of course,” I told her, “the pills are always there as a backup. But in your case, the symptoms are still mild enough that you could probably give more natural measures a try.”
Sarah took a deep breath. “If there’s even a chance that those other options would work,” she answered, “I’d like to start with them.”
We agreed that Sarah would begin a short course of psychotherapy with one of my colleagues, start getting regular exercise, change her diet to the serotonin-enhancing regime I describe in the next chapter, and begin taking B vitamins and fish-oil supplements (see Chapter 5). During more stressful times, I suggested that she add a dosage of 5-HTP, a supplement that helps the brain produce serotonin (again, see Chapter 5). If she didn’t respond to these measures, Sarah agreed, she would come back to see me so we could discuss our next move.
Sarah was excited to have options presented to her that involved more natural ways to replenish her brain and gave her a greater measure of control over her own health. She left feeling hopeful for the first time in months, and it was obvious that her mood had improved just in the time we had spent together. I saw her again several weeks later to check on her progress, and her symptoms had improved markedly. While she still had some occasional down times, she no longer worried about them or saw them as a harbinger of a downward spiral. She now saw them as a simple sign of stress overload or some other temporary cause of imbalance, and was able to take immediate steps to replenish herself.
Sarah was particularly relieved not to have gone on medication. “Maybe at some point I will need to take antidepressants for a while,” she told me. “But whether that happens or not, I don’t have to end up like my mother. I can overcome the depression, with or without medications. And I don’t have to stay on medications forever—it can be a temporary thing.”
Although we’ve focused so far on SSRIs and serotonin depletion, the principle is the same with other types of antidepressants. Other medications do the same thing for norepinephrine and dopamine that SSRIs do for serotonin: They manipulate brain chemistry but don’t restore it. And you may run into the same problems with them as with the SSRIs if you don’t do enough to remedy the cause of the depletion.
Although I encouraged Sarah to try alternatives to antidepressants, I want to make one thing perfectly clear: No one should look upon the need for medication as a failure or a sign of weakness. Over the years, I’ve seen many, many examples of how antidepressants have made an extraordinary difference in the lives of my patients, enabling people who had lived “under a cloud” for years to come out into the sunshine and enjoy their lives, or empowering people who’d had a lifelong history of feeling timid and worthless to discover their strengths and their worth. I believe too deeply in the profound interconnection of mind and body ever to think that depression is “all in your mind” or that it can simply be willed away. Nor do I believe that diet, exercise, meditation, and the other techniques described in this book are always sufficient, or that they work equally well for everyone. Sometimes, whether for a few months or as a lifelong support, medications are simply needed, and we should all be grateful that they work as well as they do.
However, whether or not you are on medications, I also believe that if you’re suffering from any type of depression, you need to consider how to nourish your brain with the right type of diet, supplements, and exercise, and how to feed your soul with the meditations and heart-opening techniques that are right for you. So I hope you’ll see this chapter as one end of a spectrum of choices, opening up new choices rather than precluding any one approach.
How do you know if you do need medications? In the end, this is a decision you must make with your doctor, therapist, or health professional, based on the specifics of your situation and the particular way your own biochemistry responds to stress, nutrition, exercise, and other types of therapy. Here, however, are a few guidelines to help you evaluate your condition:
You might consider short-term medication if . . .
. . . you have undergone one or more severe stressors—a death in the family, a move, a job loss or job change, the birth of a child, or some other life-altering event—and are unable to “bounce back” after more than a month.
. . . you are finding yourself unable to function normally in your daily life.
. . . you have lost the zest for life, finding it hard to get interested in things or to experience pleasure in them.
. . . you have recently had periods of prolonged, unexplained sadness that last for more than a few hours at a time and occur more than once a week.
. . . sleep, appetite and sexual interest are diminished.
. . . you are plagued by suicidal or self-destructive thoughts.
You might consider long-term medication if . . .
. . . you have had frequent or prolonged periods of being unable to function.
. . . you have had frequent or prolonged periods of unexplained sadness over the past several years.
. . . you are subject to frequent or periodic bouts of disabling depression or anxiety that interfere with your ability to work, socialize, or enjoy your life.
. . . you have a family history of depression, alcoholism, or suicide.
. . . you have a long history of suicidal thoughts.
. . . you have already had one or more depressive episodes of such an extent that you experienced devastating consequences.