The Ups And Downs of Depression Treatment

The journey from depression rarely follows a straight line.

Medically Reviewed by Brunilda Nazario, MD on April 29, 2011
5 min read

Depression can be like an old blanket -- a smothering, sometimes comforting cloak between you and the world. Unfortunately, getting free of its symptoms is not as simple as crawling out from under the blanket. Most people experience ups and downs in the journey from depression. The fluctuations are normal, and professionals have ways of dealing with them.

“The rate of what used to be called Prozac poop-out -- the rate of relapse on an antidepressant -- is about 30% over a one-year period,” says Jonathan E. Alpert, MD, PhD, chief of clinical psychiatry at Massachusetts General Hospital in Boston.

There are numerous explanations for this high rate of relapse, says Alpert. Most often, there’s something interfering with the effects of the antidepressant drug.

Other medications -- such as steroids or antibiotics -- can interact with and blunt the impact of an antidepressant. So can heavy smoking or drinking.

Stresses can also disrupt your peace of mind. Divorce, foreclosure, money problems, painful fights with one’s children -- all can generate the wrong brain chemicals just as surely as a pill can. Even changes like the birth of a child or a new job can create jagged levels of stress.

Sometimes, though, the drug just stops working. Perhaps receptors in the brain become less sensitive to the effect of antidepressants over time, leading to a kind of tolerance. The biochemistry of this effect hasn’t been well studied, but it seems to be real enough in some patients who have no other explanations for a drug’s waning effect.

Sometimes, people stop taking their antidepressant medication because of aggravating side effects. Or they may try to deal with the side effect by taking the medication intermittently.

“Impaired sexual responses -- impotence in men, inability to reach orgasm in women, and lack of libido in both sexes -- are among the side effects most likely to lead patients to stop taking a medication,” says Myrna Weissman, PhD, professor of epidemiology and psychiatry at Columbia University.

Another problem that causes people not to comply with their treatment routine is weight gain. Weissman says that if you are having difficulty dealing with problems like these, it can help to talk with your doctor about using a different antidepressant. Changing medications, she says, may be appropriate if such symptoms persist.

Gabrielle Melin, MD, MS, a clinical psychiatrist at the Mayo Clinic in Rochester, Minnesota, says that relapse is most common in people who are not taking their medications properly. “They’ll say they are, but if you press they admit, ‘Oh I miss it three or four times a week.’ That makes it ineffective because the drug takes some time to work into your system."

Alpert points out that a small percentage of patients with depression feel that selective serotonin reuptake inhibitors or SSRIs -- the first line of treatment for most cases of depression -- dull or blunt their emotions.

“A small number,” he says, “will say, ‘I don’t get as sad as I used to get but I don’t get as happy as I used to get either.’”

In some of these patients, Alpert says, the drugs may be interfering with dopamine, which is a brain chemical that affects feelings of pleasure. If that is the case, Alpert might add or switch to bupropion (Wellbutrin) to offset the effect the SSRI is having. Unlike SSRIs, bupropion is aimed at both the serotonin and dopamine systems to bring them into balance.

“I have had patients say they feel numb, or can’t cry, or that their feelings aren’t there like they used to be,” says Melin. “It’s mostly men, and it’s rare. But in the 14 years I’ve been doing this, I’ve never found someone who didn’t have the symptom go away when we switched medications.”

When your depression symptoms come back, talk with your doctor. “Maybe you need to increase your dose,” says Alpert. “Or maybe you need to change medications, or add a new one, or add psychotherapy.”

Sometimes, he says, when the depression is severe enough, shock therapy is a useful alternative. “One way or another, we need to step up treatment.”

Weissman agrees. “If a patient is on a medication,” she says, “and hasn’t gotten a reduction in symptoms, that patient should consider asking the doctor to increase the dose, try a different medication, or try psychotherapy.”

Often, a few months of talk therapy can help a person going through stressful times. Because so many insurance companies won’t cover psychotherapy, therapists like Weissman have created shorter, goal-oriented approaches that work faster.

Interpersonal psychotherapy or IPT, which Weissman helped develop, is one such approach. It works by getting people to examine life events that triggered a bout of depression. Cognitive therapy is another approach. It works by getting people to recognize distorted attitudes and needlessly negative thoughts.

“It doesn’t change personalities,” Weissman says. “It’s time limited and based on a medical model.”

She thinks the approach is especially helpful for parents who are depressed. Her research has shown that when parents clear away depression, their children are happier and less likely to become depressed or to have other psychiatric problems.

“You get a two-for,” she says. “Parents are less hopeless and helpless and have more interest and affection. It’s hard to be depressed when you’re being warm and attentive and energetic.”

What psychiatrists don’t want to see is patients being scared off of treatment by depression’s stigma or by the feeling that depression is their own fault. You are not responsible for your depression, and treatment is not something to be embarrassed about.

In studies where people were on an antidepressant then switched to a placebo, depression returned at a rate two to three times higher than it did for those who remained on the drug.

“We know that antidepressants prevent depression from coming back,” Alpert says. If you work with your doctor and therapist and continue treatment, adjustments can be made to help treatment continue to work.