Friday, October 8, 2010

Some things you may not know about antidepressants.

Antidepressants have been around for fifty years. The first one was imipramine. How they work on the brain and central nervous system has not really evolved  much over the last fifty years. Our understanding of why and how they work has evolved, and the bottom line is we still don't know exactly why or how they work. They tend to effect neurotransmitters in the brain, that is the chemical connections between nerves. The three big neurotransmitter we know the most about are serotonin, norepinepherine and dopamine. The old and most of the newer antidepressants inhibit reuptake of these neurotransmitters into the pre-synaptic nerve. The original theory on why they work was related to the fact that you kept more serotonin or norepi around and this somehow helped treat depression.
Then in the 80's, 90's and into this century more attention was paid to the area on the nerve cell where these chemicals bind to. The so-called synaptic neuroreceptor.
For a long time it was felt that because you kept more of the neurochemcial around and it moved forward from the presynaptic to post synaptic nerve site, that somehow the neurorepceptors got desensitized or "downregulated".
Over the last 10 years the theory has evolved even more as to why these things work to treat depression and many anxiety disorders.
Now the science has led us to believe that the binding of the neurochemical (caused by keeping more of the chemical around) cause changes within nerve cell and somehow this affects the genetic coding of proteins within the cell, (remember RNA and DNA?) and somehow this causes an uptick or a positive swing in encoding for proteins within the cell that help protect the cell and treat the depression or anxiety problem.
The theory continues to evolve.
Some other facts- most antidepressants are prescribed by primary care physicians, internists, obgyns, and even pediatricians. Yes psychiatrists prescribe them all the time, but there are a lot less psychiatrists, and in terms of total volume of scripts, more come from primary care.
For many reasons, culturally speaking, it is much more socially acceptable to be depressed now. We are more open to talking about it and being aware of it. Depression is still debilitating and potentially fatal and we have a long way to go. Primary cares screen for it better now.
Within the demise and so called restructuring of the health care system in this country, there is much buzz and initiatives to screen earlier, treat and be aware of depression and its consequences.
The problem is now in screening for it, there is a tendancy to diagnose most mental health problems and simplify them simply into depression. The screenings will pick up symptoms of depression, but often not the specific and primary mental health problem. for examply Bipolar disorder (horribly misdiagnosed) and often missed and PTSD or post traumatic stress disorder, to name just a couple.
There are a whole host of antidepressants out there, the SSRI's which were developed back starting in the 80's with prozac, then in the 90's and into this century. Zoloft, Paxil, Luvox, Celexa and Lexapro.
The SNRI's which stands for selective noradrenergic serotinergic reuptak inhibitors, Effexor, Cymbalta, Pristiq. Basically these work pretty similarly to the old imipramines and elavils of the 60's and 70's, with a couple huge differences. The newer ones have way less side effects, and they are not so lethal alone in overdose. They are also felt to be more effective by many, compared to the old ones, -which may be a product of the fact that they are eaiser to take and tolerate and stay on since the side effects are better. The key to antidepressants working, is staying on the meds. They don't work if you don't take them.
Antidepressants have been used to treat chronic pain almost for thirty years. It was generally off label meaning the FDA did not approve or recognize these things in use for chronic pain. Then the popular media campaign came that "depression hurts" and cymbalta being approved for various pain problems a few years ago. Sometimes they really work well and sometimes not for chronic pain.
You do get more physical aches and pains and such if you are depressed. That is not new and has been known like forever in the medical world, well at least the psychiatric medical world.
Antidepressants are not there to hurt a patient or make them worse, and they do save lives. We are taught as a society to be afraid of them, suspicious of them and wary of them. Popular culture and media and the government regulation and subsequent media fiascos make this worse.
Conversely we are also taught and expect that these meds are a panacea, a cure a fix it all for all of our emotional and psyhoclogical pains. That simply isn't true. But with those two polar ends of the spectrum suspicion, fear,  and an attitude of this "should fix everything', you have the perfect storm.
There are many other antidepressants out there I did not mention, so that block certain receptor sites like Remeron and Serzone and Trazedone. They have also been around for years. Wellbitrin tends to block reuptake of dopamine and norepi. Some people generally like Wellbutrin becouse it does not affect weight gain like some of the others can. It sometimes does not work so well for anxiety symtoms often associated with depression.
There is a ton of information on antidepressants on the Internet. We tend to love the devaluation of them, and when we find a negative article on them we like to say "Aha I knew it" as if they are bad and there is some awful conspiracy. Some psychiatrists have even made a cool name for themselves in devaluing them. Very politically correct. We also tend to devalue them in this way:
Think about it: the average family doctor has a few weeks of training in psychiatry but they prescribe the most antidepressants.  Non-physicians prescribe them- nurses practicioners, in most states and also psychologists want to prescribe them and in a couple states they are actually legally allowed to.
 We convince ourselves that is all okay. It is not. This comes from the shortage of psychiatrists. Most doctors don't want to go into psychiatry. For a lot of reasons. It is very little pay compared to most medical specialties, with health care reform that will only get worse. Also people don't always get better, it takes a long time and a lot of psychiatric problems tend to be chronic and recurring.
so you will see more unqualified and marginally qualified people prescribing and treating psych disorders.
The sell-out blogs jump on the politically correct bandwagon of supporting psychologists and the so-called mid-level practitioners, prescribing, as well as non-psychiatric physician. With that comes an underlying devaluation of psychiatry in general. You are not allowed in this day and age to even consider that maybe a specialist in psychiatry should be treating many psych problems out there. That is so politically incorrect, you get lambasted and you are very unpopular, so most doctors can't even speak up any more. It is just the way the world is. But with the sort of disdainful reduced attitude towards psychiatry and mental health issues in general, and the lack of accurate information that is truly disseminated, it is easy to see why we are so wary of psych treatment.
Before I get hate mail yes there are good nurse practicioners out there, just like there are good physicians out there.
Generally the popular buzz is "doctors don't talk to their patients, but nurses do". I am sure that is true in some case, but we like to convince ourselves that this is the norm. It is probably going to get worse with health care reform.
Antidepressants are used in Alzheimer's, People with AD can get depressed, it make the AD worse. They often can't articulate it to us, becouse of the dementia, so it is often overlooked. You generally have to use much smalled doses of antidepressants in the elderly (like any med) sometimes if not carefully prescribed or prescribed wrong they can make things worse, and if diangosed right and carefully monitored they can help tremendously.
There is much more to talk about with antidepressants, the suicide issue (horribly misunderstood) side effects, target effects, (what they are actually supposed to do. All of the natural remedies, (chemicals also like the meds) they are a financial; boom to many and severly unregulated, but as a fairly uninformed society or shall I say misinformed, if we hear the world "Natural" we are profoundly reassured.  Stay tuned.

1 comment:

Monitoring Blood Glucose said...

Yeah great information about, i was unknown about this antidepressants...
Thank you for the post..

Talking about the book with the Lake Superior wind....... a calm day