Treatment without an answer: who will not be helped by antidepressants

The number of visits to doctors due to depression is growing year by year. Most often, specialists fight it with the help of antidepressants, but not always the treatment is effective. How to recognize depression and who will not be helped by pills.

Today, almost everyone has heard about depression — the frequency of complaints about depressive symptoms is growing year after year. At the same time, however, not everyone understands what is really hidden behind this diagnosis, and they are also afraid to take antidepressants, considering them almost narcotic drugs.

“People began to complain about depression more often, but I don’t think this is because there are more depressions— people have increased psychological literacy, awareness. Modern antidepressants are easier to use — they have fewer side effects, they are easier to start taking.”

Depression has been known since ancient times — it was described in detail by Hippocrates under the name “melancholy”. He also identified the main symptoms: depression, insomnia, irritability, anxiety, and sometimes aversion to food. Hippocrates, however, considered the cause of the disease to be an excess of “black bile” in the body and offered to treat it with a special diet and an infusion of herbs with a laxative and emetic effect to remove excess bile from the body.

References to depressive states are found even in ancient Egyptian papyri — there, however, it is recommended to treat it by expelling demons from the patient.

Later methods of treating depression were also not particularly effective. In the Middle Ages, depression was treated with prayers, abstinence from certain foods, and “moderation” in sexual life. During the Renaissance, depression was considered a disease of the aristocrats, and the treatment was appropriate — sunbathing, wine, theatrical performances.

Later, the approaches became more radical — patients were unwound in centrifuges, watered with cold water and even infected with scabies and lice as an external irritant. In the XIX century, emetic tartar, henbane, camphor solution in tartaric acid became popular “medicines”. Later, cocaine was added to them — they, however, with the help of Sigmund Freud, tried to treat many ailments.

The main risk factor for developing depression is severe experiences both in childhood and in adulthood. Episodes of violence, the death of loved ones, significant changes for the worse-all this can provoke a depressive episode. But in about a third of cases, depression occurs without noticeable external shocks. In the first case, depression is called reactive, in the second — endogenous.

Depression can also occur against the background of alcoholism, drug use, a number of medications, or be the result of diseases affecting the brain (Alzheimer’s disease, traumatic brain injuries, atherosclerosis of the arteries of the brain, etc.). Order Antidepressants at sale.

Depression differs from the usual bad mood in its duration and influence on the usual way of life.

“The simplest things required enormous effort. I remember I burst into tears because a piece of soap was washed off in my bathroom. I was crying because a key on the computer keyboard had sunk for a second. Everything was deadly difficult for me. For example, the desire to pick up the phone required efforts comparable to the need to press a two-hundred-kilogram barbell lying down, ” the American writer Andrew Solomon described his condition during his illness in the book “The Midday Demon. The anatomy of depression”.

“If the condition interferes with normal daily life, affects the decisions made, work, in general, goes beyond the usual norm, you should consult a doctor,” — The second criterion is continuity, constancy. If a bad mood does not go away for two weeks or more — it is no longer just a bad mood. Because normally, no matter what the melancholy is, it can not last continuously. When a person feels lousy day after day — this is already a pathological condition.”

Recurrent or chronic depression is detected in at least 20% of patients. Prolonged course or frequent relapses of depressive attacks, separated by incomplete remissions, can eventually lead to complete disability.

The most tragic outcome of depression is suicide. Suicide attempts are made by 30-70% of patients suffering from depression (every seventh patient makes such an attempt), and the frequency of completed suicides is 15%. Young patients with depression attempt suicide more often than adults.

Of the 10-20 million suicide attempts made annually (one million of which are successful), up to 50% are patients suffering from depression.

Due to the combined influence of suicidal risk factors and increased vulnerability to other diseases (hypertension, endocrine, dermatological, etc.diseases), depression reduces life expectancy by 10 years.

There are several theories that explain the mechanism of depression. According to the most popular of them, depression occurs as a result of a failure in the mechanism of exchange of neurotransmitters, substances that are responsible for transmitting signals between neurons. In depression, serotonin, norepinephrine, dopamine and other neurotransmitters do not enter the synapses in sufficient quantities. This leads to apathy, despondency, anxiety, social phobias. The balance of neurotransmitters turns out to be different in different patients, so depression has its own “shade” for each of them.

The main problem is the lack of serotonin, so most modern antidepressants are aimed at increasing its concentration in synapses (however, many also affect the concentration of other neurotransmitters).

The first antidepressants appeared in the 1950s in the United States. This happened by accident, during the testing of new anti-tuberculosis drugs. It turned out that they not only effectively fight tuberculosis, but also contribute to an increase in mood and a surge of strength in patients. In the 1960s, antidepressants appeared in the USSR.

Early antidepressants had many side effects, from sleep disorders and seizures to liver damage and even heart attacks, and also helped a small number of patients. With the development of psychiatry and a more in-depth understanding of the mechanisms of depression, safer and more effective drugs emerged.

The most modern antidepressants are selective serotonin reuptake inhibitors (SSRIs). They block the reuptake of serotonin by its secreting neurons, which leads to an increase in its amount in the synaptic cleft. Among the common side effects of SSRIs are nausea, anxiety, and a decrease in sexual desire.

“Side effects in modern drugs are usually tolerable. In about 40% of cases, it turns out that there are unpleasant effects, but in order to improve their condition, the patient is ready to suffer. In percentages of 10-15%, the effects are such that the patient refuses the drug and needs to look for another one for him. Despite the abundance of drugs, there are difficulties in the selection. There are also resistant depressions that simply cannot be treated”

Now doctors are more willing to prescribe antidepressants than 20 years ago — they have become widely used.

Contrary to popular opinion, antidepressants are not “happiness pills” that increase mood and give a surge of strength. Their task is to even out the disturbed balance of neurotransmitters in the brain. They will have no effect on a person who does not suffer from depression. They will help a patient with depression to get rid of melancholy, lethargy and irritability, increase mental activity.

There are also drugs that affect the capture of norepinephrine, dopamine or several neurotransmitters at once. Not all of them are tolerated as well as SSRIs, so they rarely become the first-choice drugs.

There is a lot of debate around antidepressants about their effectiveness. Some studies and even meta-analyses show that they work not much better than placebo, and can be recommended only in the most severe cases. In particular, in 2017, Danish scientists published a meta-analysis of 131 studies, during which they concluded that the possible small positive effect of SSRIs is outweighed by serious side effects.

The answer to this was a much more extensive meta-analysis, which included 522 double-blind randomized trials that compared the effectiveness of 21 antidepressants with placebo and with each other in the treatment of clinical depression. In particular, the data available to pharmaceutical companies that were not published in journals were also used.

Each of the drugs demonstrated a 15-55% higher efficacy than placebo.

The most effective were agomelatin, amitriptyline, escitalopram, mirtazapine, paroxetine, the least effective were fluoxetine, fluvoxamine, reboxetine, trazodone.

The researchers, however, remind that the effectiveness of a particular drug may vary from patient to patient — this is influenced by the severity of the condition, gender, age and other features. In the analysis, the average values were considered. In addition, the work investigated the two-month period of taking antidepressants, while in reality they are sometimes taken for years.

“It still works. There is a consensus on this in the professional society.

Indeed, there are studies that show that antidepressants are useless, but there is a huge body of work against them that confirms their effectiveness. Here it is necessary to consider each study separately — the design of the experiment, how correctly the questions were posed, how the subjects were examined, ” Beschastnov notes. — Based on my experience, antidepressants are undoubtedly effective. This is not a panacea, but in certain situations they help. Over twenty years of work, I have appointed them thousands of times and have repeatedly seen the results, like all my colleagues.”

One of the problems of SSRIs is that up to a third of patients do not respond to therapy. The reasons for this are still unclear, but scientists from the Salk Institute for Biological Research believe that it may be in the structure of serotonergic neurons. They came to these conclusions by taking skin samples from 800 patients with depressive disorders, reprogramming them into pluripotent stem cells and growing serotonergic neurons from them. The study participants responded to SSRI therapy to varying degrees, and the researchers found a correlation between the structure of neurons and the effectiveness of drugs.

The researchers also identified genes that determine the features of the structure of neurons. They expect that in the future this will allow selecting the most suitable drugs for patients with depression, as well as finding out the reason for the immunity of neurons to SSRIs.

British experts complain that psychiatrists do not warn patients about withdrawal syndrome when they refuse drugs — they take its symptoms for a new depressive episode and return to medications again. It is believed that the withdrawal syndrome is poorly expressed and passes within a week, but the experience of patients shows that this is not so — nausea, anxiety attacks, insomnia, “flashes” in the head, similar to electric shocks, and other unpleasant sensations can haunt them for quite a long time.

Experts call on the National Institute of Health and Clinical Excellence (NICE) of the UK Ministry of Health to review the clinical recommendations and bring them into line with the real state of things, and doctors should be obliged to inform patients about possible symptoms so that they are not afraid of their appearance.

The symptoms and their severity in withdrawal syndrome are very individual.

However, the longer the drug is taken, the higher the probability of encountering them. To relieve the condition, it is necessary to abandon the drug gradually, reducing its dosage by a quarter or a third within a few weeks. When prescribing an antidepressant, it takes from two weeks to a month for it to take effect — about the same time it takes to “get off” it. If the withdrawal syndrome increases, the dosage should be reduced even more slowly.

Psychotherapy can facilitate the process of giving up antidepressants.

Cognitive behavioral therapy is the most effective, which allows developing new behavioral models in response to external factors.

Also, during the period of refusal from antidepressants, it is recommended to devote more time to physical activity, proper nutrition, hobbies. The mood diary will allow you to track your condition, notice in time if it worsens, and seek help.

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