Humans are social creatures, attuned to seeking supportive relationships with other people. But with antidepressants, we have a different kind of significant other.
We all have different needs at different times. For me, it recently became necessary to form a relationship with something I thought I’d never need—antidepressants. It happened following a number of major life changes, including the disintegration of my parents’ seemingly strong marriage. Ironically, this was five years after I’d worked as a medical representative promoting antidepressants. I had learned about the causes of anxiety and depression and the ways these conditions can manifest, but at the time felt detached from the concepts. I spent my days talking to doctors about their various patients and available treatments, all while trying to convince them that the medication I was pedalling would be the drug they needed. I was so naïve. Anxiety and depression are complex conditions with no quick fix. Learning to manage them has been a long, painful and confusing process.
The World Health Organisation classified depression as the leading cause of disability worldwide in 2018, and as a major contributor to the overall global burden of disease. In 2017-18, one in eight Australians had an anxiety-related condition, and one in ten had depression. Untreated depression can kill, not only by suicide but also by the worsening of other comorbid medical illnesses. It’s no wonder that the prescribing of antidepressants has reached record levels, with the Organisation for Economic Co-operation and Development reporting an on average doubling of prescriptions in 29 countries.
The reasons for this increase in anxiety and depression remain unclear. One explanation could be the way our society has changed, becoming increasingly busy and more individually focused within our relationships. Despite this increased use, the stigma around antidepressants remains, with these treatments often dismissed by the media as happy pills. Adding to this is the debate amongst experts on the biochemical effects of antidepressants, the side effects, withdrawal symptoms and the potential for addiction. So, are antidepressants a necessary sidekick to life, and how do we know how to make that decision?
Through my experience, I’ve come to think of antidepressants as similar to another “sidekick” in life—a romantic partner. I know it’s an unlikely metaphor, and you certainly can’t treat a love interest as a panacea for mental health. But it’s an analogy I’ve found helpful in my journey towards wellbeing.
Both falling in love and treating anxiety/depression involve changes in brain chemistry. Research from the 1960s suggests that anxiety and depression were caused by biologically unlucky chemical imbalances in the brain, thus claiming antidepressant action relied solely on the modulation of brain chemicals. Interestingly, antidepressant development has focused on modulating the neurochemicals serotonin, noradrenaline and dopamine, all of which are also important in relationship development. Our understanding has now evolved but it is still believed these neurochemicals play some role in anxiety and depression.
During a period of anxiety and/or depression, the brain itself changes, not just its chemicals. An increased understanding of the brain, in part due to technological advances, suggests brain reorganisation, damage and disconnection play a role in the development of depression. For example, chronic stress, ever-present in modern life and a risk factor for anxiety and depression, has been suggested to negatively impact brain circuits. Brain imaging studies show the size of brain areas, such as the hippocampus, are reduced in association with depression, suggesting decay of brain tissue and altered brain connectivity. Considering multiple classes of antidepressants were developed based on a theory that is now being partly challenged, it is not surprising their use resulted in unanticipated side effects.
Many antidepressants list numerous mild to severe side effects, and like any relationship, management involves compromise and overcoming conflict. Common complaints associated with antidepressants include dizziness, sexual side effects, weight change, nausea, vomiting, insomnia and gastrointestinal disturbance. Newer (second-generation) selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) have been found to be safer than older (first-generation) monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs), but safety at the individual level is complex.
Selection of an antidepressant requires consideration of a range of clinical, environmental and genetic factors (for example age, sex, other medical conditions, diet, smoking habits, genetics related to drug metabolism, liver/kidney function and neurotransmission). It requires consultation with the right doctor to maximise response and minimise side effects. For example, there are strategies available for managing antidepressant-induced sexual dysfunction. Atypical antidepressants, such as mirtazapine, have been shown to result in a low rate of sexual dysfunction.
Although unaddressed side effects (sexual or otherwise) may impact relationships, avoiding antidepressant use in cases where it is recommended may also create obstacles within relationships. Depression is associated with relationship distress, with couples therapy being investigated but not yet confirmed as a promising solution. Antidepressant use can be adopted to help improve social and emotional responses within relationships. It appears to reverse negative bias, or the tendency toward negative interpretation of events, that is associated with depression.
Just like it can take a few dates to find the right person (or people) for you, it can take a while to find the right treatment. According to Dr Pierre Blier, Professor of Psychiatry and Cellular and Molecular Medicine at the University of Ottawa, tailoring medication to a patient’s profile will improve effectiveness. There is a possibility this may require switching therapies or a combination of two or more medications. Using a single agent (monotherapy) versus combination therapy depends on patient severity and physician qualification. Several studies have shown that adding an additional drug treatment (the combination approach) is effective. For example, in the STAR*D study where monotherapy, switch and combination therapies were compared, it was shown there was a 10% higher remission rate with combination compared to switch.
And yet, primary care physicians prescribe monotherapy 92% of the time. Dr Blier highlights the discrepancy with other fields: "In other fields of medicine, prescribing a single agent for an illness, like asthma or septicemia, would be considered inadequate”. Stigma is re-emphasised by language in the media. Terms such as “drug cocktail” are tossed around to describe combination therapy for depression, in contrast to the term tri-therapy when discussing multi-drug treatment for HIV. Personally, I trialled at least four different medications and was classified as having treatment-resistant depression before I found a combination of agents that work for me.
An oft-cited problem in relationships is commitment issues and similarly, we seem to have an issue committing to treatments. One of the most common issues that affect the success of antidepressants is poor adherence. According to Dr Blier, half of the patients taking medication for depression stop within three months of treatment initiation, with a further one in five patients giving up after another six months.
As a medical representative, I heard numerous accounts of patients starting to feel better, thinking they were cured and stopping their medication without professional advice. The downfall of approaching an antidepressant with this non-committal mindset is that clinical responses, as opposed to changes in emotional processing, take time. In the acute phase of treatment, a patient will be trialled on a medication for at least 2-4 weeks before treatment is reassessed. Dr Blier states, “The clinical reality is that only about a third of depressed patients achieve remission after an antidepressant medication trial given at an adequate dose for a sufficient time. Sequential switches (to alternative medications) may eventually lead to remission, but each step requires at least 6 to 8 weeks”.
Part of the reason for this required time commitment is that medication commonly used to treat anxiety and depression is associated with withdrawal symptoms. To reduce this negative impact, the current guidelines recommend gradually reducing doses over a period of four weeks, known as tapering, followed by a drug-free washout period before starting a new agent. This is to avoid drug toxicity or serotonin syndrome. Luckily, the agents I trialled did not require a significant tapering period, and I was able to stop one drug and start another relatively quickly. However, this was only under guidance from a medical professional, which is crucial to the discontinuation process. Prior to discontinuation, patients should be educated on common withdrawal symptoms they may experience. These include dizziness, disturbance of balance, headache, nausea, insomnia and vivid dreams, which can last for a week or two.
Just as the emotional pain experienced after a break-up may lead us to reconnect with an old lover, antidepressant withdrawal syndromes can be severe enough to encourage recommencement of medication. A review of human studies from the last ten years advising best methods of antidepressant discontinuation found that recommencement of medication and a slowed process of tapering following severe withdrawal symptoms was warranted. It appears from the literature there is no definitive tapering procedure that will work for everyone. It is important to communicate regularly and honestly with your medical team to switch between medications if this is deemed necessary for remission.
The main goal of long-term or maintenance treatment is to prevent the original condition from recurring, but the guidelines for this period are still unclear. Even if a patient complies with treatment and achieves remission, the Royal Australian and New Zealand College of Psychiatrists clinical guidelines advise that antidepressants be continued for a minimum further six months, depending on patient severity. This is required to reduce relapse. Long-term treatment options depend upon the number of episodes a patient has previously experienced. Treatment approaches also need to reflect the complexity of major depression, taking into account temperament and personality traits, exposure to stressful life events and genetic predisposition. Aside from known side effects and withdrawal symptoms, which have led some to question whether antidepressants are addictive, the long-term risks of antidepressants are still largely unknown.
I’m personally reluctant to be on medication for the rest of my life. But I’m also terrified to stop, at least until I’ve returned to what I believe to be my full capacity. I sought varied forms of help, and eventually (and reluctantly) started to take antidepressants for the first time. It took much trial and error, and time, to find the right agents and see a positive effect. But I am convinced antidepressants were necessary for me to reach the next stage of recovery. Within two weeks of my current combination and dose, I noticed improvements in appetite, sleep, decision-making and generalised, over-exaggerated anxiety. Within six months, I felt comfortable on public transport, returned to driving a car, reduced the frequency of medical appointments and am extremely proud to say I returned to my PhD part-time. For me, these improvements were not possible with psychotherapy and lifestyle changes, alone. I have adopted antidepressants as a non-negotiable part of my life, at least for now. I have largely overcome the shame of admitting I need medication and it seems worth the financial cost.
Whether you reach a point of needing to take antidepressants or not, there are factors to consider when developing and maintaining a relationship that may support you for the rest of your life. I believe I developed a serious relationship with my romantic partner as a result of my parents’ divorce, when I challenged the relationship model I’d learned and adopted from childhood. In hindsight, I was simultaneously learning to develop a healthy relationship with my partner and with my treatment approach. There are benefits and drawbacks of taking antidepressants, just as there are for developing and maintaining other relationships, but the decisions we make might just lead us to a sidekick for life.
If you or anyone you know needs help:
Book an appointment with your GP
Lifeline on 13 11 14 and https://www.lifeline.org.au/
MensLine Australia on 1300 789 978 and https://mensline.org.au/
Suicide Call Back Service on 1300 659 467
Beyond Blue on 1300 22 46 36 and https://www.beyondblue.org.au/
Headspace on 1800 650 890 and https://headspace.org.au/
Edited by Sumudu Narayana and Ellen Rykers