A major reason, if not the main reason, why SSRIs take a lon time to have an effect is that they have very long half lives in the body. On a given dosage of Prozac, IIRC, it takes on the order of two weeks for the drug’s concentration in the body to reach steady state.
Half-lives in the SSRI class vary widely. It’s nearly two weeks for fluoxetine, but it’s only about 20 hours for paroxetine. So far as anyone can tell, the most salient practical concern for the patient is the potential for severe SSRI withdrawl syndrome should the drug be terminated, or a dose is missed, with the shorter half-life drugs. Delay to therapeutic onset is roughly the same for all of them, despite the differences in pharmacodynamics.
Half-lives in the SSRI class vary widely. It’s nearly two weeks for fluoxetine, but it’s only about 20 hours for paroxetine. So far as anyone can tell, the most salient practical concern for the patient is the potential for severe SSRI withdrawl syndrome should the drug be terminated, or a dose is missed, with the shorter half-life drugs. Delay to therapeutic onset is roughly the same for all of them, despite the differences in pharmacokinetics.
The Hell? I hit Preview, dammit. Please delete first post above…
I agree (with Metacom et al.) that anti-depressives are probably overprescribed, at least in large part because of the push of the pharmaceutical industry.
Another problem is that the expensive SSRIs are pushed in preference to good old-fashioned dirt-cheap tricyclics. While it is true that the tricyclics have troubling side effects for some, this is not a blanket statement. I am one person for whom the side effects for the tricyclics are non-existent to positive (e.g., to the extent that the one I’m on produces a little sedation…which for me seems to be fairly little anyway…it is a good thing). My one trial on an SSRI (Prozac, as this was ~1990 and it was the only one around) was a complete disaster…I was agitated and couldn’t eat or sleep.
Anyway, this is just by way of saying that these drugs are certainly not one-size-fits-all. They affect different people in different ways. And, one shouldn’t necessarily assume that the newer, way more expensive drugs will be more effective (or more tolerable) for you than the older, cheaper ones.
Blanket statements can’t be made about any drug class, even the SSRIs these days, as dirt-cheap generic brands of fluoxetine and paroxetine are now available.
In the tricyclic class, there are the secondary and tertiary amine subclasses, and the latter tend to have particularly noxious side-effects for some, due to their potent anticholinergic and anti-histaminergic properties. If you were on desipramine, for instance, your side-effects might be relatively minor, but you might find amitriptyline unbearable. Also, the tertiary amines have a more potent ability to block alpha-1 adrenergic receptors, which can lead to dangerous AV block in certain cardiac patients, and yield an abnormal EKG even in heart-healthy patients. As it so happens, the secondary amine tricyclics have little or no ability to potentiate serotonin (inhibiting only the reuptake of NE significantly), while the tertiary amine tricyclics are good dual-acting compounds (sometimes even more selective for 5-HT, as in the case of clomipramine), and hence may be better for a broader spectrum of depressed patients, as well as OCD (clomipramine was the first drug approved for that indication).
For the great majority of patients needing a serotonergic drug, an SSRI is a much better choice than a tricyclic. Same goes for a dual-acting drug, in that venlafaxine or duloxetine is probably going to be much better tolerated. This is the primary reason why tricyclics are no long first-line drugs. It’s not because people are being discouraged from for specious marketing reasons, it’s because the side-effects of these drugs are typically unpleasand, can can be downright dangerous for some. No antidepressant has exceeded the effectiveness of MAOIs, but would you want to be the doctor prescribing them to patients who you can’t trust to stick to the diet?
You guys should really read up on this stuff before you proclaim it’s all a big conspiracy. Yeah, the benefits of Prozac were oversold, but the excitement over the SSRI class was as big among the clinicians as anyone else, who knew the biggest reason patients who needed the meds kicked them was because of the unbearable side-effects of older agents.
My personal experience is with Sinequan (Doxepin), which I believe is a tertiary amine…at least I know it is a tricyclic that is supposed to have amongst the most potent anticholinergic and anti-histaminergic properties.
Well, I don’t doubt that the SSRIs may be best for most people. However, doctors need to recognize that not everybody is the same and I, in particular, find the side effects of what is probably the most sedating tricyclic to be a positive…And I found the side effects of at least one of the SSRIs to be completely intolerable. Am I an average patient? Probably not…but I am sure there are others like me. If I were a physician, I would ask patients things like how they react to sedating or activating drugs…and, if they are someone like me who tries to avoid almost any activating substances and finds little effect…usually beneficial if at all…from sedating drugs, I would at least consider the possibility of using tricyclics on this patient.
Personally, I am trying to walk a middle road between some of the extremes in this thread. I am not saying it is all a big conspiracy. I know that there are legitimate reasons to be excited about the SSRI class. However, I do wonder if the extreme to which the preference has evolved toward SSRI’s (and particularly the newest few that are still not in generic form and are quite expensive) is at least partly a result of marketing.
Well, those qualifications sound perfectly reasonable, but your earlier post more than implied the majority of prescription of SSRIs (at least, the non-generic variety) was a function of marketing.
Of course direct-to-consumer marketing is a vile practice, but it’s not limited to antidepressants, and it’s not consumers who are ultimately writing the prescriptions. I’m sure it has an impact on overprescription in general, but again, this is not a problem limited to the mental health field. I think among the biggest reasons physicians are happy to write scripts when asked for Prozac or its ilk is because those drugs are actually quite safe for the vast majority of people. Not true of the tricyclics, which are quite lethal in overdose, for instance (my Mom once told me that 20,000 people a year OD’d on tricyclics in 1995, and 500 of those died, whereas it’s almost impossible to kill yourself with a typical supply of Prozac), or MAOIs, which can not only be lethal in overdose, but also with the wrong foods or drug. combos (including common cold remedies).
Just wondering, AHunter3, Metacom, et al, what are your opinions of those who seek psychiatric help? (Either talk therapy or drugs.) Do you think they’re brainwashed? Sell-outs? Conformists? Do you think less of people when you find out they take medication or do therapy? I believe that people should be allowed to decline treatment but I also try to respect the treatment decisions of others (to a point… I do think ECT should be outlawed and the doctors who perform it kicked out of the profession), and I was just wondering where you stand personally with people who choose to employ such treatment options.
Before you say ECT should be outlawed, you should hear the stories of those who have found that it helped them. Yes, it should be IMHO a last resort, but it does sometimes have beneficial results. For a story about one such person, check out the book Electroboy by Andy Behrman. After numerous failed therapies, and a life in ruin, he found that a series of (voluntary) electroshock treatments enabled him to finally find some balance.
Did you read my posts earlier in the thread? ECT can be a virtual lifesaver for some people…and it is done very differently now than it was in the days of old. It is actually safer and far more effective for the treatment of severe depression in the elderly than drugs are. Let’s try to keep an open mind here.
The post numbers are #34 and #49, BTW.
Correct. Now they use sedatives so it’s not as emotionally traumatic to the patient; however, they have to use more current to overcome the sedatives and induce convulsions to it’s more physically traumatic.
Much better.
No I’m not. I gave some reasons for why I think the biological model is becoming predominant. That’s not at all equivalent to saying that those things are what motivates the mental health industry.
I’ve got a friend who’s life was pretty much saved by ECT. It’s probably not for everyone, and it can have serious side effects, but it can work wonders.
So can placebos, which is why anecdotal testimony like this isn’t the best evidence.
davenportavenger:
I think they are in the same position as someone who finds it necessary to go shopping for a good used car in a northern Mexican town close to the US border. Caveat fucking emptor. Watch your back. I do not have contempt for these people. I was one of them once. Consider me, ummm, thrice burned and ultrashy or something like that but I have absolutely no contempt for someone seeking the help.
Me too. I’m not saying I don’t have some prejudices and uneasinesses, but I, of all people, have no business second-guessing someone else’s medical decisions. I mean, talk about not being able to have it both ways!!
Nope, not that either. I think with fully informed consent (which ain’t happening right now, more lies and/or absence of whole truths), hey, if you want to lick the live end of a lamp socket and your doc recommends it, who am I to get in your way? I have an abysmally bad opinion of ECT though.
Well, there have been controlled studies of this. But, you also have to realize that we are talking in most cases about people with very severe depression who have had a number of other treatments that they did not respond to. The effect is incredibly dramatic and strongly correlated in time with the treatments which last a couple of weeks in most cases (and, to be honest, with my relative specifically with when the treatments also started to show the side effects in her memory). While it can’t be ruled out in any individual case that some sort of “miraculous recovery” occurred spontaneously, it seems rather unlikely…And, as I said, there are more rigorous studies too.
Look, our family (which includes both a psychologist and a social worker) was very leery of ECT and really held out against it for a while when it was being strongly advised by the doctors. But, I think its dramatic effects has made believers out of all of us. I know everybody’s experience is not as positive…But, as I said, it is the single most effective treatment for severe depression and, in elderly patients who don’t tolerate medication well, it is also said to be the safest.
My guess, although I am not sure I read this anywhere, is that ECT also probably works best for someone who has generally been mentally well but has a severe depression with a sudden, acute onset. That describes my relative well…She has always been a worrier, prone to anxious and obsessive thinking, but was otherwise fine and happy and fully functional in the world. In a manner of a week or so’s time she descended into a severe depression. And, concurrent with the ECT, within a week or so’s time, she completely pulled out of it.
Well, as safe as running thousands of volts of electricity through a sensitive organ can be. Even aside from the memory loss, some of the side effects of ECT are cognitive impairments (though not standard, a drop in IQ is not all that unlikely), brain hemorrhage, and broken bones caused by jerking against restraints. Brain damage as a result of ECT, from the American Journal of Psychiatry. And though death is uncommon, it still occurs at a rate of one out of 10,000. And according to this site (warning: PDF!), you can receive ECT without consent, and it can also be given to children over 12 (something I didn’t know), in which case their parents decide for them. I don’t care how “safe” it is, I don’t see any good reason for pumping volts into a growing brain.