Melanie Cole (Host): There’s no doubt, that the use of antidepressants is on the rise. So many people with major depression use these medications as a primary form of their treatment. Welcome to Conversations with MIT Health. I'm Melanie Cole. My guest to tell us about antidepressants today is Dr. Anthony Van Niel. He’s a psychiatrist at MIT Student Mental Health and Counseling Services. Dr. Van Niel, welcome back. I’m so glad to have you join us and what a great topic this is. When we talk about depression, do we know what some of the main causes are? Is it chemical imbalance, genetic? Do we know?

Anthony Van Niel MD (Guest):  That’s a great question because the word depression is commonly used to encompass many aspects of feeling sad, depressed, down, even lonely and unhappy. So, it’s hard sometimes to know when someone says they’re depressed, what that really means. And one of the jobs of a counselor, whether it’s a psychiatrist or a nonprescriber; is to talk with the client and determine exactly what they are talking about when they use the word depressed.

Very commonly, people will come in saying I’m depressed, I’ve been depressed, I feel life is depressing and it encompasses a wide variety of conditions. Now within that range, there are people who do have what we think of as a serious biologically oriented depression which will respond to antidepressants. And once we determine that that’s the case, antidepressants can be very useful for that subset of people. But just feeling depressed by itself, does not indicate a need for medication.

Host:  Then let’s talk about that particular type of medication because we hear so many people, as I said in my intro, are on antidepressants today. Tell us what they are. How do they work? What are they intended to do?

Dr. Van Niel:  Well let me, once again, reiterate that using antidepressants for someone who is depressed is only a part of the treatment. Usually talking with a counselor and understanding the causes is very important and in fact, antidepressants work best when combined with psychotherapy. So, although I will talk about the use of medication, I want to emphasize that seeing a therapist and talking about how you are feeling and what the problems are, is an extraordinarily important part of the treatment and it’s actually been shown in many studies to enhance the efficacy of antidepressant medication.

Now having said that, antidepressant medication has been around since the 1950s, so we have a record of almost 70 years of people being on antidepressant medication. From about 1950s to around 1990s, the primary antidepressant medications were called the tricyclic medications and although those are still used and are very effective; they are not as common as first line agents. Since 1990, we use primarily what we call the SSRIs or selective serotonin reuptake inhibitors. And that includes many of the common medications that people have heard of such as Prozac, Zoloft, Paxil, Celexa, Lexapro and so on. And those are the trade names although there are generic names common as well.

Now, these medications are usually prescribed once a day and hopefully that when people take them, they have no noticeable side effects. It would be like taking a vitamin where you don’t notice anything particular. But over the course of a week or two, people can notice that there is gradually a lifting of some of the low mood and sense of being overwhelmed that they experience. And that’s really our goal in using these kinds of medications.

Host:  What a great explanation. Dr. Van Niel thank you so much for that. So, a lot of people are hesitant and as you say, it’s not the answer for all of them and it does need to combine with cognitive therapy, with all kinds of other treatments but people are so afraid sometimes. Tell us why? What are the side effects that we’ve heard about? Are those myths? Do they turn you into a zombie? You know people have all these thoughts in their head about what antidepressants might do, are any of those true?

Dr. Van Niel:  I think there are two issues in the reluctance that people have in terms of taking antidepressants. The first is a general reluctance to take any medication. There are some people, although I would say they are in a minority; who feel relieved that a pill will take care of their problems. But I think many people feel ashamed or embarrassed that they have to turn to medication and that they can’t “handle it themselves.” So, for those people, taking any medication is a barrier and they may be quite skeptical about the potential efficacy and even be very, very sensitive to the side effects of the medication. And that’s one reason why a relationship with a psychiatrist who is prescribing is very important because they can talk about those concerns and feel that they are understood and not just given a pill that is supposed to take away all their problems.

Now, having said that, the class of medications called the SSRIs are most commonly used primarily because the side effects are so low. There are some often transient and minor side effects like fatigue, or loss of appetite. Those usually will dissipate within a short period of time. The most common side effect are sexual side effects where people will notice a decrease in sex drive or libido and sometimes delayed orgasm, which can be quite annoying and sometimes lead to a change in medication. Those are not frequent side effects, but they do occur and when they do, that would be something that you would talk with your prescriber about because there are alternative medications that may not have those side effects that may be equally beneficial.

Host:  How long does someone have to based on other treatment modalities that they might be involved in; how long do people typically stay on an antidepressant? Is it something that ebbs and flows as we go through different cycles of our life, into menopause and postmenopause, whatever it is; or is it something you stay on for life?

Dr. Van Niel:  Well, that’s something that I think people try to think about in very individual ways with their patients. There have been studies in the past that people who have a major depression; should remain on antidepressants for at least six months in order to consolidate the gains that they are making. But often people are started on antidepressants for conditions that are not as serious as a major depression that involve more transient phases in their lives. And there, I think people are often recommended to stay on the medication somewhere between three to six months at which point working with a psychiatrist and their therapist; they may decide that they are feeling well enough and have resolved some of the stresses that have been going on that they may want go off.

There is a small group of patients who have a very sensitive predisposition to depression who may elect to stay on antidepressants for a long, long time. And I’ve had some patients who have been on them for their entire lives and feel very secure in that. So, I would say generally, somewhere three months to a year is the common duration of medication, but it can vary a great deal depending on the person.

Host:  Dr. Van Niel, do antidepressants interact with other medications? What should we be concerned about and can you drink alcohol safely while taking an antidepressant?

Dr. Van Niel:  One of the reasons that the SSRIs are so popular is because they are quite safe to take, and they have relatively few interactions with other medications. So, in general, you can take other medications, although if you’re taking prescription medications, it’s always good that you check with your doctor or even online to see if there are any subtle interactions that you might want to be aware of.

In terms of alcohol, it’s a – I guess I would answer that in two ways. One is drinking alcohol when you’re having mood problems is always a – I wouldn’t say risky but unpredictable sort of effect. It may relieve some of the anxiety or depression or it may exacerbate them. And that is depending on how much your drink and how your own sort of condition is responding to that. So, someone who is let’s say starting antidepressants is clearly in a situation where they’re struggling with some emotional problems and it may be unclear how alcohol may contribute to that.

The medication by itself, does not prohibit you from taking alcohol, although some people find that they are more sensitive to the effects of alcohol when they are on these medications and if someone wants to enjoy a drink; I will often tell them to be very cautious when starting and just to drink a little bit less to make sure that the effect is not heightened by being on the medication.

Host:  Well, that’s a great answer and I’m sure helpful to so many people. Dr. Van Niel as we wrap up, your best advice for somebody who is looking into antidepressants, who feels that they are depressed or who has talked to someone and been diagnosed with clinical depression and the other modalities that you like to go along with medicational intervention. Just really, wrap it up. What do you want them to know?

Dr. Van Niel:  Just focusing on medication as fixing your problems, I think is a hopeful and optimistic wish which occasionally will be true. But more often, the situation that people find themselves in is a complicated one and involves talking at some length with a therapist or a psychiatrist to see if medication is the right approach. Often, there are other interventions, not just psychotherapy, but using relaxation techniques, focusing on exercise, and healthy living that can also help people feel better and they should be ignored just in the wish that a medication will be the answer.

Host: Thank you so much Dr. Van Niel, for coming on with us today, for sharing your incredible expertise and answering questions that so many people have that are concerned about depression and taking antidepressants. Listeners can visit Health.mit.edu for more information and to get connected to one of our providers. That concludes this episode of Conversations with MIT Health. Please remember to subscribe, rate and review this podcast and all the other MIT Health podcasts. . I'm Melanie Cole. Thanks so much for joining us today.