- How Long Do Antidepressants Take to Work?
- Going off antidepressants
- Coming off your medication can cause antidepressant withdrawal – and could set you up for a relapse of depression
- How to go off antidepressants
- Number One Reason SSRIs Take Four to Six Weeks to Work
- Side effects
- Sex and fertility
- Pregnancy, post-natal and breastfeeding
- Driving and transport
- School and exams
- Friends and family
- Alcohol and street drugs
- Prescription medicines
- References and further reading
- How Long Until My Prozac Starts Working for My Depression?
- ‘Prozac changed my life. It makes me feel normal’
How Long Do Antidepressants Take to Work?
A common treatment for clinical depression is a type of medication called an antidepressant. Antidepressants come in a variety of forms, but all of them work by impacting certain neurochemicals in your brain, such as serotonin and norepinephrine. Antidepressants are most commonly prescribed by a psychiatrist, but may also be prescribed by a family physician or general practitioner to treat depression.
The different classes of antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), norepinephrine (noradrenaline) reuptake inhibitors, atypical antidepressants, tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs). Different classes of antidepressants take different amounts of time before you will start to feel their anti-depressant effects.
The most commonly prescribed modern antidepressants include SSRIs — such as Prozac, Lexapro, Celexa and Paxil — and SNRIs — such as Pristiq, Cumbalta and Effexor. Although the claim is made that some people may be able to start to feel less depressed within 2 weeks of taking one of these kinds of antidepressants, most people won’t start experiencing the full positive effects of the medication until 6 to 8 weeks after beginning it.
In addition to feeling less depressed from antidepressant medications, people will often experience the side effects of antidepressants first. While these side effects vary from person to person and from medication to medication, the most commonly observed side effects in antidepressants are:
- Decreased sex drive or no sex drive at all
- Dry mouth — your mouth feels very dry and cannot produce the same amount of saliva as usual
- Mild to moderate nausea
- Insomnia — inability to get to sleep, or difficulty staying asleep
- Increased anxiousness or restlessness
- Weight gain
- Constipation or diarrhea
- Increased sweating
- Tremors or dizziness
You shouldn’t be overtly concerned if you experience any of these side effects while taking an antidepressant, but you should still tell your psychiatrist or doctor about them. Some side effects may go away on their own once your body adjusts to the medication. Others may not, and may be addressed through an adjustment of your medication dose or when you take it.
Antidepressants don’t work for everyone. Sometimes the first antidepressant a doctor prescribes may not work for you (as they don’t in 50 percent of people who try an antidepressant). Don’t get frustrated, just accept that either another medication may need to be tried, or the doctor may suggest a higher dose may be required. Talk to your doctor about adjusting your medication if you’re not feeling any positive effects of the medication after 6 to 8 weeks.
Older classes of antidepressants — MAOIs and tricyclic antidepressants — take about the same amount of time to work — anywhere from 2 to 6 weeks for most people, while most people will start to feel a benefit within 3 to 4 weeks. It is not well understood why antidepressant medications appear to take longer to work than other types of psychiatric medications.
How Long Do Antidepressants Take to Work?
Going off antidepressants
Coming off your medication can cause antidepressant withdrawal – and could set you up for a relapse of depression
Updated: August 13, 2018Published: November, 2010
Can going off your medication cause antidepressant withdrawal symptoms (antidepressant discontinuation syndrome)? About 10% of women ages 18 and over take antidepressants. As many of us know, these medications can be a godsend when depression has robbed life of its joy and made it hard to muster the energy and concentration to complete everyday tasks. But as you begin to feel better and want to move on, how long should you keep taking the pills?
If you’re doing well on antidepressants and not complaining of too many side effects, many physicians will renew the prescription indefinitely — figuring that it offers a hedge against a relapse of depression. But side effects that you may have been willing to put up with initially — sexual side effects (decreased desire and difficulty having an orgasm), headache, insomnia, drowsiness, vivid dreaming, or just not feeling like yourself — can become less acceptable over time, especially if you think you no longer need the pills.
The decision to go off antidepressants should be considered thoughtfully and made with the support of your physician or therapist to make sure you’re not stopping prematurely, risking a recurrence of depression. Once you decide to quit, you and your physician should take steps to minimize or avoid the discontinuation symptoms that can occur if such medications are withdrawn too quickly.
Why antidepressant withdrawal?
Antidepressants work by altering the levels of neurotransmitters — chemical messengers that attach to receptors on neurons (nerve cells) throughout the body and influence their activity. Neurons eventually adapt to the current level of neurotransmitters, and symptoms that range from mild to distressing may arise if the level changes too much too fast — for example, because you’ve suddenly stopped taking your antidepressant. They’re generally not medically dangerous but may be uncomfortable.
Among the newer antidepressants, those that influence the serotonin system — selective serotonin reuptake inhibitors (SSRIs, now commonly known as SRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) — are associated with a number of withdrawal symptoms, often called antidepressant or SRI discontinuation syndrome. Stopping antidepressants such as bupropion (Wellbutrin) that do not affect serotonin systems — dopamine and norepinephrine reuptake inhibitors — seems less troublesome over all, although some patients develop extreme irritability.
Having discontinuation symptoms doesn’t mean you’re addicted to your antidepressant. A person who is addicted craves the drug and often needs increasingly higher doses. Few people who take antidepressants develop a craving or feel a need to increase the dose. (Sometimes an SRI will stop working — a phenomenon called “Prozac poop-out” — which may necessitate increasing the dose or adding another drug.)
Antidepressant withdrawal can look like depression
Discontinuation symptoms can include anxiety and depression. Since these may be the reason you were prescribed antidepressants in the first place, their reappearance may suggest that you’re having a relapse and need ongoing treatment. Here’s how to distinguish discontinuation symptoms from relapse:
Discontinuation symptoms emerge within days to weeks of stopping the medication or lowering the dose, whereas relapse symptoms develop later and more gradually.
Discontinuation symptoms often include physical complaints that aren’t commonly found in depression, such as dizziness, flulike symptoms, and abnormal sensations.
Discontinuation symptoms disappear quickly if you take a dose of the antidepressant, while drug treatment of depression itself takes weeks to work.
Discontinuation symptoms resolve as the body readjusts, while recurrent depression continues and may get worse.
If symptoms last more than a month and are worsening, it’s worth considering whether you’re having a relapse of depression.
Antidepressant withdrawal symptoms
Neurotransmitters act throughout the body, and you may experience physical as well as mental effects when you stop taking antidepressants or lower the dose too fast. Common complaints include the following:
- Digestive. You may have nausea, vomiting, cramps, diarrhea, or loss of appetite.
- Blood vessel control. You may sweat excessively, flush, or find hot weather difficult to tolerate.
- Sleep changes. You may have trouble sleeping and unusual dreams or nightmares.
- Balance. You may become dizzy or lightheaded or feel like you don’t quite have your “sea legs” when walking.
- Control of movements. You may experience tremors, restless legs, uneven gait, and difficulty coordinating speech and chewing movements.
- Unwanted feelings. You may have mood swings or feel agitated, anxious, manic, depressed, irritable, or confused — even paranoid or suicidal.
- Strange sensations. You may have pain or numbness; you may become hypersensitive to sound or sense a ringing in your ears; you may experience “brain-zaps” — a feeling that resembles an electric shock to your head — or a sensation that some people describe as “brain shivers.”
As dire as some of these symptoms may sound, you shouldn’t let them discourage you if you want to go off your antidepressant. Many of the symptoms of SRI discontinuation syndrome can be minimized or prevented by gradually lowering, or tapering, the dose over weeks to months, sometimes substituting longer-acting drugs such as fluoxetine (Prozac) for shorter-acting medications. The antidepressants most likely to cause troublesome symptoms are those that have a short half-life — that is, they break down and leave the body quickly. (See the chart “Antidepressant drugs and their half-lives.”) Examples include venlafaxine (Effexor), sertraline (Zoloft), paroxetine (Paxil), and citalopram (Celexa). Extended-release versions of these drugs enter the body more slowly but leave it just as fast. Antidepressants with a longer half-life, chiefly fluoxetine, cause fewer problems on discontinuation.
Besides easing the transition, tapering the dose decreases the risk that depression will recur. In a Harvard Medical School study, nearly 400 patients (two-thirds of them women) were followed for more than a year after they stopped taking antidepressants prescribed for mood and anxiety disorders. Participants who discontinued rapidly (over one to seven days) were more likely to relapse within a few months than those who reduced the dose gradually over two or more weeks.
Antidepressant drugs and their half-lives*
Half out of body in
99% out of body in
Serotonin reuptake inhibitors
27 to 32 hours
Four to six days
Serotonin and norepinephrine reuptake inhibitors
Dopamine and norepinephrine reuptake inhibitor
*Discontinuation symptoms typically start when 90% or more of the drug has left your system.
Source: Adapted from Joseph Glenmullen, M.D., The Antidepressant Solution: A Step-by-Step Guide to Safely Overcoming Antidepressant Withdrawal, Dependence, and “Addiction” (Free Press, 2006).
How to go off antidepressants
If you’re thinking about stopping antidepressants, you should go step-by-step, and consider the following:
Take your time. You may be tempted to stop taking antidepressants as soon as your symptoms ease, but depression can return if you quit too soon. Clinicians generally recommend staying on the medication for six to nine months before considering going off antidepressants. If you’ve had three or more recurrences of depression, make that at least two years.
Talk to your clinician about the benefits and risks of antidepressants in your particular situation, and work with her or him in deciding whether (and when) to stop using them. Before discontinuing, you should feel confident that you’re functioning well, that your life circumstances are stable, and that you can cope with any negative thoughts that might emerge. Don’t try to quit while you’re under stress or undergoing a significant change in your life, such as a new job or an illness.
Make a plan. Going off an antidepressant usually involves reducing your dose in increments, allowing two to six weeks between dose reductions. Your clinician can instruct you in tapering your dose and prescribe the appropriate dosage pills for making the change. The schedule will depend on which antidepressant you’re taking, how long you’ve been on it, your current dose, and any symptoms you had during previous medication changes. It’s also a good idea to keep a “mood calendar” on which you record your mood (on a scale of one to 10) on a daily basis.
Consider psychotherapy. Fewer than 20% of people on antidepressants undergo psychotherapy, although it’s often important in recovering from depression and avoiding recurrence. In a meta-analysis of controlled studies, investigators at Harvard Medical School and other universities found that people who undergo psychotherapy while discontinuing an antidepressant are less likely to have a relapse.
Stay active. Bolster your internal resources with good nutrition, stress-reduction techniques, regular sleep — and especially physical activity. Exercise has a powerful antidepressant effect. It’s been shown that people are far less likely to relapse after recovering from depression if they exercise three times a week or more. Exercise makes serotonin more available for binding to receptor sites on nerve cells, so it can compensate for changes in serotonin levels as you taper off SRIs and other medications that target the serotonin system.
Seek support. Stay in touch with your clinician as you go through the process. Let her or him know about any physical or emotional symptoms that could be related to discontinuation. If the symptoms are mild, you’ll probably be reassured that they’re just temporary, the result of the medication clearing your system. (A short course of a non-antidepressant medication such as an antihistamine, anti-anxiety medication, or sleeping aid can sometimes ease these symptoms.) If symptoms are severe, you might need to go back to a previous dose and reduce the levels more slowly. If you’re taking an SRI with a short half-life, switching to a longer-acting drug like fluoxetine may help.
You may want to involve a relative or close friend in your planning. If people around you realize that you’re discontinuing antidepressants and may occasionally be irritable or tearful, they’ll be less likely to take it personally. A close friend or family member may also be able to recognize signs of recurring depression that you might not perceive.
Complete the taper. By the time you stop taking the medication, your dose will be tiny. (You may already have been cutting your pills in half or using a liquid formula to achieve progressively smaller doses.) Some psychiatrists prescribe a single 20-milligram tablet of fluoxetine the day after the last dose of a shorter-acting antidepressant in order to ease its final washout from the body, although this approach hasn’t been tested in a clinical trial.
Check in with your clinician one month after you’ve stopped the medication altogether. At this follow-up appointment, she or he will check to make sure discontinuation symptoms have eased and there are no signs of returning depression. Ongoing monthly check-ins may be advised.
Image: © Charlieaja | Dreamstime.com
To learn what you can do to get the sleep you need for optimal health, safety, and well-being, buy the Harvard Special Health Report Improving Sleep: A guide to a good night’s rest.
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Number One Reason SSRIs Take Four to Six Weeks to Work
Source: Wikimedia Commons
Skeptics of the most commonly prescribed antidepressants—the selective serotonin reuptake inhibitors (SSRIs)—often cite the fact that it takes four to six weeks for these medications to kick in as a reason to think that SSRIs don’t really work. Or if they work, skeptics argue, it’s not because depressed or anxious individuals have low serotonin levels in the brain.
SSRIs are commonly believed to work by blocking the serotonin transporter—a molecule that carries serotonin back into brain’s cells. When serotonin is inside a brain cell, it does not do anything good or bad. For it to work as a neurotransmitter that can help activate brain signaling, it needs to be on the outside of the brain’s neurons. If SSRIs work by blocking the serotonin transporter, they will result in more serotonin sitting on the outside of the neurons (or, more specifically, in the gap between two neurons), where it can do its job.
Although serotonin has multiple functions in the brain, one of them is to keep us calm and content. So, when too little serotonin is active outside our brain cells, we become nervous, unhappy or unable to feel any pleasure. Blocking the transporter that inactivates serotonin can thus restore our brain’s levels of active serotonin and once again make us calm and content.
Those who are skeptical of SSRIs and of the whole idea that low serotonin levels in the brain can be a reason we suffer from anxiety and depression, occasionally make mention of the long time it takes for SSRIs to work.
It is certainly peculiar that SSRIs do not work instantaneously after popping the first pill. After all, SSRIs are not the only drugs to block the serotonin transporter. Street drugs like cocaine and ecstasy also reportedly block the serotonin transporter. But it does not take four to six weeks for cocaine or ecstasy to have a noticeable effect on us.
Some skeptics think that this difference between street drugs like cocaine and SSRIs is strong evidence that depression and anxiety are not due to low serotonin levels in the brain but rather to something else altogether. When SSRIs work, they say, (which they do—roughly—for 30 percent of depressed/anxious people who take them), it is because the SSRIs activate some other brain system after increasing serotonin for weeks or months.
There is, however, a different explanation of why SSRIs, unlike cocaine and ecstasy, take so long to kick in. Consider an analogy. Let’s say you go to a dietician and set up a new meal plan in an effort to shed weight. You and your dietician come up with a good regimen that is likely to work. However, your refrigerator and freezer are stocked with the foods you and your family used to eat. Since you do not want to waste the food you already have, you decide to finish it before starting your new and healthier eating habits. Because you have a lot of food in your house, it takes a few weeks before you have replaced most of it with healthier alternatives. So, your weight remains stable for a while. After a month or so, however, you start to lose weight. This is the time when most of the old foods in your house have been replaced by healthier alternatives.
More recent research suggests an analogous explanation of why SSRIs don’t kick in right away. The reason suggested is that SSRIs don’t target the serotonin transporter directly. Although some SSRIs (for instance, Lexapro) bind directly to the transporter, the direct binding is not the underlying mechanism of action. Instead antidepressants target our DNA, in particular the genes that code for the serotonin transporter. They make these genes less active, so fewer serotonin transporter molecules are available in the brain. This, it is argued, explains the delayed action of antidepressants.
Since our brain has plenty of active serotonin transporter molecules when we start taking antidepressants, it takes a while before a suppression of the genes that code for the transporter has an effect on serotonin in the brain. When we start taking the medication, our brain is like a refrigerator stocked with our old food choices. It takes a few weeks for us to get through that food and replace it with the healthier alternatives that can ultimately stabilize us and make us function optimally.
Please do not be worried by the side effects listed on this page. Many people take fluoxetine without any side effects or only a few mild side effects. Starting with a lower dose can sometimes help if side effects do occur.
Side effects that do appear should disappear or get better after a few days. If they do not, you should go back to your doctor.
Do not stop taking the fluoxetine until you talk to your doctor, or you may get withdrawal symptoms as well.
Very common side effects when taking fluoxetine (affecting more than one in ten people) include:
- insomnia (sleep problems)
- headache and feeling tired
- diarrhoea (loose poo)
- nausea (feeling sick)
Common side effects of taking fluoxetine (affecting up to one in ten people) include:
- not feeling hungry
- weight loss
- nervousness, anxiety, restlessness, poor concentration, feeling tense
- decreased sex drive or sexual problems, including difficulty maintaining an erection (staying hard)
- sleep problems, unusual dreams, tiredness or sleepiness
- change in taste, or dry mouth
- uncontrollable shaking movements
- blurred vision
- heartbeat feels quick and uneven
- flushing, sweating more, feeling shaky or chills
- indigestion, being sick
- rash, itching lumps (hives, urticaria), other skin itching
- joint pain
- needing to wee more often
- unexplained vaginal bleeding
There are other side effects that you can get when taking this medicine – we have only included the most common ones here.
Please look at the leaflet inside your medicine box, or ask a doctor or pharmacist, if you want to know whether you are getting a side effect from your medicine.
If you do get a side effect, please think about reporting it via the Yellow Card Scheme.
Your weight can be affected by fluoxetine.
A side effect of fluoxetine can be not feeling as hungry as normal, which might lead to weight loss.
It is very difficult to know how this will affect each person who takes it.
Talk to your doctor about this if it worries you.
You can feel drowsy in the first few days of taking fluoxetine. However, it should get better after the first week or two.
If you feel very sleepy, and you’ve been taking it for more than a month, you should go back to the doctor and see what else you could do.
Sex and fertility
Fluoxetine can have side effects that might affect your sex life. These include:
- painful erections that last for a long time (this is rare but serious – visit a hospital or see your doctor straight away if you experience this side effect), or problems getting an erection (getting hard) and ejaculating (coming)
- bleeding from the vagina
- difficulty reaching orgasm the same way as before
- some growth of the breasts and some milk flow, regardless of gender
- you may have a lower sex drive
Fluoxetine has been known to slow growth and delay sexual development (puberty) in a small number of children and young people. Your doctor should check your growth while you are taking it. If this worries you, talk to your doctor or pharmacist about it.
These effects should pass after the first couple of weeks. If they do not, and this is a problem for you, go back to the doctor and see what else you could try.
The good effects of fluoxetine may, after a while, have a positive impact on your sex life as your mood lifts and you become interested in life and relationships again.
Fluoxetine does not seem to affect human fertility.
Talk to your doctor about your fluoxetine if you are trying to get pregnant.
Pregnancy, post-natal and breastfeeding
If you become pregnant while you are on fluoxetine, you should carry on taking the medicine and go back to your doctor as soon as possible, to see if you should change or stop your medicine.
There is a slightly higher risk of problems in the developing baby if you take fluoxetine it in the early stages of pregnancy. However, fluoxetine and related antidepressants (known as SSRIs) are thought to be better choices if you need antidepressant medicine.
Remember that you need to stay well through your pregnancy, and you may need a medicine to help you to do that.
Fluoxetine may cause heart problems in the developing baby, and other symptoms in new-born babies.
If you and your doctor agree that you will continue taking fluoxetine during your pregnancy, then you should tell your midwife that you are taking it before you give birth.
If fluoxetine is taken in the last five months of a pregnancy, it can cause a serious condition called persistent pulmonary hypertension of the new-born (PPHN). This can make the baby breathe faster and look a bit blue in colour. PPHN affects around 12 in 1,000 babies born to mums who take SSRIs. This compares with a rate of two in 1,000 among babies born to mums who do not take SSRIs.
PPHN appears in the first 24 hours after birth. You will need help from the midwife and doctors, so it is better if they are looking out for symptoms.
The newborn baby may also develop withdrawal effects, which might not appear straight away but might develop over the first few days of life. These could include:
- being irritable and crying a lot
- having difficulty sleeping or sucking
- poor weight gain
Fluoxetine is passed to the baby in breast milk, and side effects have been seen in breastfed babies. The main one is likely to be colic.
The amount of fluoxetine in breast milk is usually around 7% of the mum’s dose, but it can build up over time. This is because fluoxetine is hard for your baby to get rid of. This does not mean breastfeeding will be a problem, but do look out for side effects.
If your baby was premature or has health problems, then you may be better off not breastfeeding as your baby will likely struggle even more to get rid of the fluoxetine.
Talk to your doctor or midwife about your feeding options, or ask to be referred to a lactation consultant.
Driving and transport
Do not drive or ride a bike just after you start taking fluoxetine.
Taking fluoxetine may affect your ability to do things like drive a car, ride a bike, use machines, or anything else that needs a lot of focus.
It might be best to stop doing these things for the first few days, until you know how it affects you, or until the effects pass.
Do not worry – most people drive as normal while taking fluoxetine.
School and exams
Try not to take fluoxetine for the first time just before your exams.
Taking fluoxetine may affect your anility to do things that need a lot of focus, like exams.
You should talk to your doctor about any future exams if you are starting fluoxetine.
You might decide together to delay starting it until you have done them. If they are more than a month away, however, you might find that it is better to start fluoxetine to lift your mood and improve your motivation to study.
Do not worry – most people do exams as normal while taking fluoxetine.
Friends and family
You may want to let your family and friends know you are taking fluoxetine so they can support you and help you look out for side effects.
For guidance on this, check out our page on getting support with your medication.
Fluoxetine is not a banned substance in sport.
Taking fluoxetine may affect your ability to do things like riding a bike, competitive gymnastics, or anything else that needs a lot of focus.
It might be best to stop such sports for the first few days, until you know how it affects you or the effects get better.
Do not worry – most people play sports as normal while taking fluoxetine.
Alcohol and street drugs
You can continue to drink some alcohol while taking fluoxetine, but it is best to do so in moderation. Fluoxetine can sometimes cause drowsiness as a side effect, so it is possible that alcohol might make you feel more drowsy than usual.
Drinking alcohol every day, however, can make the symptoms of depression worse and you will not feel the benefit of your medicine.
Side effects might make you sleepy or you might lose your focus when you first start taking fluoxetine.
This could be dangerous if you drive or use machines or do anything that needs a lot of focus.
During the first few days, it might be best to stop drinking alcohol until you see how the medicine affects you, or until the effects pass.
Be careful if you are also using street drugs.
Cannabis can have unpredictable effects when taken with fluoxetine, so great care is needed.
Cannabis and other drugs may have their own side effects on your mental health, like anxiety or psychosis. For more information, have a look at our drugs and alcohol page.
Methadone and fluoxetine together can seriously affect your heart so these should only be combined under doctor supervision.
Fluoxetine has been shown to dampen down the ‘high’ of cocaine.
Taking fluoxetine with cocaine, ecstasy or amphetamines could bring on serotonin syndrome. You could get a high temperature/fever, agitation, confusion, trembling or weird muscle movements. You need to go to hospital if this happens. Tell the doctor everything that you have taken.
Fluoxetine can produce a false positive test for amphetamines and LSD on a urine drug screen. Talk to your doctor about this if it is a problem for you.
Fluoxetine does not mix well with some other medicines and drugs.
Do not take fluoxetine if you take an antidepressant medicine called a monoamine oxidase inhibitor (MAOI), or if you have taken one in the last two weeks.
Tell your doctor or pharmacist before you take fluoxetine if you are prescribed any other medication, to check that the combination is safe.
Before you start taking fluoxetine, tell your doctor if you are taking any other medications, including things you have bought over the counter for common illnesses like colds and flu or topical applications that you put on your skin.
References and further reading
For more helpful links and information, have a look at our references and further reading page.
How Long Until My Prozac Starts Working for My Depression?
The exact words you use or the way you go about achieving the silencing of the negative voice can vary. I encourage people to find the version that works best for them. Personally, I like to poke fun at my negative voice — it takes its power away.
Q3. How big a role does sunlight exposure play in mood? Do light-therapy lamps really help depressed people feel better? If so, what type of light therapy should I look for?
Many people living in temperate climates report that they feel better during the transition from winter to spring, as the days grow longer and sunlight exposure increases. Conversely, a parallel drop in mood is often noted during the transition from fall to winter.
So it seems likely that sunlight has some natural mood-lifting effects, at least for some people. There are marked individual differences relating to seasonality, however, and the term seasonal affective disorder was coined to describe the subset of people who regularly develop major depressive episodes in the fall or winter that reliably go away or lessen during the spring and summer.
The potential therapeutic effects of bright (full-spectrum) white light have been evaluated in people with such winter depressions, and studies using appropriate control groups indicate significant benefit for these light treatments. The usual daily “dose” of light therapy is 30 minutes of exposure to 10,000 lux (a scientific measurement of the intensity of light) of full-spectrum light; some people do better with longer (60 to 120 minutes) periods of exposure.
It’s not necessary to gaze directly into the light, but you should have your eyes open and sit within 3 feet of the light source. Several companies sell “light boxes” that have been developed to reliably deliver the correct dose; the typical cost is about $300. The easiest way to find a light box is to Google “light therapy for seasonal depression.”
Q4. I am getting “brain zaps” yet again from a decrease in another antidepressant, this time from nortriptyline. I’ve looked this up online, and they are common withdrawal side effects — feelings of very brief tingling in the head, sometimes extending through the body; vision jolting; dizziness. They feel literally like being zapped for half a second or more. But all I see is lack of research and the answer “they don’t appear to be harmful.” What I want to know is, has any actual research been done to show what part of the brain is activated during these zaps? Specifically, has a functional MRI ever been done in research? I ask because I get these darn things when I move and when I turn my head — things that MRI can pick up on. A functional MRI would also be able to detect eye jolts with the zaps, true?
What you are referring to as “brain zaps” (also sometimes called “electric shocks”) are one of the common symptoms associated with discontinuation of antidepressants. Other discontinuation symptoms that are even more common include nausea and lightheadedness and can mimic a case of the flu.
Although there is no reason to think of these symptoms as dangerous (they almost always go away within several weeks of stopping the antidepressant without specific treatment), they certainly can be annoying and on occasion warrant slowing the withdrawal of the medication or temporarily shifting to a medication such as fluoxetine, which has a longer “biological” life and stays in your system for a longer time.
To my knowledge, there have been no studies using functional MRI or other neurophysiologic measures and I do not know what these experiences might look like on this type of assessment. I think it is fair, however, to assume that these symptoms have a real basis in terms of the activity of neurons and aren’t simply a mental phenomenon.
Q5. My daughter died from SIDS in February of this year. My niece was born two days before my daughter died, and every time I see her it’s like a knife stabbing me and I start crying. My husband likes our niece and actually plays with her, but I just can’t seem to do that. Do you have any suggestions?
— Sunshine, California
I’m so sorry that your daughter died. I can only imagine how painful it is for you. Of course you want to avoid reminders of her death. The problem, however, isn’t that you start crying when you see your niece. The problem is that you seem to have an idea that you shouldn’t be crying. Here are some strategies that may help.
First, explain to your niece’s parents (even if you think they already know this) that you have really mixed feelings about being with your niece. For example, you can say that you are so happy for them and think your niece is adorable but that you find yourself thinking about your daughter when you are around her and sometimes it’s too painful to handle. Just be honest and authentic, tears and all.
Then, consider asking them if you could spend some time alone with your niece when they are nearby. Infants can be incredibly healing — they are amazingly tuned in to our emotions. They are also quite tolerant and don’t judge adults for crying! When you are alone with her, just hold her and softly tell her how you feel. Tell her all about your daughter. Tell her that it’s hard to see her sometimes because it reminds you of how much you miss your daughter. Tell her how unfair your daughter’s death is. Tell her your favorite things about your daughter. Most important, let yourself cry as much as you need to. Studies have shown that tears from grief are chemically different from other kinds of tears, indicating that the body releases certain chemicals when we are deeply sad.
Your crying probably won’t even scare your niece, as some adults fear. Just watch her face; if your crying becomes uncontrollably loud or if she looks scared, just take her back to her parents and tell them you need a break. You will find that sharing this emotional process with your niece is intimate as well as healing and will actually connect you to her more. I’d even bet that she becomes one of the people with whom you allow yourself to cry easily and safely.
Q6. I have been having abdominal pain on the left side and sometimes on the right side of my abdomen. I did various tests such as CT scans and ultrasounds but they didn’t pick up anything. My internist and gynecologist think it relates to Paxil since I started Paxil for depression two weeks prior to the pain starting. Its not acid reflux or gas — it’s more of a pain feeling. Have you heard of this?
Paxil (now more commonly known by the generic name paroxetine) is thought to treat depression via effects on the chemical serotonin, which is present in the gut as well as the brain. Paxil can cause a range of gastrointestinal side effects, including nausea, diarrhea and less commonly constipation. It therefore may well be the cause of your stomach pain. If your pain persists, you should talk with your doctor about switching medication.
See the Everyday Health blog “Dr. Z’s Medical Report” for more on seasonal affective disorder.
Learn more in the Everyday Health Depression Center.
‘Prozac changed my life. It makes me feel normal’
The research, published in The Lancet, is based on a six year international study involving 522 trials and 116,477 individuals from Europe, Asia and North America, and was led by Dr Andrea Cipriani, associate professor of psychiatry at Oxford University. The average age of the participants was 44, of whom 87,052 were given antidepressants, and 29,425 a placebo. The result? “In terms of efficacy,” says the report. “All antidepressants were more effective than placebo.”
Some antidepressants proved more effective than others. Amitriptyline showed the highest efficacy, followed by mirtazapine, venlafaxine, paroxetine, sertraline, fluoxetine, citralopram and reboxetine – 21 types of anti-depressant were tested and these are the top eight. The reason this is such a big deal is because psychiatric disorders make up 22.8pc of global ill health, with depression being the most prevalent and universal, yet only one in six people with depression are being appropriately treated for it in the developed world, and one in 27 in the developing world. That’s an awful lot of untreated depression – The Lancet estimates that in total, depression affects around 350 million people globally, a figure which since 1990 has increased substantially, due to population growth and ageing.
“I think it’s important to note how big a worldwide problem clinical depression is,” says Stephen McWilliams, consultant psychiatrist and clinical lead of the Psychosis Programme at St John of God Hospital, Dublin. “The World Health Organization (WHO), in its Global Burden of Disease (GBD) study, has calculated the levels of disability attributable to various diseases. Called ‘disability adjusted life years’ (DALYs), this is based on how common a disease is, age at onset, how long it lasts, severity of disability, mortality and so forth. In this context, the WHO has found that depression it the third leading cause of disease burden worldwide, after lower respiratory tract infections and diarrhoeal diseases.”
This latest research – that the drugs do work – does not come as a surprise to the psychiatric profession. “My own view as a practicing clinician is that antidepressants definitely work and are often lifesaving when it comes to severe depression,” says Dr McWilliams. “Remember, untreated severe depression carries a mortality of around ten percent. Cipriani et al’s recent study in The Lancet, which is highly reputable as source of research evidence, rings very true in terms of daily practice in psychiatry.
“Of course, non-pharmacological treatments (such a cognitive behavioural therapy, other forms of therapy, carer information sessions, mindfulness and other measures) are very important for recovery, but antidepressants are usually essential where depression is moderate to severe.”
Which is why I love Prozac. Eight years after my first prescription, I remain in its debt, and have no plans to stop using it. Why would I, when it has changed my life so profoundly?
Pre-Prozac, I had not understood that there was a difference between endogenous (clinical) depression and reactive (situational) depression – in fact I had not understood depression at all, thinking it was all about crying and being miserable, usually after something terrible had happened.
Yet I had a nice life with nothing ‘wrong’ – good physical health, little stress, no external worries beyond the usual first world problems, great friendships and relationships, lovely kids, a comfortable home. Why did I so often feel insanely irritable, and at times unable to get out of bed, overwhelmed by the thought of even the washing up? Why did I feel so numb? Why did I self-medicate with booze? Why did I duvet-dive so much, an avoidant strategy employed since my teens?
Eventually I decided to take action. I quit booze, quit smoking, changed my diet, exercised more, had weekly sessions with a really good psychotherapist, took up yoga four times a week, and got a bicycle. And yes, of course all of these things made me feel better, because how could they not?
But if I stopped exercising for even one day, the numbness and irritability and inability to get out of bed were right behind me, stalking me like a big black dog. An overwhelming feeling of what’s-the-point was waiting for me, breathing over my shoulder. It was debilitating, and went on for years.
Until one day, when with some people who were discussing in detail the symptoms of depression, it dawned on me – could this be what I had? Listlessness, sleeping too much, craving carbs, irritability, back ache, low energy, indecision, a feeling of wading through treacle even with the simplest tasks? Yes to all of them – not all at the same time, but enough to spur me to make an appointment with my GP. She suggested antidepressants.
Here is what I ‘knew’ about antidepressants. They were a cop-out; they would stop me feeling my feelings; they were addictive; they were dangerous; they only treated the symptoms, rather than the underlying causes; they were for losers. Certainly, I knew people who used them alongside too much alcohol and said they didn’t work; people who took them instead of any talking therapies and said they didn’t work; people who took them briefly, then stopped and said they didn’t work.
Finding the right anti-depressant is like finding the right therapist – you may have to try a few before you hit the one that works for you. We are not all neurologically identical. So I tried mirtazapine (made me sleep too much), sertraline (made me awake too much), citalopram (made me want to kill myself, despite zero suicidal ideation before I took it), until I found the one that worked – fluoxetine, or Prozac.
It took two weeks. Two weeks of no change, then a day of mad intrusive thoughts about violent self-harm (I’d read the label, and knew it was part of the process, so was able to rationalise the thoughts even as my head was urging me to cut myself with broken glass, something I had not done since my teens).
And then, the sun came out. It was quite extraordinary. Nothing whatsoever changed in my external world, only my reactions to it. I no longer felt overwhelmed, or unable to get up, or irritable. Life remained exactly as it always had been, but my mood lifted, numbness replaced with optimism, heaviness replaced by lightness. Everyone noticed. Yet I did not feel chemically altered or high or out of it in any way – I just felt normal. For the first time in my life, aged 42, I felt normal. The relief was indescribable, reminding me of the end of Elizabeth Wurtzel’s 1995 memoir Prozac Nation, when the then-new drug started to work on her. When the depression lifted, and life became illuminated and textured and doable.
Two years ago, having been on antidepressants for six years, I came off them. Not on purpose – I’d had emergency surgery and forgot to take my daily 20mg, because I was too busy being in intensive care. Oh well, I thought. Might as well stay off them now, they’ve done their work. Within two months, the depression was back, this time with added anxiety, which was new and awful. My doctor suggested I start taking fluoxetine again, which I did, and went almost immediately back to feeling normal. I now fully accept that my normal needs some chemical assistance.
The research published in The Lancet shows that while the lives of many more of us could be improved by using antidepressants, we still don’t present for treatment because of our lack of understanding and our reluctance to acknowledge mental health problems. Left untreated, depression can be a killer. My former husband died of untreated depression. An unopened packet of antidepressants was found by his body - I have often wondered if he had taken them, might he be alive today.
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