Fri May 13, 2016 BY LISA RAPAPORT
(Reuters Health) - Antidepressants don’t work for everyone, and having a history of abuse during childhood may signal a low likelihood that the drugs will improve an adult’s symptoms of major depression, a recent study suggests.
While there are few reliable predictors of which people will respond to specific antidepressants, lots of previous research links a history of trauma early in life with how well people tend to do on these drugs, researchers note in the journal Translational Psychiatry.
"The presence of trauma history should be taken into account when making treatment decisions," said Leanne Williams of Stanford University and the VA Palo Alto Health Care System in California, lead author of the new study.
"Based on our findings, if you have experienced abuse or neglect early in life you are 1.6 times less likely to benefit from a typical first line antidepressant than a person who hasn't had this experience," Williams said by email. "In this case, consideration should be given to alternative medications plus adjunctive therapies that address the trauma issues as well as the current experience of depression."
To see how common childhood trauma is among depressed patients, Williams and her team compared 1,000 people diagnosed with major depression to 336 similar people who didn't have depression. They also looked at how each of the patients with depression responded to eight weeks of treatment with one of three randomly assigned antidepressants – escitalopram (Lexapro), sertraline (Zoloft) or extended release venlafaxine (Effexor).
Childhood trauma was much more common among the depressed adults, with about 63 percent reporting two or more experiences of either childhood abuse, neglect, loss of a parent or sibling, exposure to domestic violence, family breakup, severe health crisis, or some other significant violence or loss in childhood. Roughly 28 percent of people in the healthy control group reported two or more such childhood traumas.
About 22 percent of the people with depression in the study, and 5 percent of the healthy controls said they had experienced some type of physical abuse during childhood.
Sexual abuse occurred during childhood for 16 percent of the depressed participants and 5 percent of the controls.
Depressed patients in the study were also four times more likely to report a history of emotional abuse – 43 percent of them experienced this compared with 9 percent of the controls.
In addition, 41 percent of the depressed participants and 31 percent of the control group said their parents divorced or separated during childhood.
Overall, the presence of one traumatic event of any kind was not linked to whether depressed patients saw symptom improvements after eight weeks on antidepressants.
A specific history of physical, sexual or emotional abuse, however - particularly if it occurred at age 7 or younger - was associated with a worse response to the drugs, the study found.
By the end of the treatment period, only about 18 percent of depressed participants with a history abuse from age 4 to 7 experienced at least a 50 percent reduction in depression symptoms and just 16 percent achieved remission.
In contrast, among patients with no history of abuse, 82 percent saw symptom severity cut in half and 84 percent achieved remission.
Globally, about 405 million people experience depression, and less than half of patients with severe depression achieve remission from antidepressants.
One limitation of the study is its reliance on adults to accurately recall and report on trauma that happened during early childhood, the authors note. The study also only looked at three antidepressants and the findings might be different with other medications.
Even so, the study adds to growing body of evidence showing that childhood trauma is associated with an increased risk for a variety of mental health disorders including depression, said Dr. Katie McLaughlin, a psychology researcher at the University of Washington in Seattle who wasn’t involved in the study.
“This study suggests that child maltreatment and trauma not only predict greater likelihood of developing depression and a more chronic course of depression, but also reduced likelihood of responding to antidepressant medication treatment,” McLaughlin said by email.
Showing posts with label medicine. Show all posts
Showing posts with label medicine. Show all posts
Monday, May 16, 2016
Friday, April 08, 2016
Going Off Antidepressants
Harvard Women’s Health Watch Updated: October 27, 2015
If not handled carefully, coming off your antidepressant medication can cause disturbing symptoms and set you up for a relapse of depression.
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.
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.)
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.
*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).
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 it. 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.
If not handled carefully, coming off your antidepressant medication can cause disturbing symptoms and set you up for a relapse of depression.
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 discontinuation symptoms?
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.)
Discontinuation symptoms 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.
A range of 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*
Drug
|
Half out of body in
|
99% out of body in
|
Serotonin reuptake inhibitors
| ||
paroxetine (Paxil)
|
24 hours
|
4.4 days
|
sertraline (Zoloft)
|
26 hours
|
5.4 days
|
escitalopram (Lexapro)
|
27 to 32 hours
|
6.1 days
|
citalopram (Celexa)
|
36 hours
|
7.3 days
|
fluoxetine (Prozac)
|
Four to six days
|
25 days
|
Serotonin and norepinephrine reuptake inhibitors
| ||
venlafaxine (Effexor)
|
5 hours
|
1 day
|
duloxetine (Cymbalta)
|
12 hours
|
2.5 days
|
desvenlafaxine (Pristiq)
|
12 hours
|
2.5 days
|
Dopamine and norepinephrine reuptake inhibitor
| ||
bupropion (Wellbutrin)
|
21 hours
|
4.4 days
|
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).
Slow and steady
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 it. 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.
source: www.health.harvard.edu
Subscribe to:
Posts (Atom)