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Comments and Thoughts from Mark J. Schlickman, M.D

Some Thoughts on the Use of Antidepressants Dinosaurs and the Origins of Mental Illness

 

Some Thoughts on the Use of Antidepressants

Mark J. Schlickman, M.D.



The use of medication for psychiatric problems (psychopharmacology) has been rapidly expanding, and has resulted in a great deal of media attention. Much of the information disseminated is correct and important for people who are prescribed psychiatric medication to know. Unfortunately, some of the information is misleading and horribly inaccurate. The following is an overview of some important issues in the use of antidepressant medications, and some factual information necessary to make an informed decision for their use.

There are many different kinds of antidepressants. They work by increasing the activity of certain pathways in the brain. These pathways not only modulate mood, but also modulate anxiety, pain tolerance, and day-to-day energy and interests. Depression results in a constellation of life changes, and antidepressants act to guide people back to a more usual state of being. Depression affects sleep, appetite, energy, concentration, as well as the ability to feel pleasure. Antidepressants act to improve all of these areas.

You may also be prescribed an antidepressant to treat anxiety-related difficulties, or chronic pain. The use of antidepressants in other illnesses is because, as noted above, there are many different brain pathway s that utilize the same chemicals.

Medication cannot affect just one pathway. This is both an advantage and disadvantage. The advantage is in the ability of an antidepressant to improve a variety of illnesses; depression, obsessive / compulsive disorder, panic disorder, and fibromyalgia, among others. The disadvantage is that this intermixing of pathways makes it difficult to separate side effects from good effects. The good effects of antidepressants occur gradually, often taking from three to twelve weeks to feel the full improvements. Because of this gradual improvement, these medications have no ability to cause addiction. With some antidepressants, however, this also means that you will feel side effects before you begin to notice improvements. Typical side effects vary by class of medication. Commonly, dryness, constipation, headaches, nausea, and sexual difficulties can occur. You sh ould feel free to ask about any physical or emotional changes you do not understand.

Often, a combination of medications is necessary. This frequently concerns people, but when done carefully and thoughtfully, can result in improvements not possible with only one medication. Taking a single antidepressant is like using the volume control on your television; increasing the dose is like turning up the volume. If the quality of the improvement in mood is not as robust or complete as desired, adding another medication is similar to using the sound mixer on your stereo; a more individualized approach is possible.

Antidepressants are not happy pills. They do not make you forget your feelings, or blunt your feelings, or make you suddenly gleeful and unaware. Medications like Valium and Xanax (two in a class of medications called benzodiazepines – which are not antidepressants) have the potential to blunt feelings or cause short-lived elation. These effects are identical to the effects of alcohol. Unfortunately, alcohol decreases brain activity, and consequently acts as a powerful depressant. Any person who uses enough alcohol and medication complicates the metabolism and excretion of both from your body. The result is a possible increased risk of liver damage from alcohol, and potential toxicity from medication.

Abstinence from alcohol is an important part of the treatment of depression. If sobriety is a problem, treatment must first focus on this issue.
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Antidepressants have the ability to give you energy and improve concentration before improving your mood. On rare occasions, this effect causes people to act on feelings of suicide, or even more rarely, act on rage towards others (Prozac had been targeted as dangerous, but ALL antidepressants carry this uncommon risk). This is why you will be repeatedly asked about feelings of suicide and homicide, and why many people are asked to make a treatment contract for their safety and the safety of others. Communication minimizes the risk, and improves your treatment.

Many antidepressants are known to cause birth defects when taken during pregnancy. Because of this risk, if you are capable of becoming pregnant, a reliable form of=2 0birth control is an important part of your treatment. Birth control pills are safe with antidepressants, and many women start an oral contraceptive when they start antidepressant medication.

The combined use of medication and a talking therapy has been shown to be the most effective treatment for depression; in general, all difficulties involving emotions and behavior are best treated by combining the use of medication and psychotherapy. Medication is a tool for helping you do the “talking work” necessary for lasting improvements. Close contact among all your health providers insures the best possible care. You should never hesitate to contact anyone on your treatment with questions you may have.

Dinosaurs and the Genetics of Mental Illness

There is ample evidence of the genetics of mental illness. Schizophrenia, an illness of disconnection from reality, occurs in one percent of all human populations, indicating a prehistoric timeline to explain its ubiquitous prevalence. Amish populations were the first to show a gene on chromosome 11 that is responsible for bipolar illness. Additionally, twin studies, and numerous family studies have shown a genetic correlation for the incidence of mood disorders (major depression, bipolar illness, and schizoaffective illness).

The rules of Darwinian evolution explain that a population will tend to strengthen a particular genetic variant if the variant improves the survival of an individual and its offspring. Interestingly, most mental illnesses are diseases of adulthood. For example, the average age of onset of bipolar illness in women is 29 years old. This implies that there is no Darwinian selective pressure either in favor or against mental illness.

That means we are left with our genetics, our biological predisposition for illnesses like depression. Evolution further notes that multiple generations are required to strengthen a particular genetic variant in a population. Let's imagine that there is a genetic variant that would improve our ability to deal with the stresses of modern life. How long might it take for this genetic variant to gather steam in the general population?

Some of our past inhabitants of the planet, the dinosaurs, can shed light on this question. Dinosaurs existed from about 225 million years ago until the comet smashed into the Gulf of Mexico about 65 million years ago. This is roughly 150 million years. During that time, dinosaurs came to inhabit every environment on the planet, including a challenging Antarctic climate of temperate summers and harsh winters. 150 million years is a long time for adaptation and evolution- a really, really long time. If we hypothesize five to fifteen years per dinosaur generation, this means that there were from 10 million to 30 million generations of dinosaurs constantly selecting for adaptive genetics that improved survival. That's a lot of generations.

How many generations of humans have there ever been? If we are generous, Homo sapiens have been on the planet for 100,000 years. At 15 to 20 years per generation, that means that all of human existence covers 5,000 to 6,000 generations. That means that dinosaurs had 2,000 times the generations humans have had for evolution. But humans live in a dramatically different environment than 100,000 years ago. Humans have been "civilized" (living in non-nomadic settlements) for about 6,000 years; that's several hundred generations at most. Humans have been living in an industrial age for over several hundred years; that's only a couple of dozen generations. Humans have been living in an age of technology for only a few generations.

A few generations are hardly the time necessary to adapt to a new environment. Therefore, we presently carry with us the genetic adaptations that were useful 10,000 or 100,000 years ago. As an example, being alert to the point of anxiety may have been adaptive for early humans. The more alert an individual is, the less likely the individual is to be eaten by predators or attacked by other marauding humans (sad, but that aspect of our history goes way back, too). But this level of anxiety is not always useful in the modern world; panic attacks, agoraphobia, and post traumatic stress disorder cause disability not adaptability.

If cognitive-behavioral or "talking" therapy does not control symptoms, then what do we have to use to adapt to our technological society? The answer is in technology, in the use of psychopharmacology, the use of medicines in mental health. We use technology to adapt while genetic selection takes its time to catch us all up to what we've done to our environment. In 1970, Alvin Toffler's "Future Shock" predicted the social difficulties of dealing with "too much change in too short a time". Our best way to cope in this future world is to use all the modern tools we have to adapt and function in this modern world.