PAC 610 Module 3 Antidepressants Example

Three Weeks Is Not a Trial: What the Evidence Says About Antidepressants for a Client in Early Recovery

Student Name

Psychology and Addiction Studies Program, Aspen University

PAC 610: Psychopharmacology

Instructor Name

Month Day, Year

Three Weeks Is Not a Trial: What the Evidence Says About Antidepressants for a Client in Early Recovery

Lena, a thirty-four-year-old client at Ridgeview Recovery Center, the Knoxville outpatient program created for these papers, had been free of opioids for four months and taking buprenorphine. Her low mood had outlasted withdrawal by many weeks, and the program's nurse practitioner diagnosed major depression and started sertraline. Three weeks later, Lena told her counselor she wanted to stop: "I feel the same. It doesn't work on me, nothing ever does." This paper reviews what antidepressants are, how well they work and what a counselor can reasonably do in Lena's situation.

The Main Classes

How Well They Work

Cipriani et al. (2018) conducted a network meta-analysis of 522 randomized trials involving more than 116,000 adults with major depression, comparing 21 antidepressants with placebo and with each other. Every one of the 21 drugs was more effective than placebo at producing a response over about eight weeks. The odds of responding ranged from roughly twice those on placebo for the most effective drug, amitriptyline, to about one third higher for the least effective, reboxetine. The drugs also differed in acceptability, measured by how many people stopped taking them for any reason. Several commonly used drugs, including escitalopram and sertraline, combined relatively good effectiveness with relatively good acceptability. The authors cautioned that the average differences between drugs were modest and that most trials were short.

When the First Drug Does Not Work

Rush et al. (2006) reported the main outcomes of STAR*D, a large study that followed several thousand outpatients with depression through up to four steps of treatment in ordinary clinical settings. Everyone began on citalopram. Those who did not remit could move to another drug, a combination or, at the second step, cognitive therapy. About 37 percent remitted at the first step, about 31 percent of those who continued at the second step, and around 13 to 14 percent at each of the third and fourth steps. Over all four steps, about two thirds of participants who stayed in the study remitted. Two lessons stand out. Not responding to one drug does not mean that no treatment will help. And remission became harder with each step, while relapse became more likely for those who needed more steps.

STAR*D also showed that remission took time. Many participants who eventually remitted did so only after six weeks or more on an adequate dose, which bears directly on Lena's three weeks.

Severity and the Placebo Question

Fournier et al. (2010) pooled data from individual patients in six trials comparing antidepressants with placebo. In people with mild or moderate depression, the advantage of medication over placebo was small and might not be clinically meaningful. In people with very severe depression, the advantage was substantial. Part of the reason is that people with milder depression often improve substantially with placebo and the attention that comes with a trial. This finding does not mean antidepressants fail in milder depression; it means the added benefit of the drug is harder to detect, and that psychotherapy and other approaches deserve equal consideration.

Side Effects and Stopping

Side effects are a major reason people stop antidepressants, and they often arrive before any benefit does. Nausea, headache and jitteriness tend to appear in the first week or two and often fade. Sexual side effects are common with SSRIs and SNRIs, tend to persist and are often not mentioned unless someone asks. Stopping some antidepressants suddenly, particularly those with short half-lives such as paroxetine and venlafaxine, can cause discontinuation symptoms, including dizziness, irritability, flu-like feelings and electric-shock sensations, which a client may mistake for relapse or for a sign that the drug was harmful. For these reasons, a decision to stop is best made with the prescriber, who can taper the dose.

Depression Alongside Substance Use

Depression is common among people in addiction treatment, and some low mood lifts with weeks of abstinence as the effects of intoxication and withdrawal fade. Lena's prescriber waited until her depression had lasted well past withdrawal before diagnosing it, which supports treating it as a separate condition. Two practical points follow. Alcohol and other sedating drugs can worsen depression and interact with some antidepressants. And treating depression may support recovery, since persistent low mood is a common reason people return to use.

What the Counselor Can Do

Lena's counselor cannot change her medication and should not tell her to keep taking it against her wishes. She can do several things within her role. She can share what the research shows about timing: that antidepressants usually take several weeks to show their full effect and that three weeks is early. She can ask about side effects, since unpleasant effects without benefit are a common reason people stop, and many can be addressed by the prescriber. She can point out that Lena's belief that "nothing ever works" may itself be part of the depression. She can explain that if sertraline does not help after a fair trial, the STAR*D results suggest other options may. And with Lena's permission, she can arrange for her to talk with the nurse practitioner before stopping, so that any change is planned and does not cause discontinuation symptoms.

Conclusion

Antidepressants act mainly by increasing the availability of serotonin, norepinephrine or both, and all the commonly used drugs outperform placebo for adults with major depression, though by modest margins on average and more clearly in severe depression. Benefits usually take weeks, and failure on a first drug does not predict failure on all. For a client in early recovery, depression that persists beyond withdrawal deserves treatment, and the counselor's task is to support a fair trial and an informed conversation with the prescriber.

References

Cipriani, A., Furukawa, T. A., Salanti, G., Chaimani, A., Atkinson, L. Z., Ogawa, Y., Leucht, S., Ruhe, H. G., Turner, E. H., Higgins, J. P. T., Egger, M., Takeshima, N., Hayasaka, Y., Imai, H., Shinohara, K., Tajika, A., Ioannidis, J. P. A., & Geddes, J. R. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. The Lancet, 391(10128), 1357-1366. https://doi.org/10.1016/S0140-6736(17)32802-7

Fournier, J. C., DeRubeis, R. J., Hollon, S. D., Dimidjian, S., Amsterdam, J. D., Shelton, R. C., & Fawcett, J. (2010). Antidepressant drug effects and depression severity: A patient-level meta-analysis. JAMA, 303(1), 47-53. https://doi.org/10.1001/jama.2009.1943

Rush, A. J., Trivedi, M. H., Wisniewski, S. R., Nierenberg, A. A., Stewart, J. W., Warden, D., Niederehe, G., Thase, M. E., Lavori, P. W., Lebowitz, B. D., McGrath, P. J., Rosenbaum, J. F., Sackeim, H. A., Kupfer, D. J., Luther, J., & Fava, M. (2006). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: A STAR*D report. American Journal of Psychiatry, 163(11), 1905-1917. https://doi.org/10.1176/ajp.2006.163.11.1905