What medications are used to treat depression?

Depression is commonly treated with antidepressant medications. Antidepressants work to balance some of the natural chemicals in our brains. These chemicals are called neurotransmitters, and they affect our mood and emotional responses. Antidepressants work on neurotransmitters such as serotonin, norepinephrine, and dopamine.

The most popular types of antidepressants are called selective serotonin reuptake inhibitors (SSRIs). These include:

• Fluoxetine (Prozac)
• Citalopram (Celexa)
• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Escitalopram (Lexapro).

Other types of antidepressants are serotonin and norepinephrine reuptake inhibitors (SNRIs). SNRIs are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta). Another antidepressant that is commonly used is bupropion (Wellbutrin). Bupropion, which works on the neurotransmitter dopamine, is unique in that it does not fit into any specific drug type.

SSRIs and SNRIs are popular because they do not cause as many side effects as older classes of antidepressants. Older antidepressant medications include tricyclics, tetracyclics, and monoamine oxidase inhibitors (MAOIs). For some people, tricyclics, tetracyclics, or MAOIs may be the best medications.

What are the side effects?

Antidepressants may cause mild side effects that usually do not last long. Any unusual reactions or side effects should be reported to a doctor immediately.

The most common side effects associated with SSRIs and SNRIs include:

• Headache, which usually goes away within a few days.
• Nausea (feeling sick to your stomach), which usually goes away within a few days.
• Sleeplessness or drowsiness, which may happen during the first few weeks but then goes away. Sometimes the medication dose needs to be reduced or the time of day it is taken needs to be adjusted to help lessen these side effects.
• Agitation (feeling jittery).
• Sexual problems, which can affect both men and women and may include reduced sex drive, and problems having and enjoying sex.

Tricyclic antidepressants can cause side effects, including:

• Dry mouth.
• Constipation.
• Bladder problems. It may be hard to empty the bladder, or the urine stream may not be as strong as usual. Older men with enlarged prostate conditions may be more affected.
• Sexual problems, which can affect both men and women and may include reduced sex drive, and problems having and enjoying sex.
• Blurred vision, which usually goes away quickly.
• Drowsiness. Usually, antidepressants that make you drowsy are taken at bedtime.

People taking MAOIs need to be careful about the foods they eat and the medicines they take. Foods and medicines that contain high levels of a chemical called tyramine are dangerous for people taking MAOIs. Tyramine is found in some cheeses, wines, and pickles. The chemical is also in some medications, including decongestants and over-the-counter cold medicine.

Mixing MAOIs and tyramine can cause a sharp increase in blood pressure, which can lead to stroke. People taking MAOIs should ask their doctors for a complete list of foods, medicines, and other substances to avoid. An MAOI skin patch has recently been developed and may help reduce some of these risks. A doctor can help a person figure out if a patch or a pill will work for him or her.

How should antidepressants be taken?

People taking antidepressants need to follow their doctors' directions. The medication should be taken in the right dose for the right amount of time. It can take three or four weeks until the medicine takes effect. Some people take the medications for a short time, and some people take them for much longer periods. People with long-term or severe depression may need to take medication for a long time.

Once a person is taking antidepressants, it is important not to stop taking them without the help of a doctor. Sometimes people taking antidepressants feel better and stop taking the medication too soon, and the depression may return. When it is time to stop the medication, the doctor will help the person slowly and safely decrease the dose. It's important to give the body time to adjust to the change. People don't get addicted, or "hooked," on the medications, but stopping them abruptly can cause withdrawal symptoms.

If a medication does not work, it is helpful to be open to trying another one. A study funded by NIMH found that if a person with difficult-to-treat depression did not get better with a first medication, chances of getting better increased when the person tried a new one or added a second medication to his or her treatment. The study was called STAR*D (Sequenced Treatment Alternatives to Relieve Depression).2,3

Are herbal medicines used to treat depression?

The herbal medicine St. John's wort has been used for centuries in many folk and herbal remedies. Today in Europe, it is used widely to treat mild-to-moderate depression. In the United States, it is one of the top-selling botanical products.

The National Institutes of Health conducted a clinical trial to determine the effectiveness of treating adults who have major depression with St. Johns wort. The study included 340 people diagnosed with major depression. One-third of the people took the herbal medicine, one-third took an SSRI, and one-third took a placebo, or "sugar pill." The people did not know what they were taking. The study found that St. John's wort was no more effective than the placebo in treating major depression.4 A study currently in progress is looking at the effectiveness of St. John's wort for treating mild or minor depression.

Other research has shown that St. John's wort can dangerously interact with other medications, including those used to control HIV. On February 10, 2000, the FDA issued a Public Health Advisory letter stating that the herb appears to interfere with certain medications used to treat heart disease, depression, seizures, certain cancers, and organ transplant rejection. Also, St. Johns wort may interfere with oral contraceptives.

Because St. John's wort may not mix well with other medications, people should always talk with their doctors before taking it or any herbal supplement.

FDA warning on antidepressants

Antidepressants are safe and popular, but some studies have suggested that they may have unintentional effects, especially in young people. In 2004, the FDA looked at published and unpublished data on trials of antidepressants that involved nearly 4,400 children and adolescents. They found that 4 percent of those taking antidepressants thought about or tried suicide (although no suicides occurred), compared to 2 percent of those receiving placebos (sugar pill).

In 2005, the FDA decided to adopt a "black box" warning label—the most serious type of warning—on all antidepressant medications. The warning says there is an increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to include young adults up through age 24.

The warning also says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation, or withdrawal from normal social situations. Families and caregivers should report any changes to the doctor. To find the latest information visit the FDA website.

Results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders.5 The study was funded in part by NIMH.

Finally, the FDA has warned that combining the newer SSRI or SNRI antidepressants with one of the commonly-used "triptan" medications used to treat migraine headaches could cause a life-threatening illness called "serotonin syndrome." A person with serotonin syndrome may be agitated, have hallucinations (see or hear things that are not real), have a high temperature, or have unusual blood pressure changes. Serotonin syndrome is usually associated with the older antidepressants called MAOIs, but it can happen with the newer antidepressants as well, if they are mixed with the wrong medications.

Reprints:

This publication is in the public domain and may be reproduced or copied without permission from NIMH. We encourage you to reproduce it and use it in your efforts to improve public health. Citation of the National Institute of Mental Health as a source is appreciated. However, using government materials inappropriately can raise legal or ethical concerns, so we ask you to use these guidelines:

• NIMH does not endorse or recommend any commercial products, processes, or services, and our publications may not be used for advertising or endorsement purposes.
• NIMH does not provide specific medical advice or treatment recommendations or referrals; our materials may not be used in a manner that has the appearance of providing such information.
• NIMH requests that non-Federal organizations not alter our publications in ways that will jeopardize the integrity and "brand" when using the publication.
• Addition of non-Federal Government logos and Web site links may not have the appearance of NIMH endorsement of any specific commercial products or services or medical treatments or services.

If you have questions regarding these guidelines and use of NIMH publications, please contact the NIMH Information Center at 1-866-615-6464 or e-mail at nimhinfo@nih.gov.

The photos in this publication are of models and are used for illustrative purposes only.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication No. 08-3929
Revised 2008

What medications are used to treat bipolar disorder?

Bipolar disorder, also called manic-depressive illness, is commonly treated with mood stabilizers. Sometimes, antipsychotics and antidepressants are used along with a mood stabilizer.

Mood stabilizers

People with bipolar disorder usually try mood stabilizers first. In general, people continue treatment with mood stabilizers for years. Lithium is a very effective mood stabilizer. It was the first mood stabilizer approved by the FDA in the 1970's for treating both manic and depressive episodes.

Anticonvulsant medications also are used as mood stabilizers. They were originally developed to treat seizures, but they were found to help control moods as well. One anticonvulsant commonly used as a mood stabilizer is valproic acid, also called divalproex sodium (Depakote). For some people, it may work better than lithium.6 Other anticonvulsants used as mood stabilizers are carbamazepine (Tegretol), lamotrigine (Lamictal) and oxcarbazepine (Trileptal).

Atypical antipsychotics

Atypical antipsychotic medications are sometimes used to treat symptoms of bipolar disorder. Often, antipsychotics are used along with other medications.

Antipsychotics used to treat people with bipolar disorder include:

• Olanzapine (Zyprexa), which helps people with severe or psychotic depression, which often is accompanied by a break with reality, hallucinations, or delusions7
• Aripiprazole (Abilify), which can be taken as a pill or as a shot
• Risperidone (Risperdal)
• Ziprasidone (Geodon)
• Clozapine (Clorazil), which is often used for people who do not respond to lithium or anticonvulsants.8

Antidepressants

Antidepressants are sometimes used to treat symptoms of depression in bipolar disorder. Fluoxetine (Prozac), paroxetine (Paxil), or sertraline (Zoloft) are a few that are used. However, people with bipolar disorder should not take an antidepressant on its own. Doing so can cause the person to rapidly switch from depression to mania, which can be dangerous.9 To prevent this problem, doctors give patients a mood stabilizer or an antipsychotic along with an antidepressant.

Research on whether antidepressants help people with bipolar depression is mixed. An NIMH-funded study found that antidepressants were no more effective than a placebo to help treat depression in people with bipolar disorder. The people were taking mood stabilizers along with the antidepressants. You can find out more about this study, called STEP-BD (Systematic Treatment Enhancement Program for Bipolar Disorder), here.10

What are the side effects?

Treatments for bipolar disorder have improved over the last 10 years. But everyone responds differently to medications. If you have any side effects, tell your doctor right away. He or she may change the dose or prescribe a different medication.

Different medications for treating bipolar disorder may cause different side effects. Some medications used for treating bipolar disorder have been linked to unique and serious symptoms, which are described below.

Lithium can cause several side effects, and some of them may become serious. They include:

• Loss of coordination
• Excessive thirst
• Frequent urination
• Blackouts
• Seizures
• Slurred speech
• Fast, slow, irregular, or pounding heartbeat
• Hallucinations (seeing things or hearing voices that do not exist)
• Changes in vision
• Itching, rash
• Swelling of the eyes, face, lips, tongue, throat, hands, feet, ankles, or lower legs.

If a person with bipolar disorder is being treated with lithium, he or she should visit the doctor regularly to check the levels of lithium in the blood, and make sure the kidneys and the thyroid are working normally.

Some possible side effects linked with valproic acid/divalproex sodium include:

• Changes in weight
• Nausea
• Stomach pain
• Vomiting
• Anorexia
• Loss of appetite.

Valproic acid may cause damage to the liver or pancreas, so people taking it should see their doctors regularly.

Valproic acid may affect young girls and women in unique ways. Sometimes, valproic acid may increase testosterone (a male hormone) levels in teenage girls and lead to a condition called polycystic ovarian syndrome (PCOS).11,12 PCOS is a disease that can affect fertility and make the menstrual cycle become irregular, but symptoms tend to go away after valproic acid is stopped.13 It also may cause birth defects in women who are pregnant.

Lamotrigine can cause a rare but serious skin rash that needs to be treated in a hospital. In some cases, this rash can cause permanent disability or be life-threatening.

In addition, valproic acid, lamotrigine, carbamazepine, oxcarbazepine and other anticonvulsant medications (listed in the chart at the end of this document) have an FDA warning. The warning states that their use may increase the risk of suicidal thoughts and behaviors. People taking anticonvulsant medications for bipolar or other illnesses should be closely monitored for new or worsening symptoms of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior. People taking these medications should not make any changes without talking to their health care professional.

Other medications for bipolar disorder may also be linked with rare but serious side effects. Always talk with the doctor or pharmacist about any potential side effects before taking the medication.

For information on side effects of antipsychotics, see the section on medications for treating schizophrenia.

For information on side effects and FDA warnings of antidepressants, see the section on medications for treating depression.

How should medications for bipolar disorder be taken?

Medications should be taken as directed by a doctor. Sometimes a person's treatment plan needs to be changed. When changes in medicine are needed, the doctor will guide the change. A person should never stop taking a medication without asking a doctor for help.

There is no cure for bipolar disorder, but treatment works for many people. Treatment works best when it is continuous, rather than on and off. However, mood changes can happen even when there are no breaks in treatment. Patients should be open with their doctors about treatment. Talking about how treatment is working can help it be more effective.

It may be helpful for people or their family members to keep a daily chart of mood symptoms, treatments, sleep patterns, and life events. This chart can help patients and doctors track the illness. Doctors can use the chart to treat the illness most effectively.

Because medications for bipolar disorder can have serious side effects, it is important for anyone taking them to see the doctor regularly to check for possibly dangerous changes in the body.

Reprints:

This publication is in the public domain and may be reproduced or copied without permission from NIMH. We encourage you to reproduce it and use it in your efforts to improve public health. Citation of the National Institute of Mental Health as a source is appreciated. However, using government materials inappropriately can raise legal or ethical concerns, so we ask you to use these guidelines:

• NIMH does not endorse or recommend any commercial products, processes, or services, and our publications may not be used for advertising or endorsement purposes.
• NIMH does not provide specific medical advice or treatment recommendations or referrals; our materials may not be used in a manner that has the appearance of providing such information.
• NIMH requests that non-Federal organizations not alter our publications in ways that will jeopardize the integrity and "brand" when using the publication.
• Addition of non-Federal Government logos and Web site links may not have the appearance of NIMH endorsement of any specific commercial products or services or medical treatments or services.

If you have questions regarding these guidelines and use of NIMH publications, please contact the NIMH Information Center at 1-866-615-6464 or e-mail at nimhinfo@nih.gov.

The photos in this publication are of models and are used for illustrative purposes only.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication No. 08-3929
Revised 2008

Counseling can help children with bipolar disorder, and everyone around them, to understand that their symptoms reflect a biological illness with complex genetic and environmental origins--not personality or an oppositional attitude. Counseling also can reduce the impact of symptoms on daily life. A variety of psychological interventions can be helpful, and parents should discuss their child's particular needs with their clinician to determine which psychological treatments could be most beneficial for their child.

• Individual psychotherapy may be useful for young people with bipolar disorder, particularly when there are ongoing stressors in their lives that make symptoms worse. Children with the disorder often carry a sense of failure, as if the illness was their fault. In many cases, they are aware that when they are unable to control their behavior, they may hurt people closest to them, which can increase their sense of self-blame. Individual psychotherapy can help young people become aware of and address these feelings.
• Cognitive Behavior Therapy (CBT) helps a child or adolescent to become aware of, and to describe, negative thoughts, feelings or reactions. A trained clinician guides the child to think of new, more positive alternatives. The young person is then given a chance to practice new thoughts, feelings, or reactions outside the clinical visit, and to discuss his or her experiences with the clinician afterwards. These methods are based upon practices that have helped many children and adolescents.
• Parent guidance sessions can help parents to manage their child's illness, identify effective parenting skills, learn how to function as a family despite the illness, and to address complex feelings that can arise when raising a child with a psychiatric disorder. Family therapy may be beneficial when issues are affecting the family as a whole.
• Group psychotherapy can be valuable to a child by providing a safe place to talk with other children who face adversity or allowing a child to practice social skills or symptom-combating skills in a carefully structured setting
• School-based counseling can be effective in helping a child with bipolar disorder navigate the social, behavioral, and academic demands of the school setting

Special thanks to Dr. Bostic and the School Psychiatry Program at Massachusetts General Hospital for permission to reproduce these recommendations.

For more information, visit www.schoolpsychiatry.org.

I am writing to give you an update regarding your student, who having Mood Problems, i.e. Depression.   

Accommodations are essential for this student to function in the academic program. Feel free to adapt this list, however, here is a general list of suggested accommodations.

Instructional Strategies

Interpersonal interventions

• Feeling connected to people is particularly important with mood problems, particularly because students with mood problems youth tend to withdraw from others. Help connect the student to supportive peers, and offer opportunities to participate in organized school activities such as clubs, sports.
• Make a special contact with the student each day. Maybe a specific greeting at the door followed by a question about something that has been of interest to the student.

Build strength and resiliency by reinforcing successes and positives

• What times has your student been successful at things in the past? What are your student’s strengths? Tell the student about any positives.
• Being successful and accomplishing tasks increases self-esteem so find ways to ensure the student has chances to achieve, even at his/her lower energy level and reduced ability to concentrate.

Reduce workload

• Mood problems such as depression may lower the student’s ability to work. Consider temporarily reducing the academic expectations and workload. Just like one might modify job tasks for a worker with back injury, it is important to modify tasks for a student with mood problems.

Give more time

• Students with mood problems tend to have problems with attention and concentration. Give more time, break assignments into smaller pieces, offer extra help in setting up schedules or study habits, or pair the student with others who express an interest in helping.

Coping / Stress Breaks (aka ‘Chill Time’) (Try to avoid the term ‘Time Out’ because for some students this has a negative connotation…)

• Expressing stress  -- Come up with a system to help the student identify when s/he is getting overwhelmed, and be able to communicate that to the teachers.
• For example, using a 5-point scale, where 1 is no problems, and 5 is being stressed and overwhelmed

Create a safe space

• Designate a “chill out zone” / “safe place” where the student can go if s/he is feeling overwhelmed. By giving the student the ability to calm down at school, this will lessen the chances that the student will end up leaving the school.
• Talk ahead of time privately with the student, and set up some signal or cue so that the student can leave the class if the student is getting overwhelmed.

Set clear expectations

• Many students have anxiety because they are uncertain about their teacher’s expectations. To help with this, provide the student with explicit guidelines for assignments. In addition, explicit guidelines for assignments help mitigate the negative impact of anxiety and depression symptoms on executive functioning. (Executive skills help a student to regulate his or her behavior. Through the use of these skills a student can plan and organize activities, sustain attention, and persist to complete a task.)

Classroom Education / Anti-Stigma

• Consider having a lesson about mood problems, in order for other students to know about anxiety so that they can understand what the student with mood problems is going through. Do not single out the student with mood problems, but make the lesson a about mood problems in general. For more information, the CMHA has an excellent curriculum here www.cmha.ca/highschoolcurriculum/
• Prevent stigma / teasing: Deal immediately with any negative behavior by peers toward this student
• Provide copies of classroom notes to cover absences due to anxiety, as the student may be missing classes due to anxiety, or doctor’s appointments.

Coping Plan

• Involve the student in coming up with a coping plan, whose elements might include:
• Student’s strengths
• Potential problems or issues
• Strategies and solutions to try

Suicidal ideation and crises

• Although depression does get better in the vast majority of situations, youth with mood problems may become overwhelmed to the point where they may feel passively suicidal (“Life isn’t worth living”), or actively suicidal (“Life isn’t worth living, and I’m going to do something to end my life.”)
• Learn about local resources (i.e. where you might get professional help) in case there are concerns about suicidality. Most likely, your school board already has a policy and procedure in place for such urgent situations.

Examples of Common Workplace Accommodations

Accommodations should be based on your needs and the employer’s resources. There is no standard list of reasonable accommodations, but here is a list of commonly provided workplace accommodations:

• Job coach assistance in hiring and on the job mentoring as necessary. Job coach/mentor could be from an external agency or be from within the organization.

• Flexible scheduling to accommodate effects of medications, time for appointments, more frequent breaks, switch to temporary part-time hours without fear of losing job.

• Changes in supervision, for example how feedback and instruction are given, or having weekly supervision appointments to check in and prevent problems before they can happen.

• In training, allowing more time for tasks to be learned, or allowing for individualized, one-on-one training.

• Appropriate technology like a tape recorder to tape instructions, head phones to block out loud noise, etc.

• Modifying work space or changing location so it is quieter, fewer distractions; allowing an employee to work at home.

• Allowing an employee to exchange minor job tasks with others.

Rights and Responsibilities of the Employer & Employee

The Employer Should:

• Create and maintain an atmosphere where people feel comfortable asking for accommodation, including providing information about the organization’s policies and creating ways for requests to happen confidentially.

• Assume that the employee’s request for accommodation is made in good faith.

• In a timely manner, work with the employee (and a professional, if necessary), to explore all options for accommodation.

• Maintain records of the request and steps taken to deal with the request.

• Maintain and respect confidentiality issues.

• Pay the cost of the accommodations, including fees for any medical certificates required.

• Request only information that is directly related to developing an appropriate accommodation.

• Ensure that managers and supervisory staff will not tolerate any discrimination or harassment as a result of an illness or an accommodation.

The Employee Should

• Tell the employer you need an accommodation, due to a disability, and give them the information they need to understand what the limitations are and what accommodations would address them.

• If requested, provide supporting documentation or medical certificates.

• Meet all relevant job requirements and standards once the accommodation has been provided.

• Continue to work with the employer to ensure that the accommodation remains effective and to check in with how you are doing.

SOURCE

Adapted from “Employment” , in “From Rollercoaster to Recovery”.

ADDITIONAL INFORMATION

• The Alberta Human Rights Commission has additional information on responsibilities for employers around employees with addictions issues
  http://www.albertahumanrights.ab.ca/publications/bulletins_sheets_booklets/ sheets/protected_grounds/drug_and_alcohol_dependencies.asp