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Antidepressants – Do you want the good news or the bad news first?

First concern I want to address is the possibility that you might be feeling depressed due to some underlying medical problem such as thyroid gland dysfunction, other hormonal, neurological, autoimmune, blood, or cardiovascular system-related diagnoses, etc...

Let’s assume that was done, and after a detailed assessment, we did rule out other stuff, and we did come to a diagnosis of depression. Ok, so depression = Antidepressant. Well, yes, but there is a few types of depression and plenty of different antidepressants. My job is to suggest the one that is the best match for you, best in targeting your symptoms and with the lowest possibility of side effects.

So let’s address the side effects.

"Primum non nocere" is a Latin phrase that means “first, do no harm,” yet every medication and every intervention will come with a risk, so what is your risk with antidepressants? Here is the first one of the good news. Antidepressants are relatively well-tolerated medications. You have about a 25% chance of experiencing significant side effects, AKA you do have a 75% chance of suffering no side effects or a minor side effect most people describe as not significant enough to cause them to stop the medication.

Other good news is that tolerability is dose-dependent, and it increases over time. These medications are started in a lower dose range and gradually optimized. Even if something is uncomfortable, it tends to go away within a few days, exceptionally weeks. Lastly, not tolerating one medication does not mean that you will not tolerate a different one, and there is plenty of choices out there. To conclude, we are talking about a relatively low risk and a good risk-benefit ratio. In other words, it is reassuring that if you give it a shot and something goes wrong, all you need to do is stop the medication, and pretty much within a day or two, the problem will go away; there is no permanent damage.

Ok, great, but what problems could there be…

some groups of antidepressants may come with rare but dangerous side effects, but let’s keep it simple. For most of the first and second-line treatment, one of three things may happen:

1) Stomach problems

2) Brain problems

3) sex problems

So stomach problems:

In other words, you might be nauseous or get some cramps and/or diarrhea. This tends to go away in a few days.

Brain problems:

Some people feel foggy and more tired; some people feel more nervous and activated, almost like after having too much coffee. Sleepy or insomniac and maybe a bit more nervous.

Sex problems

This is quite dose-dependent, but both males and females sort of experience the same thing: a lack of desire to have sex and a delay or inability to have an orgasm. Erection is not impacted, and this problem is sort of more rare and indirect; in other words, if you are not feeling horny and not really in the mood for sex, it will be difficult to get hard.

Simply said that’s about it. If any of this happens, we stop the medication, and it goes away, or we switch to another medication that might not cause any of it, or we use many strategies available to mitigate this. I don’t think any of this would be a reason not to give it a shot.

Now the bad news.

Time ! Antidepressants take time to work, and before say two to four weeks of treatment in a proper dose, we can't really tell for sure if the medication is working or not. I usually tell people to imagine this treatment like going to the gym. Once you start exercising, nothing really happens except maybe being a bit more tired or having some muscle pain (workout side effects, lol), but we all know that consistently lifting weights for a month will change our body and grow our muscles. I really want you to think about the antidepressant treatment like the gym for the brain; it will take time for you to feel the result. No point starting this medication if there is not at least a month's commitment to give it a go and see what happens. I do want to emphasize that a quicker response is possible and that some people feel better sooner

Efficacy ! These meds could be a bit more effective, and it is very hard to know if one is going to be better for you than another. We do rely on a detailed history, consider heredity, brainstorm specific symptoms of your depression, and sometimes even do genetic testing, but we really do not know for sure if the medication will work. Sometimes it takes a few trials and errors to find a perfect match. The bad news is that for the medication to get approved, we are looking at the response, but there is a big difference between response and recovery. Response means you are feeling better, and recovery means you are symptom-free and feeling completely ok. That tends to be more difficult to achieve.

To summarize, there are many classes of antidepressants and many medications within each class. It is not an easy process, but we can and we will find the medication that causes no problems or the least possible amount of problems while aiming not just for a response but for a recovery. Despite all the challenges and the fact that there is no perfect medication out there your risk-benefit ratio remains on the side of choosing the medication.There is no reason for hesitation or for any further suffering. I want you to know that all risks and limitations considered over many years I personally witnessed so many cases where this treatment completely changed people's lives and I will not be exaggerating when I say literally saved the lives of many of my patients.

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