Fourth in the series of major breakthroughs in medical care in the last 30 years is the development of tolerable and effective treatment of depression. In my residency training from 1980-83 every resident dreaded seeing a patient with depression. The side effects of the medications we used were almost worse than the depression itself, and it seemed like there was just very little we had to offer. We encouraged exercise, referred patients for counseling, and prescribed medications that made patients feel terrible. When Prozac came out in 1987 it was incredibly popular. It was so effective that it spawned a cult movement to spread misinformation about its use. Why? It was really the first effective antidepressant that did not cause predictable and significant side effects long before it helped with the depression symptoms. Prior to Prozac, the tricyclic antidepressants (TCA) amitriptylene, imipramine, desipramine and other similar drugs were the primary antidepressants available. Those drugs cause major sedation, constipation, dry mouth, and weight gain. To try to allow patients to come to tolerate those side effects we would start at doses we knew were too low to help, and slowly taper up in dose to a dose that might work. It often took 8-12 weeks or more to get noticeable improvement. In addition we needed to give very small supplies because these medications taken in only 4-5 times the daily effective dose could cause fatal overdose. Nearly every weekend on call in those days we had one or more ICU admissions for TCA over dosage, and many deaths were attributed to these medications from accidental and intentional over dosage. It was a tough sell to a depressed patient to ask them to take a medication and to have to tell them that they would probably feel worse for the first 8-10 weeks before they started to notice improvement. With Prozac we had a drug that we could start at a dose that often worked, and could see benefit within 2-3 weeks in most cases. A whole slew of additional selective serotonin reuptake inhibitors (SSRIs), Zoloft, Paxil, Celexa, and others followed, and now we have these medications and several other classes of meds that are effective and generally well tolerated.
Now when we see a depressed patient who is a candidate for medication, we can choose from several effective and well tolerated medications, and when discussing the side effects we can emphasize the only common annoyance, delayed orgasm from most of these meds. We no longer have to feel apologetic for prescribing a medication expected to make things worse before helping. I feel like depression is now one of the most gratifying problems that I see patients for in the office. In the last few years with generic versions citalopram, fluoxetine, paroxetine and sertraline we have inexpensive options too.
Check out the first 3 posts in my series of observations in medical progress over the last 30 years:
Vasectomy: Faster, Safer and Better than before the No-Scalpel Technique
Now we have Effective Treatment of Congestive Heart Failure
Peptic Ulcer Disease – From Curse to Cure
Also enjoy: 30 Years of Progress – Antipsychotic Therapy
in third world countries, mental health is never a priority.:,.