Unless you’re medically trained in drug usage, you won’t be expected to be an authority on psychotropic drugs, their potential benefits and side effects, or even withdrawal protocols. But it’s useful to have a rough idea as to what these medications are and any drawbacks clients may experience, because so many clients have been on, are on, or are thinking about going on medication for emotional problems.
Here I want to give you just a rough and ready guide so that you don’t draw a complete blank when your client discusses medication.
We’ll focus on drugs commonly prescribed for depression and anxiety. As it is rare to be consulted by a psychotic patient, I won’t talk about antipsychotic drugs. And of course, you can always consult your client’s doctor.
So let’s get to it.
I’ve previously written a blog post on this topic – 5 Vital Facts to Tell Your Clients About Antidepressants – so here’s just a rough reminder. It’s not necessary to discuss a client’s history of medication unless it’s somehow relevant, but it’s good to have some kind of context to your own knowledge.
Antidepressants were first used in the late 1950s. They are divided into three main classes:
- Tricyclic antidepressants (TCAs)
- Monoamine oxidase inhibitors (MAOIs)
- Selective serotonin reuptake inhibitors (SSRIs).
Tricyclic agents are used in the treatment of:
- panic disorder
- obsessive-compulsive disorder
- post-traumatic stress disorder
- occasional chronic pain.
SSRIs are used in the treatment of:
- panic disorder
- obsessive-compulsive disorder
- bulimia nervosa
- social phobia.
MAOIs are used for all types of depression. They have also been used when ‘atypical’ features are present with depression, such as excessive sleeping, overeating, and/or anxiety.
SSRIs, which were developed in the 1990s, are now the most popularly prescribed antidepressant. The most famous brand names for this type of antidepressant are Prozac and Seroxat.
Why are SSRIs the current preferred antidepressant?
One of the reasons that SSRIs are so widely prescribed by doctors and psychiatrists is that they are safer in overdose than the older antidepressants. This is obviously a good thing, because traditionally the most popular form of suicide was to overdose on the antidepressants that were meant to help.
Some of the tricyclics, including dothiepin, amitriptyline, and imipramine, are extremely toxic in overdose.
So if your client tells you they have been prescribed an older-style antidepressant it may be because they have some rare symptom which isn’t common among patients with depression or anxiety.
But the big question is: Do these drugs work, and if so, how?
How do these drugs work?
All three classes of antidepressants are said to work by increasing the amount of monoamine neurotransmitter – that is, serotonin or noradrenaline – available between nerve synapses in the brain, but they do so in different ways. The effect of this should be increased energy and improvement of mood. We also know that they reduce the amount of REM sleep, which will also cause an increase in energy levels.
Neuroscientists now recognize that depression doesn’t seem to be connected to low serotonin levels, or at least not in any fathomable and simple way.1
It could be the suppression of REM sleep which some antidepressants produce that derails the cycle of depression, and/or for many people it may simply be belief in the efficacy of antidepressant medication, which itself produces positive expectancy – the so-called placebo effect.
Are antidepressant meds better than placebo?
Hope is a very powerful natural antidepressant.
According to one paper, a whopping 40-60% of people taking antidepressants reported some improvement in symptoms, versus 20-40% of people taking placebo (that is, non-psychoactive sugar pills).2
But other researchers found that antidepressants are no better than placebo for about 85% of people.3 Using the Hamilton Rating Scale for Depression (HAMD-17), they found that the average difference between drug and placebo effects was 1.75 points in adults – tiny enough – and a mere 0.71 points for children and adolescents. (And that might not be so bad… if it weren’t for the side effects!)
If placebos are ‘active’ – that is, if they produce side effects so the person consuming them is more likely to believe they are taking the real drug – then, research suggests, the difference in efficacy between placebo and genuine antidepressants shrinks into statistical insignificance.4
Your client may tell you that they find antidepressants to be wonderfully effective, and if so, then we would do well to remember how important positive expectation is and maybe at least tread carefully around their belief rather than cite a bunch of research indicating that antidepressants don’t significantly outperform placebos. But many clients come for psychotherapy because they feel drugs didn’t or wouldn’t work for them.
They may not be keen on antidepressants, or perhaps they’ve suffered side effects.
So what are some common side effects you might hear about?
Side effects of antidepressants
Because all antidepressants have similar efficacy – that is, no one antidepressant, despite glossy marketing, has shown to be more effective than any other or indeed significantly better than placebo5 – the choice of which drug to prescribe often rests on their markedly different side effects. So people may have to ‘shop around’ to see not just which product helps the most, but which seems to damage them the least.
Side effects of the various antidepressants can include:
- dry mouth
- difficulty urinating
- blurred vision
- sedation (can interfere with driving or operating machinery)
- weight gain
- gastrointestinal disturbance/diarrhoea
- abdominal pain
- erectile dysfunction
- inability to achieve an orgasm (men and women)
- anxiety (which, of course, may have been the reason for the prescription in the first place!).
Some clients may, of course, feel empowered by taking meds, or even destigmatized, since it means depression can be seen as a ‘disease’ or something which is permanent and therefore not their ‘fault’.
But for others taking meds, there may also be feelings of damaged self-esteem, a sense that they are genetically ‘faulty’ and that no improvement can be permanent – despite the fact that relapse back into depression is much lower even after taking up physical exercise than after medication.6
Depression seems to be fuelled by negative expectation and rumination,7 so if a client starts to experience side effects such as sexual dysfunction, insomnia, or anxiety, and starts to negatively ruminate about these symptoms (as would be quite natural to do!), then their depression may worsen, at least while the side effects persist.
Antidepressants don’t seem to be addictive in the way that, say, morphine-based medication might be, but a kind of physical or psychological dependency may result in part because of the withdrawal effects that may be experienced when clients reduce their usage.8
The need for sensitivity
So we need to sensitively ask about our client’s beliefs and attitudes about and experiences of antidepressant usage, as it’s clear that some people experience worse side effects than others and some people have greater belief in these products – and therefore possibly better outcomes from them.
Next let’s take a broad and brief look at benzodiazepines for anxiety and insomnia, another common type of drug your clients may be taking.
Benzodiazepines for anxiety and insomnia
Benzodiazepines, or ‘tranquillizers’, replaced barbiturates in the 1960s as the drug of choice for the treatment of anxiety and insomnia. They were greeted initially with much enthusiasm, until it became increasingly apparent that they were strongly associated with dependence and withdrawal problems.9
First, let’s look at what specifically your client might be prescribed benzodiazepines for:
- Insomnia – Short-acting benzodiazepines such as temazepam are often prescribed for insomnia or delayed sleep onset. Tolerance can develop if these are used continuously.
- Anxiety – Diazepam (Valium) and lorazepam are regularly prescribed for anxiety disorder or after a traumatic event such as a car crash. They are also given to people suffering from panic attacks and social phobia. Sometimes they are prescribed alongside antidepressants when the patient is suffering depressive and anxious symptoms.
- Alcohol withdrawal – Sometimes when a person is withdrawing from alcohol dependency, alcohol intake is gradually replaced by prescribed benzodiazepines, which are then gradually reduced over a period of seven to ten days.
Benzodiazepine misuse, including dependency, is a worldwide problem.10
But if you are suffering, having panic attacks or dreadful insomnia or a general sense of pervasive fear, and you don’t have the opportunity to seek psychological help then, of course, it’s tempting to take these kinds of meds. And certainly, when used in a controlled way for a limited time they really can seem to aid wellbeing.
So what are some of the more common side effects of ‘benzo’ usage?
Side effects of benzodiazepines
Side effects of benzodiazepines may include:
- dizziness (especially in the elderly)
- respiratory depression (benzodiazepines depress respiratory centres in the brain and must be used with caution in patients with chronic respiratory disease)
- unsteadiness (especially in older people, who may fall and injure themselves)
- slurred speech
- muscle weakness
- memory problems
- dry mouth
- blurred vision.
Just as concerning are the withdrawal effects that may be experienced when a client tries to stop using benzodiazepines.
Benzodiazepine withdrawal symptoms
Withdrawal symptoms may occur up to three weeks after stopping benzodiazepines, and can include:
- extreme anger
- tremors (‘the shakes’)
- loss of appetite
- general irritability
- depersonalization (a sense of being distant from the surroundings)
- perceptual disturbance, visual or auditory disturbance, even hallucination.
So what should you or I do with all this information?
Your role as therapist regarding your clients’ use of prescribed drugs
As your field of expertise may well lie elsewhere, you are not expected to be an expert in medication or to have an opinion on it.
I don’t tend to pass too much comment about medication unless my client asks my opinion or expresses doubts themselves. And if they find or expect to find medication useful then we can respect that too.
However, we can inform ourselves about the more commonly prescribed drugs for emotional and behavioural problems in a very broad sense so we have some basis for understanding our clients’ experiences.
Part of understanding our clients may well be understanding their experience with prescribed psychoactive medications.
Some clients are unaware of the potential side effects of their medication, and if this seems to be the case then it is wise to advise them to consult their doctor.
And it’s easier to see how well your therapy is working when someone is clear of drugs, as you have a more measurable baseline from which to work.
We should certainly never tell our clients to stop their medication or cut down without the help of their doctor, as they may need to taper very slowly if they have been consuming meds for a long time and/or in significant quantities.
But people who have been on tranquillizers are often greatly impressed when you show them they can relax deeply without the use of medication.
Teaching skills rather than giving drugs can often greatly increase confidence and self-esteem in your clients.
And of course your therapy may be the best antidepressant and anti-anxiety treatment your client ever gets – with plenty of (positive) ‘side effects’.
How to Lift Depression Fast
If you’d like to get a new approach to treating depression for your therapeutic toolkit, you can join Mark on his online depression treatment course. The course includes video footage of Mark working with a depressed client, full course notes, Q&A calls and much more. Read all about it here.
- https://pubmed.ncbi.nlm.nih.gov/10547175/ – James A. Blumenthal, PhD and his colleagues surprised many people in 1999 when they demonstrated that regular exercise is as effective as antidepressant medications for patients with major depression. The researchers studied 156 older adults diagnosed with major depression, assigning them to receive the antidepressant Zoloft (sertraline), 30 minutes of exercise three times a week, or both. According to Blumenthal, “Our findings suggest that a modest exercise program is an effective, robust treatment for patients with major depression who are positively inclined to participate in it. The benefits of exercise are likely to endure, particularly among those who adopt it as a regular, ongoing life activity.”
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