Antidepressant drugs have been found to be effective in alleviating many of the symptoms of chronic diseases. They are used to ease pain, improve sleep disorders, and increase energy-three of the major symptoms of most chronic illnesses, including CFIDS. Research even documents that some antidepressants can actually improve immune system response.
Depression is a major symptom (though not a cause) of CFIDS, manifesting itself in two ways. First, having a chronic illness that severely disrupts one's ability to function, causing immeasurable suffering and isolation, is inherently very depressing. Second, studies indicate that diseases like CFIDS that affect the nervous system often cause a biochemical depression.
The decision to use drugs should be made in consultation with a physician. Antidepressants in low doses may alleviate physical symptoms at any time during the course of the illness, but should always be considered when serious depression exists.
Most people must overcome the stigma associated with antidepressants before they will commit themselves to a regimen of them because these drugs are associated with mental illness, which is often perceived as a weakness of will rather than an organic disease, some people are embarrassed or ashamed to take a drug labeled "antidepressant." However, evidence is mounting that people who suffer from the mental illness known as depression have insufficiencies or imbalances in certain brain chemicals. So, people with depression should feel no more ashamed to take a drug that regulates their brain chemistry than diabetics should feel ashamed to take insulin injections to regulate their blood sugar levels.
Safety and Side Effects
Many people are also reluctant to take antidepressants either because they are afraid of the side effects or are concerned that the drug could alter their personality. Antidepressants are in fact among the safest on the market (unless, as with any drug, they are taken in overdose quantities). When taken as directed, antidepressants do not cause physiologic toxicity, (i.e., they have no significant adverse impact on the liver, heart, or kidney) and are not addictive. While there may be side effects, these are mostly annoying, not life threatening. Alt studies suggest that there are no negative cumulative effects with long term use of antidepressants.
Side effects can be a problem, and can sometimes be worse than the condition being treated. The good news is that the newest antidepressants (Prozac, Zoloft, etc.) have far fewer side effects than earlier ones. The challenge in taking antidepressants is to try to stay on the drug long enough to see if the side effects subside (which they often will), and to continue to try different antidepressants until one is found which works well.
Do antidepressants alter personality? People who find an effective antidepressant find that it enables them to be their 'best"-less encumbered by traits like low self esteem, hopelessness, fear, and irritability. Antidepressants do not change a person into a different kind of personality.
Antidepressants can be divided into two groups - sedating antidepressants and energizing antidepressants. Sedating antidepressants include Elavil (amitriptyhne), Pamelor (nortryptiline), Tofranfl (imipramine), and Sinequan (doxepin). This is the group of antidepressants most likely to enhance sleep and diminish pain. For CFIDS patients, a low dosage (5-50 mg/day) of, particularly, Elavil or Sinequan, can be effective for pain and sleep, but this dosage will not affect depression. An increase to 200 mg/day can treat depression, but this usually causes undesirable side effects (daytime sedation, cognitive impairment, dry mouth, constipation, blurred vision), especially considering that many PWCs are extra-sensitive to these drugs.
A low dose of a sedating antidepressant to combat pain and sleep disorder can be combined with an energizing antidepressant such as Prozac (fluoxetine) or Zoloft (sertraline) to increase energy and reduce depression. Prozac should be started at 5-10 mg/day, and increased as tolerated; but the side effects of Prozac can sometimes cause insomnia or anxiety. Zoloft can be started at 25 mg/day, increasing to about 150 mg, and usually has fewer side effects. These drugs, like the sedating antidepressants, are not addictive.
For some CFIDS patients whose symptoms include depression but who have not responded to any of these antidepressants, Wellbutrin (buproprion) can be useful. It may improve symptoms such as attention, cognitive functioning, and energy; side effects are similar to Prozac or Zoloft, (with a slightly elevated risk of seizures). Wellbutrin too, can be taken with a low dose of Elavil or Sinequan to treat the pain and sleep disorder. Again, patients start on a low dose (100 mg/day) and gradually increase. Norpramine (desipramine) is less sedating than the other sedating antidepressants and is reported to improve cognitive clarity.
There is also a type of medication now used as an "antidepressant augmenting agent"; when taken with a primary antidepressant it boosts that antidepressant's effect. For example, Buspar (buspirone), an antianxiety drug, can augment Prozac or Zoloft if the effect of the antidepressant starts to wear off. Buspar is not addictive and has few side effects. Lithium, a drug used primarily to treat manic depression can also be used as an augmenting agent, but because it may increase neurological side effects it is not recommended for use with CFIDS patients. Cylert (pemoline) is a non-amphetamine central nervous system stimulant that can be used as an augmenting agent, and may increase physical energy, improve memory, and enhance cognitive functioning. Finally, thyroid hormone in low doses is sometimes used to augment the efficacy of antidepressants.
CFIDS clinicians have observed that antidepressants are poorly tolerated by PWCs because they are extra-sensitive to side effects. When antidepressants are prescribed by a clinician who is unaware of this, the clinician may place the patient on a large dose of an antidepressant and/or increase the dose rapidly, causing such side effects that the patient assumes he/she is intolerant of antidepressants in general or that antidepressant specifically. It is often the case that the drug can be tolerated and/or is effective at a lower dose for someone with CFIDS.
Written in consultation with Brent Cox, M.D., Martin County, California, psychiatrist specializing in psychopharmacology. Dr. Cox has treated over 50 PWCs.
Reprinted from the CFIDS Treatment News. Vol., No. 1, Fall 1993, by permission of the San Francisco CFIDS Foundation.