Treatment

General Treatment Information
What sorts of psychotherapy are effective for depression?
What is Cognitive therapy?

Medication
Do certain drugs work best with certain depressive illnesses? What are the guidelines for choosing a drug?
How do you tell when a treatment is not working? How do you know when to switch treatments?
How do antidepressants relieve depression?
Are Antidepressants just "happy pills?"
What percentage of depressed people will respond to antidepressants?
What does it feel like to respond to an antidepressant? Will I feel euphoric if my depression responds to an antidepressant?
What are the major categories of anti-depressants?
What are the side-effects of some of the commonly used antidepressants?
What are some techniques that can be used by people taking antidepressants to make side effects more tolerable?
Many antidepressants seem to have sexual side effects. Can anything be done about those side-effects?
What should I do if my antidepressant does not work?
Can someone build up tolerance to Prozac or other anti-depressants so that they stop working after a while?
If an antidepressant has produced a partial response, but has not fully eliminated depression, what can be done about it?

Prozac
What about the rumors and studies that Prozac causes suicide and/or acts of violence?
Common Depression and the Drug
About the Drug
Reports about Prozac

Electroconvulsive Therapy
What is electroconvulsive therapy (ECT) and when is it used?
Exactly what happens when someone gets ECT?
How do individuals who have had ECT feel about having had the treatments?
How long do the beneficial effects of ECT last?
Is it true that ECT causes brain damage?
Why is there so much controversy about ECT?

Substance Abuse
May I drink alcohol while taking antidepressants?
If I plan to drink alcohol while on medication, what precautions should I take?
What's the relationship between depression and recovery from substance abuse?
What does the term "dual-diagnosis" mean?
Is it safe for a person recovering from substance abuse to take drugs?
How do you know when depression is severe enough that help should be sought?

General Treatment Information

Q. What sorts of psychotherapy are effective for depression?
Two effective methods of psychotherapy for people with depressions are cognitive therapy and interpersonal therapy. Both psychoanalysis and insight oriented psychotherapy have not been shown to be effective treatments for people with a depressive disorder. Cognitive (and cognitive-behavioral) therapists can be found in most major cities.

For a referral to a properly trained cognitive therapist practicing close to your location, contact: Aaron T. Beck, MD. The Center for Cognitive Therapy 3600 Market Street Philadelphia, PA 19101 (215) 898-4100.

While many therapists call themselves cognitive therapists and interpersonal therapists, only a few have had proper training. To find an interpersonal therapist with the best training, contact: Myrna Weissman, Ph.D. New Your State Psychiatric Institute 722 West 168th Street New York, NY 10032 212-960-5880

Q. What is Cognitive therapy?
A. Congitive therapy points out a number of misconceptions or "cognitive distortions" that affect the way we view ourselves. Some of these are:

1) All or Nothing Thinking: You look at things in absolute black-and-white terms. ("I don't think cognitive therapy will solve all my problems, so what's the point in even trying." "There's no point in getting started on this, I'm so far behind I'll never catch up.")

2) Overgeneralization: View a negative event as a never ending pattern of defeat. ("I always mess things up". "He's always late.")

3) Mental Filter: Dwell on negatives and ignore positives. (Example: your boss praises your report but wants a few changes. All you can do is dwell on the criticism.)

4) Discounting the positives: you insist your positive accomplishments "don't count" or are due to luck.

5) Jumping to conclusions: a) Mind reading ("My shrink only gave me half of the cognitive distortion list because he hates me." or b) Fortune-Telling --- arbitrarily predict things will turn out badly.

6) Magnification or minimization: Blow things out of proportion or shrink their importance inappropriately.

7) Emotional reasoning: Reason from how you feel: "I feel frightened therefore this must be really dangerous."

8) "Should statements": criticise yourself or other people based on how you think they "should" act or feel. "I shouldn't have so many cognitive distortions" "I shouldn't be so apprehensive about this". The only "shoulds', "have to" etc allowed are a) moral shoulds "Thou shalt not kill", b) Legal shoulds "You shouldn't try to smuggle chewing gum into Singapore" or 3) Physical Law shoulds "If I drop this ball it should fall to the ground."

9) Labeling: Identify yourself or others with their shortcomings: Instead of "I made a mistake" you think "I am an idiot".

10) Personalization: You blame yourself for something you weren't entirely responsible for or blame others and overlook your own behavior or attitudes.

The first step in cognitive therapy is to learn to recognise cognitive distortions. At first you feel like your whole mind is a hypertext document and every thought you click on reveals some cognitive distortion. To say you "I shouldn't have so many cognitive distortions" or "Now that I've recognised my cognitive distortions I should _easily_ be able to change the way I act or feel " are cognitive distortions. To say "I feel stupid and incompetant when I see that I am always making cognitive distortions, therefore I must be a total idiot" is a whole bunch of cognitive distortions.

Medication

Q. Do certain drugs work best with certain depressive illnesses? What are the guidelines for choosing a drug?
here are very few kinds of depression for which there are specific antidepressant treatments. When it comes to people with Bipolar Disorder who are depressed there are some major problems. Most importantly, with any antidepressant, there is a possibility that the antidepressant treatment will cause depressed bipolar people not just to come out of their depressions, but to develop manic episodes. The possibility of an antidepressant causing mania is least when the antidepressant is bupropion (Wellbutrin). The possibility of mania is greatly reduced if depressed bipolar folks are on a mood stabilizer such as lithium, Tegretol or Depakote when they are started on an antidepressant.

Q. How do you tell when a treatment is not working? How do you know when to switch treatments?
Antidepressant treatment is clearly not working when the individual receiving the treatment remains depressed or becomes depressed again. When a recently started antidepressant fails to cause improvement, the depressed individual often asks that the medication be stopped, and a new one started. It generally does not make sense to change antidepressants until 8-weeks at the maximum tolerated dose have elapsed. With some tricyclic antidepressants, it is important to check the blood level of the antidepressant before it is stopped. The blood test can tell if the amount in the blood has been adequate. Only after an adequate trial of one antidepressant should another be tried. To have been on four antidepressants in an 8-week period means that one has not had an adequate trial on any of them.

Q. How do antidepressants relieve depression?
There are several classes of antidepressants, all of which seem to work by increasing levels of certain neurotransmitters (most commonly serotonin, norepinephrine, and dopamine) in the brain. It is not entirely clear why increasing neurotransmitter levels should reduce the severity of a depression. One theory holds that the increased concentration of neurotransmitters causes changes in the brain's concentration of molecules, receptors, to which these transmitters bind. In some unknown way it is the changes in the receptors that are thought responsible for improvement.

Q. Are Antidepressants just "happy pills?"
No matter what their exact mode of action may be, it is clear that antidepressants arel;l not "happy pills." There is no street-market for antidepressants; unlike "speed" which will improve the mood of almost everybody, antidepressants only improve the mood of depressed people. Also unlike the almost instant effects of speed, the mood-improving effects of antidepressants develop slowly over a number of weeks. "Speed" induces a highly artificial state, antidepressants cause the brain to slowly increase its production of naturally occurring neurotransmitters.

Q. What percentage of depressed people will respond to antidepressants?
Generally, about 2/3 of depressed people will respond to any given antidepressant. People who do not respond to the first antidepressant they have taken, have an excellent chance of responding to another.

Q. What does it feel like to respond to an antidepressant? Will I feel euphoric if my depression responds to an antidepressant?
The most common description of the effects of antidepressants is that of feeling the depression gradually lift, and for the person to feel normal again. People who have responded to antidepressants are not euphoric. They are not unfeeling automatons. The are still able to feel sad when bad things happen, and they are able to feel very happy in response to happy events. The sadness they feel with disappointments is not depression, but is the sadness anyone feels when disappointed or when having experienced a loss. Antidepressants do not bring about happiness, they just relieve depression. Happiness is not something that can be had from a pill.

Q. What are the major categories of anti-depressants?
There are many classes of antidepressants. Two kinds of antidepressants have been around for over 30 years. These are the tricyclic antidepressants and the monoamine oxidase inhibitors. While there are newer antidepressants, many with fewer side-effects, none of the newer antidepressants has been shown to be more effective than these two classes of drugs. In fact, many people who have not responded to newer antidepressants have been successfully treated with one of these classes of drugs.

The tricyclic antidepressants (TCAs) include such drugs as imipramine (Tofranil, amitriptyline (Elavil), desipramine (Norpramin), nortriptyline (Aventyl and Pamelor).

The monoamine oxidase inhibitors (MAOIs) include tranylcypromine (Parnate), phenelzine (Nardil), and isocarboxazid (Marplan) which has recently been taken off the market in the U.S.A. for marketing rather than safety or efficacy reasons.

One of the popular new classes of antidepressants are the selective serotonin reuptake inhibitors (SSRIs). The first of these drugs to be marketed in the USA was fluoxetine (Prozac). Sertraline (Zoloft), and paroxetine (Paxil) soon followed, and fluvoxamine (Luvox) is scheduled to be marketed in late 1994, or early 1995.

Bupropion (Wellbutrin) is the only drug in its class, as is trazodone (Desyrel). The most recently marketed antidepressant (4/94) is venlafaxine (Effexor), the first drug in yet another class of drugs.

Q. What are the side-effects of the commonly used antidepressants?
Below is a list of some of the more frequently prescribed antidepressants, and their most common side effects. The figure following each side effect is the percentage of people taking the medication who experience that side effect.

• Aventyl (nortriptyline): Dry mouth (15); Constipation (15); Weakness-fatigue (10); Tremor (10).
• Effexor (venlafaxine): Nausea (35); Headache (25); Sleepiness (25); Dry mouth (20); Insomnia (20); Constipation (15).
• Elavil (amitriptyline) Dry mouth (40); Drowsiness (30); Weight gain (30); Constipation (25); Sweating (20).
• Nardil (phenelzine) dry mouth (30); insomnia (25); Increased heart rate (25); Lowered blood pressure (20); Sedation (15); Over stimulation (10);
• Norpramin (desipramine) dry mouth (15); increased pulse (15); constipation (10); reduced blood pressure (10).
• Pamelor see Aventyl
• Parnate (tranylcypromine) Dry mouth (20); Insomnia (20); Increased pulse rate (20); Lowered blood pressure (15); Over stimulation (15); Sedation (15).
• Paxil (paroxetine): Decreased sexual interest and/or problems achieving orgasm (30); Nausea (25); Sedation (25); Dizziness (15) Insomnia (15)
• Prozac (fluoxetine): Decreased sexual interest and/or problems achieving orgasm (30); Nausea (20); Headache (20); Nervousness (15); Insomnia (15); Diarrhea (15).
• Sinequan (doxepin): Dry mouth (40); Sedation (40); Weight gain (30); Lowered blood pressure (25); Constipation (25); Sweating (20).
• Tofranil (imipramine): Dry mouth (30), Reduced blood pressure (30), Constipation (20), Difficulty with urination (15).
• Wellbutrin (bupropion): Agitation (30); Weight loss (25), Dizziness (20); Decreased appetite (20);
• Zoloft (sertraline): Decreased sexual interest and/or problems achieving orgasm (30);Nausea (25); Headache (20); Diarrhea (20); Insomnia 15); Dry mouth (15); Sedation (15).

Q. What are some techniques that can be used by people taking antidepressants to make side effects more tolerable
Listed below are some frequent side effects of antidepressants, and some techniques to reduce their severity:

• Dry mouth: Drink lots of water, chew sugarless gum, clean teeth daily, ask the dentist to suggest a fluoride rinse to prevent cavities, visit the dentist more often than usual for tooth and gum hygiene
• Constipation: Drink at least six 8-ounce glasses of water every day, eat bran cereals, eat salads twice a day, exercise daily (walk for at least 30 minutes a day), ask your doctor about taking a bulk producing agent such as Metamucil, also ask about taking a stool softener such as Colace, be sure to avoid laxatives such as Ex-Lax.
• Bladder problems: The effects of some antidepressants, especially the tricyclic medications may make it difficult for you to start the stream of urine. There may be some hesitation between the time you try to urinate and the time your urine starts to flow. If it takes you over 5-minutes to start the stream, call your doctor.
• Blurred vision: The tricyclic antidepressants may make it difficult for you to read. Distant vision is usually unaffected. If reading is important to you the effects of the antidepressant can be compensated for by a change in glasses. As you may compensate for the change in your vision, try to postpone getting new glasses as long as possible.
• Dizziness: Dizziness when getting out of bed or when standing up from a chair, or when climbing stairs may be a problem when taking tricyclic antidepressants and monoamine oxidase inhibitors. Changing posture slowly may help prevent this kind of dizziness. Drinking adequate amounts of liquid and eating enough salt each day is important. Be sure to speak to your doctor if this side-effect is severe.
• Drowsiness: This side effect often passes as you get used to taking the antidepressant that has been prescribed for you. Ask your doctor if it is safe for you to increase your intake of caffeine, and if so, by how much. If you are drowsy be sure not to drive or operate dangerous machinery.

Q. Many antidepressants seem to have sexual side effects. Can anything be done about those side-effects?
Both lowered sexual desire and difficulties having an orgasm, in both men and women, are particularly a problem with the selective serotonin re-uptake inhibitors (Prozac, Zoloft, Paxil and Luvox), and the monoamine oxidase inhibitors (Nardil and Parnate). There is no treatment for decreased sexual interest except lowering the dose or switching to a drug that does not have sexual side effects such as bupropion (Wellbutrin). Difficulty having orgasms may be treated by a number of medications. Among those medications are: Periactin, Urecholine, and Symmetrel. None of these are over-the-counter drugs and they must be prescribed by a physician. Unfortunately, many psychiatrists are not familiar with using these medications to treat the sexual side-effects of antidepressants.

Q. What should I do if my antidepressant does not work?
Many people decide that their antidepressant is not working prematurely. When one starts an antidepressant the hope is for rapid relief from depression. What must be remembered is that for an antidepressant to work, you must be on an adequate dose of the drug for an adequate length of time. A fair trial of any antidepressant is at least two months. Prior to a two month trial the only reason to abandon an antidepressant trial is if the medication is causing severe side effects. With many antidepressants the dose has to be increased at intervals far above the starting dose. Unfortunately, the two-month period mentioned above, refers to two months following the most recent increase in the dose, not the time from starting the particular antidepressant.

Q. Can someone build up tolerance to Prozac or other anti-depressants so that they stop working after a while?
Tolerance to Prozac and the other SSRIs is a relatively rare phenomenon. What looks like tolerance may develop because the SSRIs also have effects on the dopamine systems of the brain, and these effects can slow one down dramatically.

When an SSRI sems not to be working as well as it once did, it often can be helped to work once again by adding small doses of a dopaminergic agonist such as dextrroamphetamine, Ritalin, or bromocriptene. Also, certainly with Proxzac, and possibly with other SSRIs, too much of the drug is as ineffective as too little. If raising the dose does not help, an certainly if it makes things worse, a lowering of the dose may do much to bring back a response.

I am convinced that many patients respond best is they are treated with one of the SSRIs + a tricyclic antidepressant such as desipramine (Norpramin), or nortriptyline (Aventyl). Such combinations are often effective when an SSRI by itself fails to do the job.

Q. If an antidepressant has produced a partial response, but has not fully eliminated depression, what can be done about it?
There are many techniques to help an antidepressant work more completely. The simplest is to increase the dose until relief is experienced or side- effects are severe. If the dose can not be increased, lithium can be added to any antidepressant to augment its effect. With all antidepressants it is possible to add small doses of stimulants such as pemoline (Cylert), methylphenidate (Ritalin), or dextroamphetamine (Dexedrine) to augment the antidepressant effect. Selective serotonin re-uptake inhibitors often work better when small doses of desipramine (Norpramin) or nortriptyline (Aventyl and Pamelor) are co-administered. Thyroid hormones (Synthroid or Cytomel) may be used to augment any antidepressant. At times combinations of these techniques may be utilized.

Prozac

Q. What about the rumors and studies that Prozac causes suicide and/or acts of violence?
A link between Prozac and violence has not been proven.

Prozac is an anti-depressant known to cause problems such as nervousness, tremor, seizures, nausea and headaches, but it has not been shown to be a direct cause of violent acts, including suicide. People taking Prozac or other anti-depressants may experience personality changes for a range of reasons: The stress of waiting for improvement may worsen their mental state or the anti-depressant may produce symptoms of a different, undiagnosed mental illness. Finally, depressed people often abuse drugs and alcohol.

Common Depression and the Drug
An estimated 20 million Americans experience depression at some time in their lives, although most are never diagnosed. Depression is a serious disorder and considered life-threatening. Nearly 80 percent of all depressed people contemplate suicide, and 20 percent to 40 percent of those attempt it.

Over the past 25 years, anti-depressant drugs have been the dominant treatment for depression. Most anti-depressants are descendants of and improvements on one of the very first mood-controlling drugs, imipramine. The newer types of anti-depressants are called selective serotonin reuptake inhibitors, or SSRIs, which have the positive qualities of imipramine but try to remove or reduce some of its negative aspects, such as abnormal heart rhythms. SSRIs include serraline, paroxetine, fluvoxamine and fluoxetine, known by its brand name of Prozac.

About the Drug
Manufactured by Eli Lilly and Co., Prozac was first introduced in 1986 and is the most widely used anti-depressant. More than 10 million people have been prescribed it. Studies show it is as effective as other anti-depressants, but it has fewer side effects.

According to several studies, the side effects of Prozac can include nervousness, tremor, jitteriness, nausea, insomnia, headache, fatigue, mania or manic symptoms, dizziness and, rarely, seizures.

Reports about Prozac
Over the past several years, there have been numerous reports of violent acts and suicide by Prozac users. Although medical journals have numerous reports of such acts, medical studies have not found evidence that Prozac causes violence or suicide.

A recent study of 3,065 depression patients taking Prozac by Gary Tollefson, a researcher at Eli Lilly, supported other researchers' studies in finding that there was no increased risk of suicide. The study was published in the June issue of the Journal of Clinical Psychopharmacology.

In Tollefson's study, about 2 percent had suicidal ideas and 0.2 percent of the patients attempted suicide.

''Suicide is so common in a population suffering from depression that you can't necessarily blame the drug. As an analogy, if a migraine sufferer is given medication and then has a headache, do you blame the medication? The situation is similar with depression,'' said Susan Sonne, a researcher in the department of psychiatry at the Medical University of South Carolina, Charleston, in an interview.

However, people taking Prozac or anti-depressants may experience personality changes for a range of reasons, experts say:

• Most depressed people do not seek help until their problem is serious and often desperate. When placed on anti-depressants, including Prozac, the side effects of the medicine start immediately but the therapeutic benefits may take four to 12 weeks. During the first few weeks, a patient may become more distressed and panicked that the drug hasn't made significant changes, and as a result may act even more irrationally.

• There may be too little or no therapeutic effect from the medication. The drug may reduce the symptoms by 50 percent, which is considered a therapeutic level, but the effects experienced by the patient are not enough. Or the drug may have no therapeutic effect at all, which occurs in about 30 percent of patients. The drug dosage may also be too low and thus ineffective. Experts believe this can panic the patient and make the depression much worse.
  
  These situations may also trigger new or increased alcohol consumption ''A depressed person who isn't responding to medication may resort to self-medication with alcohol,'' said Dr. Alexander Morton, professor of psychiatry and behavioral sciences, also at Medical University of South Carolina, in an interview. Alcohol and drug abuse occurs in more than half of those with depression.

• The patient may be receiving treatment for depression, but actually has an underlying, undiagnosed bipolar disorder, such as manic-depressive disorder. Research shows that an anti-depressant can somehow trigger a switch from depression to a manic state. Symptoms typical of mania include euphoria, high energy level with poor judgment, risk-taking, delusions of grandeur and a need for excitement.
  
  ''Since a patient suffering from depression may be very compromised and, by virtue of their condition, incapable of helping themselves, it is important for family and friends to intervene when strange behavior is seen. For instance . . . after one uncharacteristic DUI I would intervene, find an alcohol or drug treatment program and try to receive a full evaluation of the situation,'' Morton said.

Electroconvulsive Therapy

Q. What is electroconvulsive therapy (ECT) and when is it used?
ECT is an effective form of treatment for people with depressions and other mood disorders. ECT may be used when a severely depressed patient has not responded to antidepressants, is unable to tolerate the side effects of antidepressants, or must improve rapidly. Some depressed people simply do not respond to antidepressants or mood controlling drugs, and ECT is a way for such people to be effectively treated. ECT is utilized in the treatment of both mania and depression. There are some people who because of severe physical illness are unable to tolerate the side-effects of the medications used to treat mood disorders. Many of these people can be successfully be treated with ECT. Pregnant women and people who have recently had heart attacks can be safely treated with ECT. Because of time pressure regarding occupational, social, or family events, some people do not have the time to wait for antidepressants or mood regulating medications to become effective. As ECT quite regularly brings about improvement within two or three weeks, people who are under such time pressure are also excellent candidates for ECT.

Q. Exactly what happens when someone gets ECT?
The physician must fully explain the benefits and dangers of ECT, and the patient give consent, before ECT can be administered. The patient should be encouraged to ask questions about the procedure and should be told that consent for treatments can be withdrawn at any time, and in the event that this happens, the treatments will be stopped. After giving consent, the patient undergoes a complete physical examination, including a chest x-ray, electrocardiogram, and blood and urine tests. A series of ECTs usually consists of six to twelve treatments. Treatments can be administered to either in-patients or out-patients. Nothing should be taken by mouth for 8-hours prior to a treatment. An intravenous drip is started and through it medications to induce sleep, relax the muscles of the body, and reduce saliva are given. Once these medications are fully effective, an electrical stimulus is administered through electrodes to the head. The electrical stimulus produces brain wave (EEG) changes that are characteristic of a grand mal seizure. It is believed that this seizure activity leads to the clinical improvement seen after a series of ECT. About 30-minutes after the treatment the patient awakens from sleep. While confused at first, the patient is soon oriented enough to eat breakfast, and return home if the treatments are being done in an outpatient setting.

Q. How do individuals who have had ECT feel about having had the treatments?
In studies of people treated with ECT it has been found that 80% of such people report that they were helped by the treatments. About 75% say that ECT is no more frightening than going to the dentist.

Q. How long do the beneficial effects of ECT last?
While ECT is a highly successful way of helping people come out of depressions, it has to be followed by antidepressant therapy. If antidepressants are not administered after a series of ECTs, there is a 50% relapse rate within 6-months.

Q. Is it true that ECT causes brain damage?
There is no scientific evidence that ECT causes brain damage. A woman who had over 1,000 ECT died of natural causes, and her brain was examined for evidence of ECT-induced brain damage. None was found. ECT does cause memory problems. These memory problems may take a number of months to clear. A small number of people who have received ECT complain of longer lasting memory problems. Such problems do not show up on psychological tests, it is not clear what causes them.

Q. Why is there so much controversy about ECT?
There is little controversy about ECT among psychiatrists. Much of the opposition to ECT seems political in nature and originates in the anti-psychiatry groups that oppose the use of Ritalin for the treatment of children with attention deficit disorder, and who oppose the use of Prozac for the treatment of depressed people.

Q. May I drink alcohol while taking antidepressants?
There are a number of problems with the mixture of alcohol and antidepressants. First, antidepressants may make you especially susceptible to the intoxicating effects of alcohol. Second, if you drink more than three or four drinks a week, the effects of alcohol may prevent the antidepressants from working. Many people who seem not to benefit from antidepressants, do so, if they reduce or eliminate their intake of alcohol. Third, you may be taking along with the antidepressant a drug such as clonazepan (Klonopin) with which one should not drink at all.

Q. If I plan to drink alcohol while on medication, what precautions should I take?
There is much misinformation about drinking while on anti- depressants. Alcohol can prevent antidepressants from being effective. This is not so much because it interferes with the absorption of antidepressants, it is because of the effects of alcohol upon brain chemistry. Antidepressants can also increase one's susceptibility to the intoxicating effects of alcohol. Also, both alcohol and some anti- depressants (especially Wellbutrin) increase the possibility of seizures.

If you are determined to drink despite taking antidepressants you should discuss the matter with your psychiatrist. If you get permission you might want to determine the extent to which the medication has made you more sensitive to the alcohol. You might start by seeing what are the effects of half a glass of wine. You might then experiment with a full glass. Remember, a 4 oz glass of wine, a 12 oz bottle of beer, and 1 oz of "hard stuff" all contain the same amount of alcohol.

Q. What's the relationship between depression and recovery from substance abuse?
It is not unusual for people who have recently been withdrawn from alcohol, or other abusable drugs to become depressed. These depressions are often self-limited, and clear in about 8-weeks. If depression has not cleared by the end of that period, anti-depressant therapy should be started.

Q. What does the term "dual-diagnosis" mean?
Dual-diagnosis is a phrase used to indicate the combination of substance abuse and a psychiatric disorder. A path to alcohol or other substance abuse is an attempt to self- medicate uncomfortable symptoms such as depression, anxiety, agitation or feelings of emptiness. The psychiatric disorders that cause such symptoms are often diagnosed in substance abusers.

Q. Is it safe for a person recovering from substance abuse to take drugs?
People recovering from substance abuse can safely take many kinds of psychiatric drugs. Most psychiatric drugs are unable to be abused. The best evidence for this is that there are not street markets for such drugs. On the other hand, The benzodiazepines (diazepam [Valium], lorazepam [Ativan], alprazolam [Xanax], etc.) and the psycho-stimulants (dextroamphetamine [Dexedrine], methamphetamine [Desoxyn], and Ritalin [methylphenidate]) are quite abusable.

For people active in AA please read the pamphlet "The AA Member--Medications & Other Drugs." This outlines AA's official attitude toward medication--that it is necessary for certain illnesses including depression. Too many depressed people who have been talked out of taking antidepressants by members of their AA groups have killed themselves as a result.

Q. How do you know when depression is severe enough that help should be sought?
Professional help is needed when symptoms of depression arise without a clear precipitating cause, when emotional reactions are out of proportion to life events, and especially when symptoms interfere with day-to-day functioning.. Professional help should definitely be sought if a person is experiencing suicidal thoughts.