Do the Drugs Work?

It takes us a while to get past the idea that taking drugs somehow makes us weak, or less than in proper control of our lives. But eventually we reluctantly start to take them, and not unreasonably, we expect that the drugs will make us better.

Wrong.

Well, they do make us better. Sort of.

Here's the problem. We expect that the mood stabilising drugs will be a bit like aspirin. You know - you get a headache and you take aspirin and the headache goes away. In fact you can pretty much assume that if you take aspirin then the headache will go away. However, mood stabilising drugs aren't like aspirin. You can't make the assumption that they will work.

Here are some of the possibilities if you are depressed and take an antidepressant to pull you out of your depression. The antidepressant

may not work and you stay depressed

may swing your mood from being depressed to being manic

may make you less depressed than you were but still leave you depressed

may work quite well to make you feel normal (whatever that is) without being manic...but then you become resistant to the antidepressant and you slide back into depression.

may even work as advertised and bring you out of depression into feeling good without being manic. Maybe.

So unlike aspirin, which you can pretty much assume will make your headache go away, with an antidepressant you have one of at least five outcomes, only one of which is really useful.

To complicate matters, your natural mood swings are happily trying to cycle from depression to mania and back. If you start taking an antidepressant at just the time when you would have cycled out of depression naturally, it may appear as if the antidepressant is working. You may not realise that it is not working (or not working well) until the time your next depression cycle begins.

With me so far?

Now imagine this scenario. A clinical trial of a drug is done in which half the persons take the drug and half take a placebo. Of the people taking the placebo, ten percent report that they feel better. Of the people taking the drug, seventy percent of the people report they feel better. Well, clearly the drug is doing something good. The mathematics can be done to show that the results aren't a fluke (i.e. they are statistically significant).

So technically, what we have is a drug that works substantially better in relieving the symptoms of depression compared to not taking anything. These results may be good enough for the drug to be marketed as an antidepressant. But what the results also show is that nearly one third of the people taking the drug did not feel better.

What it means is that if you are depressed and you are one of the seventy percent of the people for whom the drug worked, then you would probably find that you do feel better. But given the odds above, there is about a one in three chance that you would not feel better.

I don't have any axes to grind with pharmaceutical companies. And I do think that a drug that helps the majority of the people should be made available to the public. However, in addition to the usual information concerning drug dosage and warnings, I would like included the information as to what percentage of the people are helped by the drug.

Still with me so far? Because it gets worse.

Being manic depressive affects our moods and thought patterns. But anything which changes our moods and our way of thinking causes problems because it is going to feel as if some part of our character or our self is being changed or disrupted. This is partly why mood swings cause so much confusion - our character is not supposed to change over the course of three days.

But if you think about it, the whole point of taking an antidepressant is to change our moods and thought patterns from something that is useless to us to something that is useful. And the faster the better. The problem is that an antidepressant which changes our moods is going to cause the same confusion as if our moods had changed on their own. Worse yet, the faster the change, the more difficult it is for us keep up and accommodate the changes.

Should I mention that as our moods shift and we struggle to cope, our entire set of daily routines and our interactions with other people go haywire. Taking an antidepressant can be destabilising in its own right.

To summarise so far. We don't know if an antidepressant will work at all. If it does work, we don't know if it will work as advertised and it can take a while before we can determine if it does. And to confuse matters more, if it does work, the one of the first effects may be to make things worse (or at least more confusing) as our moods suddenly shift and restabilise at some other point.

The pattern I have found in changing medications is this. I stop taking my current medication and within two to four days my moods begin to swing and I destabilise. It generally takes at least two to three weeks for me to get back stable enough to actually start taking the new medication. And when I start taking the new medication, I usually destabilise again and I lose another two to three weeks as I learn to cope with my new mood pattern. And at that point, I have to learn how the new medication affects me and to fine tune it, which may take another few weeks. Then I have to see if it actually works as my moods cycle up and down.

So at minimum, each change in medication costs me about one and a half to two months of my life. Assuming things go well, that is. If things don't work as they should, I can remain unstable and fairly nonfunctional for as much as six months. As a result, although I was willing to switch medications when they were clearly not working for me, once I found a drug that worked reasonably well to stabilise me I stuck with it.

Reasonably well, by the way, does not mean that I stop having mood swings. It means that my depression episodes have become mild enough that instead of becoming nonfunctional for a week, I am nonfunctional only one or two days. And the anxiety when depressed is milder overall. It ain't great, but it is acceptable. There may well be drugs that work better for me, but I am not willing to chance losing two to six months of my life for each one I try. I've lost enough of my life as it is.

So what's the point of taking drugs at all?

Well, my personal experience is that nothing I have done for the last six years has been able to make a dent on my depression cycles. Except drugs. So I do need them for that.

In addition, when I was first learning to cope with being hypomanic, having drugs that stopped me from being manic made it possible for me to compare what manic was like to what normal is like. And once I knew what the differences were, I was then able to monitor for signs of mania and take action to stop it from getting worse (check under Ideas for Coping). I took antimanic drugs for about four years, but I don't generally need them anymore.

I've been talking about antidepressants, but the same pattern holds true for antimanic drugs as well. The differences that I have found are:

Antimanic drugs tend to work faster - you see a noticeable effect fairly quickly, within hours or a few days. What it means is that you can determine fairly quickly if the antimanic drug is working or not.

It is easier to go from manic to less manic than it is to go from depressed to less depressed. There is less confusion associated with the mood change. However, compared to mania, normal is boring. You may not want to keep taking antimanic drugs because you find they are slowing you down.

Antimanic drugs can swing your mood from mania to depression. It has happened to me and although the depression was very mild, it was very disorienting - I didn't know if my lethargy was due to the loss of manic energy, or if being normal was just so slow and tedious. It took me quite a long time to realise that I was slightly depressed (check under How I Felt on Epilim).

So. When you start taking a drug, do NOT expect that it will simply work and life will settle into normalcy. The chances are it won't. You will need to monitor yourself to see how exactly the drug is affecting you - keeping a diary from when you start taking it is a fairly good idea. Warn the people around you that the drug may make your ability to cope worse for a week or two. If it does seem to be working, warn people to give you about a month to see if the drug really is working or if you are becoming resistant to it.

If it doesn't seem to be working, and you should be able to tell by the end of the third week, adjust the dosage or ask your doctor to prescribe a new drug (check under Dealing With Your Doctors). If you do change drugs, warn the people around you that you will not be fully functional for a month or two as you come off the old drug and the new one starts to take effect.

Oh, it is also normal to start taking a drug and then miss taking it occasionally or stop taking it for a few days. This usually happens because of the confusion involved in starting a new drug - regular schedules go out of whack. It is also more likely to happen if you are depressed since with depression it is difficult to do anything at all. It is not unusual to start and stop taking a drug a few times before you get enough information to tell if it works or not. It helps to tell someone that it is their job to make sure you take your medication on time.

You will go through the cycle of "wow, this drug is really working" to "well, perhaps not as well as I thought." In some cases, you will continue into the "darn, I'm getting resistant to the drug" stage. Or none of that might happen and you may reach the "nothing is happening, am I doing this right" stage. Eventually, you will reach the point of "this is working well enough." But before you reach that point, you will often feel that this is just too much of a nuisance and you'll be at least as well off not taking any drugs and doing, say, rhythmic breathing.

Persevere.

And finally, when you start taking medication, someone, usually your spouse or parents or siblings, will say something to the effect of "why aren't you better, aren't you taking drugs for this." When this happens, hand them a copy of this page. Or smack them. Or, preferably, both.

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