Dr. Frederic

Flach, a psychiatrist and the author of "The Secret Strength of Depression,"

says that antidepressants can be very helpful in treating depression,

as long as they are used correctly.

It is true,

he says, that the number of people seeking medical help for depression

has increased significantly since the introduction of the newer antidepressants,

in particular the serotonin reuptake inhibitors that increase the levels

of the biogenic amine serotonin at the nerve junctions (where one nerve

speaks to another) in the central nervous system (the brain). Examples

of such drugs include paroxetine (Paxil), sertraline (Zoloft), and fluoxetine

(Prozac).

Some of the

other antidepressants, such as venlafaxine (Effexor), increase the amount

of norepinephrine while still others, such as bupropion (Wellbutrin),

raise the levels of dopamine. In contrast to earlier antidepressants,

like imipramine (Tofranil) or amytryptiline (Elavil), the side-effect

profile of these newer drugs is remarkably benign.

As a result,

most of the antidepressants are administered by primary care or family

physicians. That's fine, Dr. Flach feels, as long as the doctor is adequately

trained to recognize depression and use the drugs effectively, and as

long as he knows when not to use them, or when to combine them with psychotherapy

(talk therapy) or interpersonal adjustment therapy (husbands and wives

together). The doctor must also know when and where to refer patients

for these other kinds of treatment and remain in ongoing contact with

the therapist(s) throughout.

Rather than

dishing out antidepressants irresponsibly, the chances are that the primary

care physician is still using them too sparingly, or using them in isolation

and not within the framework of total treatment. "For many patients,

that may be enough," Dr. Flach said. "Given the right medications,

they can make the necessary personality and interpersonal changes on their

own initiative, 'with a little help from their friends.' Just as often,

however, they can't."

"Moreover,"

he added, "managed care seriously limits the amount of time primary

care physicians can spend with patients, making it harder for them to

arrive at an accurate diagnosis, much less to provide the supportive understanding

and empathy patients require."

The question

of whether the antidepressants really work is a more troublesome one.

In controlled studies involving large groups of depressed patients, some

receive the antidepressants while others receive a placebo (an inert substance

meant to look and taste like the real stuff). When the study is over,

the two groups are compared. If a statistically greater number of patients

receiving the drug show clinical improvement as compared with those who

received the placebo, one may conclude that the antidepressant works to

relieve depression. For practical purposes, it is enough to satisfy the

Food and Drug Administration and permit the pharmaceutical firms to market

it and doctors to use it.

"But in

any such study there are a number of patients who improve on placebo,"

Dr. Flach said. "There are also a number who do not improve on the

drug. We don't know why this is so, but we can speculate."

Even if all

patients look alike and register alike on psychological tests for depression,

it does not mean they are actually alike. Their basic conditions may be

quite different biologically. Or their personality characteristics, relationships,

and environmental considerations may be quite dissimilar as well.

In practice,

most knowledgeable psychiatrists can support the efficacy of the antidepressants.

They have given them often, and often they have seen patients who would

be unlikely to respond otherwise recover within the anticipated time frame

of 3 to 6 weeks.

"The real

issue here is that these drugs are misnamed. They probably shouldn't be

called antidepressants at all. I call them resilience-enhancing agents,"

Dr. Flach said. He envisions them restoring a biological equilibrium to

a disturbed nervous system, perhaps by increasing the amount of serotonin

at nerve junctions or more likely this effect is only the tip of a much

more complex mountain of biochemical mechanisms. This idea has meaning

far beyond the world of research, for it shapes how doctors and patients

regard the use of these medications.

"If I

tell depressed patients that the drug I am about to prescribe is a resilience-enhancing

one, meant to restore normal functioningnot unlike giving thyroid hormone

to someone whose thyroid gland is under-performing or insulin to a diabetictheir

acceptance level is enhanced; they are greatly comforted by the idea that

the antidepressant is not about to give them a false high, that it is

not habit forming or addicting, that they will likely not have to be on

it forever, and that, as they improve, their improvement will not merely

be the result of the drug, but very much a matter of their own efforts

as well," he concluded.

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