Antidepressants can be life-changing, but they are not without risk. These are some of the most commonly prescribed medications, and most of our patients who have issues with pain and the brain are either taking them now or have used them before. While a lot of research has been done to try and understand how they actually work, experts agree that we are still not sure. But they do work, at least sometimes.

Taking antidepressants

Serotonin is one of the key players in the symphony of brain chemistry. It is called a neurotransmitter because it is one of the messengers that neurons use to transmit signals to each other. For over half a century, doctors have tried to correct imbalances in these neurotransmitters to treat the brain. While it is not clear exactly how or why these imbalances occur, drugs that alter neurotransmitter levels are one way to deal with these problems.

An integrative medicine approach to treating the brain does include antidepressants. If they have not been tried, they should be. But they are not the only solution. There are many other ways to promote happiness and inner peace and deal with negative thoughts and emotions. Walking, cycling, yoga, tai chi, gardening, dance and other movement therapies are effective. Drinking more water, eating less sugar, trying a gluten-free diet, avoiding food additives can also help. Social interaction with friends and family, pets and loved ones is essential. Getting more sleep, more sunlight, and more quiet time is advised. Cognitive-behavioural therapy and other approaches to psychological counselling are very helpful for some patients. I have seen other techniques, including eye movements, tapping, ear and scalp acupuncture, achieve excellent results. And there are many natural health products that can be tried, one by one, preferably under the supervision of a doctor, naturopath or other trained healthcare provider.

When using antidepressants, a six-week trial is the most important thing to remember.  If a drug hasn’t made your mood or your life better after taking it regularly for six weeks, a change is needed.  This might mean a different dose, but it usually means a different drug.  This is how all prescribing should be done, but for various reasons, many patients end up taking drugs that don’t work for years.  If an antidepressant is working well, then it is important to consider the long-term side-effects when deciding how long to stay on the drug.

If you are struggling with depression, it is not wise to avoid antidepressants just because you are afraid of the risks.  These are generally very safe drugs, and while a dedicated integrative approach can make your brain better without drugs, this is not always possible to achieve.  Whether due to lack of time, money, will or knowledge, for many people antidepressants are a valid treatment option.  Some people need more than one drug to get results.

The risk of weight gain

There has been some evidence of weight gain with antidepressants, but this new study, one of the largest to date, makes this link stronger.  The  study involved nearly 300,000 patients in the UK who were followed for up to 10 years.  Those who took antidepressants were about 20% more likely to gain weight (5kg or more).  Men and women were affected equally, and so were all ages.  Thinner people gained more weight, and so did those taking other medications (antipyschotics and antiepileptics).  People of normal weight became overweight, and the overweight became obese.

This is clearly bad news.  While weight gain may not seem like a major side-effect, many of my patients are reluctant to take a drug that will make them gain weight.  They don’t like the way they feel, and this often means they don’t like the way they look.  It is not easy to convince my patients to take a drug that causes obesity.

Many people, including physicians, already have mixed feelings about antidepressants.  While early studies reported consistent positive results, a highly controversial review found that there are many negative antidepressant trials that never got published. This was one of the studies that has led to the creation of trial registries, to prevent drug companies from hiding the truth about their drugs by only publishing positive trials. Regardless, there is only one way to know if an antidepressant – or any other treatment, natural or pharmaceutical – will work for an individual patient. And that is to try it.

Not all antidepressants are the same.

This study change my practice in a few important ways. Of course, I will have to tell my patients about the risk of weight gain when prescribing these drugs. I will emphasize that while it is still necessary treatment, it means that they have to focus more on diet and exercise as part of their self-care plan. While this study might make some patients more willing to try non-drug treatment, some will still need medication.

When I do prescribe antidepressants, I will probably try paroxetine first. In this large UK study, this was the only SSRI that did not cause weight gain. Mirtazapine, also called remeron, was the worst offender. It is also important to mention that most of the weight gain occurred in the first year, and slowly tapered back down over 5-6 years.

This was an important study, which highlights the need for medicine to be as evidence-based as possible. But when it comes to selecting the right drug for an individual patient, doctors agree that it is more art than science, and every person is different. This is why careful history taking and a solid doctor-patient relationship are an important part of every prescription.