Using antidepressants in CFS
From DoctorMyhill
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Depression is not a primary part of CFS. Indeed I impressed by how well adjusted psychologically many of my CFSs are! However any chronic diease carries a risk of depression simply because sufferers lose hope of having a future. This is often made worse by doctors who do not look for underlying physical problems, recommend treatments likely to make the sufferer worse — see Graded exercise and cognitive behaviour therapy (CBT) — and when they are worsened, are then told they will have to "Live with it". That would certainly depress me! I would also be depressed by the lack of interest, curiosity and desire to help from my physician!
It is also important to realise that depression is a symptom which may have many causes. Obvious overlooked causes include food allergy (especially where these is also headache and irritable bowel. See PIMS - a pattern of symptoms associated with food allergy), poor sleep and diagnosis of hypothyroidism.
Antidepressants
I nearly always use anticholinergic drugs such as amitriptyline. I often find low doses of anticholinergics such as amitriptyline or dothiepin helpful, particularly in CFSs who have been poisoned by organophosphates. Anticholinergics do not just help mood, they also improve sleep and can be effective pain relievers - it is possible that this is part of the mechanism by which these drugs help mood! They may also be helpful in anxiety and hyperventilation.
The key to using antidepressants is to start with small doses. CFSs commonly do not tolerate higher doses. This intolerance is very common, like alcohol intolerance is common in CFS, and may well be symptomatic of the CFSs' inability to cope with toxic stress. See Drugs in the treatment of CFS - always start with tiny doses.
Anticholinergics for sleep
Almost always I use anticholinergics at night to help sleep, starting with 10mgs and increasing to 25mgs. Not many tolerate a higher dose, but up to 75mgs at night can be used. Amitriptyline has a liong track record of safety and I am happy to prescribe this long term.
The most sedating anti-depressant is trimipramine (Surmontil), dose range 10-75mgs and is the best anticholinergic where there is sleep distubance.
Dothiepin (Prothiaden) is similar but has increased risk of cardiovascular side effects - so I never now use this.
SSRIs - specific serotonin reuptake inhibitors
I have not been impressed by the 5HT reuptake inhibitors like fluoxetine (Prozac) or sertraline (Lustral). They are non-sedating and possibly mildly stimulant - therefore not indicated in CFSs (they increase the desire, add nothing to the performance thereby increasing the frustration and anger). There is now increasing doubt they are effective in treating depression. Again, if prescribed they need to be started in very small doses. When the drugs is started, it needs to be monitored very closely because some people will suddenly feel the urgnet need to commit suicide. All recipients and their famillies should be warned of this by the prescribing doctor. The list of side-effects in also distresses me.
Contrary to what doctors are told, SSRIs are addictive and I have seen many patients really struggle to get off them.
St John's Wort (hypericum perforatum)
This has proven antidepressant properties and is well worth trying. However, I have had two patients who have been made much worse when they took the full dose, so be careful - start on 300mgs daily and build up slowly to 900mgs daily.
Other antidepressants
Monoamine oxidase inhibitors - I have never prescribed these! Like SSRIs I would expect them to increase the desire to do things but do nothing for the performance and therefore increase the frustration factor. They have a shopping list of side effects and have to be used with great caution becaus of so many food and drug interactions.
See also Natural preparations and prescription drugs to help sleep in this section.
Related Tests
Related Articles
Extrenal links
"Treating Psychiatric Illness in Patients With Mitochondrial Disorders" a letter from a group of medical practitioners to Psychosomatics, The Journal of Consultation and Liaison Psychiatry and Official Journal of the Academy of Psychosomatic Medicine about dangers of using antidepressants in patients with mitochondrial disorders. Psychosomatics 51:179, March-April 2010
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