Using antidepressants in CFS
Depression is not a primary part of CFS. Indeed I am impressed by how well psychologically adjusted many of my CFSs are! However, any chronic disease 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 the patients are worsened, they 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! This situation is often worsened by the fact that some physicians blame the patient for not engaging properly in the Graded Exercise Programme or CBT and then go on to explain that this is the reason why it hasn't worked! Effectively they wash their hands and say that it is all the patient's fault!
It is also important to realise that depression is a symptom which may have many causes. Obvious overlooked causes include food allergy (especially where there is also headache and irritable bowel), poor sleep and diagnosis of hypothyroidism.
I nearly always use anticholinergic drugs such as amitriptyline. I often find low doses of anticholinergics such as amitriptyline 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 (often very) small doses. CFSs commonly do not tolerate higher doses. This intolerance is very common, like alcohol intolerance is common in CFS, (see Alcohol intolerance in CFS - gives us a clue as to the mechanisms of fatigue) 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 long 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 disturbance.
Dothiepin (Prothiaden) is similar but has increased risk of cardiovascular side effects - so I never now use this.
SSRIs - specific serotonin re-uptake inhibitors
I have not been impressed by the 5HT re-uptake inhibitors like fluoxetine (Prozac) or sertraline (Lustral). They are non-sedating and possibly mildly stimulant and therefore are not indicated in CFS (they increase the desire, add nothing to the performance and thereby increase the frustration and anger). There is now increasing doubt that they are effective in treating depression. Again, if prescribed, they need to be started in very small doses. When the drug is started, it needs to be monitored very closely because some people will suddenly feel the urgent need to commit suicide. All recipients and their families should be warned of this by the prescribing doctor. The list of side-effects 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.
Monoamine oxidase inhibitors - I have never prescribed these! As with 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 because of so many food and drug interactions.
"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. This article is, sadly, no longer free access.
Sarah Myhill Limited :: Registered in England and Wales :: Registration No. 4545198
Registered Office: Upper Weston, Llangunllo, Knighton, Powys, Wales LD7 1SL, UK. Tel 01547 550331 | Fax 01547 550339