When is hospitalization necessary? What does it offer?

Hospitalization is the highest level of treatment. It is reserved for the most severe forms of depression (as well as other mental disorders). One criterion used for determining the necessity of hospitalization is the presence of suicidality. Having suicidal ideation does not automatically dictate a hospital stay but prompts an inquiry into the patient's level of risk to harm oneself (or others). Hospitalization may also be indicated if a person's functional impairment is so poor that he or she is unable to care adequately for himself or herself (e.g., unable to get out of bed and not eating). Most often, depressed individuals are willing to be hospitalized if recommended and thus do so voluntarily. Situations exist, however, when the physician believes hospitalization is necessary but the patient refuses. The physician then needs to decide whether the person should be admitted involuntarily. Criteria for involuntary admission vary from state to state, but it is generally not easy to admit someone against his or her will. Most states have mental hygiene laws in place to protect patient's rights. Typically, dangerousness to self or others is the criterion required to commit someone. Usually, an appeal process is available to such a patient as well (see Question 89).

Can I drink wine with my antidepressant?

Generally speaking, because alcohol is a depressant, it is not advisable to drink alcohol of any kind when one is suffering from depression. With that being said, not everyone is on antidepressant medication for depression, and therefore this advice may not pertain to you. However, many psychiatric illnesses have overlapping symptoms, particularly anxiety and depression. Just because your doctor may have prescribed the medication for anxiety rather than depression, the risk for depression is still higher than the general population, and thus the need to abstain from alcohol remains good advice. Alcohol can also worsen anxiety and can lead to dependence[1] in people suffering from anxiety because of its inherent antianxiety effects, causing some people to self-medicate with it.

Is there any interaction between alcohol and antidepressants that could be dangerous if you still choose to drink alcohol? With some antidepressant medications such as MAOIs, the risk is serious, because the interaction with some forms of alcohol, particularly red wines, can lead to malignant hypertension[2], which is potentially life threatening. With TCAs the risks are due to their sedative effects, which are additive to alcohol, and thus causing intoxication and its incumbent risks more readily. Finally, with the newer SSRIs the additive effects are much less noticeable, because these medications are not found to be sedating or affecting cognition and motor coordination adversely. It is best to be cautious if having wine or other alcohol in monitoring its effect on your mental status while on an antidepressant.

Are there long-term dangers to taking medication?

With the recent press regarding the alleged link between antidepressant medications and suicide (see Question 78), a fear has been that antidepressant medications are a form of mind control that can have permanent long-term effects on one's personality and one's mind. Such ideas are categorically false. The TCAs have been around for the longest period of time, approximately 50 years, and have never been associated with long-term dangers. The newer class of medications known as SSRIs has been around only since the introduction of Prozac in the late 1980s. Numerous studies have attempted to link them to long-term dangers such as cancer or other medical conditions aside from their psychologic effects. None of these studies has yet held up to any scrutiny. All studies linking SSRIs to suicidal behavior analyze data at the beginning of treatment and most likely represent an unidentified side effect that can be associated with suicidal behavior. Such side effects could be increasing anxiety and insomnia or an extrapyramidal[3] side effect that causes patients to become uncomfortably restless (akathisia[4]). Another factor that may be involved is the improvement in energy levels that often occurs before an improvement in mood, which may result in increased motivation and energy to act on suicidal desires. This is why close monitoring during the initial phase of treatment with these medications is imperative.

It is best to be cautious if having wine or other alcohol in monitoring its effect on your mental status while on an antidepressant.

Although there are no documented long-term adverse effects from antidepressants, your doctor may want to monitor functioning of some organ systems with periodic blood work. The liver breaks down antidepressants, and thus some people can rarely develop a mild impairment in liver functioning. In general, however, antidepressants as a group are not associated with long-term dangers.

Other medications may be used concurrently with antidepressants, such as anticonvulsants and antipsychotics, that do have potential long-term effects on the liver or the kidney. In addition, antipsychotics have been associated with the development of a condition called tardive dyskinesia[5], which can be a permanent movement abnormality, usually of the mouth. This condition was much more common with older antipsychotic agents but can rarely occur with the newer agents. Your doctor should monitor closely for such effects and should only continue the antipsychotic for the minimum duration that is necessary. For example, in psychotic depression both an antidepressant and an antipsychotic are used in the treatment; however, the antipsychotic should be tapered and discontinued earlier than the antidepressant if possible.

  • [1] the body's reliance on a drug to function normally. Physical dependence results in withdrawal when the drug is stopped suddenly. Dependence should be contrasted to addiction.
  • [2] elevated blood pressure that is acute and rapidly progressive with severe symptoms, including headache.
  • [3] the parts of the brain responsible for static motor control. The basal ganglia are part of this system. Deficits in this system result in involuntary movement disorders. Antipsychotic medications affect these areas, leading to extrapyramidal side effects, which include muscle spasms (dystonias), tremors, shuffling gait, restlessness (akathisia), and tardive dyskinesias.
  • [4] a subjective sense of inner restlessness resulting in the need to keep moving. Objectively, restless movements or pacing may be signs of akathisia.
  • [5] a late-onsetinvoluntary movement disorder, often irreversible, typically of the mouth, tongue, or lips and less commonly of the limbs and trunk. These movements are a consequence of antipsychotic use but are less commonly observed with the newer atypical antipsychotics.
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