[Bluerose]

Question
Can you advise me on medication for depression? I have been taking St Johns Wort for 6 months now and its not helping enough. I am very wary of taking drugs because the side effects tend to make the symptoms of my menieres disease worse. The only medication I take is valium 2mg nearly every day, some days 5mg.I take it to settle the vestibular nerve and I know it is probably part of the reason for my depression but there is no way I can do without it, after 7 years of trying everything else they give you for menieres it is the only thing that works enough to be able to have a half normal life. So if you can suggest something that I can ask the doctor for I would be grateful, take into account that I am not in your country and drug names may differ. Thank you

[CamW]

Bluerose - The choice of an antidepressant these days is quite often based on the presenting symptoms of the depression.

As for Meniere's, dizziness can be a side effect of any and every class of antidepressants. Usually this is only a "start-up side effect" and will fade and disappear as your body adjusts to the drug. Antidepressants to avoid would be most of the older tricyclic antidepressants (TCAs; eg. amitriptyline [Elavilª], trimpramine [Surmontilª], doxepin [Sinequanª], etc.); probably the monoamine oxidase inhibitors because of their broad spectrum of activity (MAOIs, eg. phenelzine [Nardilª], tranylcypromine [Parnateª], and perhaps moclobemide [Manerixª]); mirtazapine (Remeronª) and some of the selective serotonin reuptake inhibitors (SSRIs, especially paroxetine [Paxil]).

All of these antidepressants significantly block muscarinic (M1) receptors; a type of acetylcholine receptors which is involved as a neurotrasmitter in the body's autonomic nervous system (ANS). The ANS is the part of the nervous system that controls involuntary bodily functions (eg. controls the diaphragm in breathing, the action of the kidneys, etc.).

When a drug blocks muscarinic receptors the most noticeable effects are drowsiness, dizziness, and also decreases anxiety to a certain extent. I am not sure that blocking M1-receptors will worsen the symptoms of Meniere's, or if this effect will disappear as the body adjusts to the M1 blocking. To tell the truth, I am not sure what the theories on what causes Meniere's disease are (I do not think that any true cause of the disease are known).

You may need to talk to someone who specializes in Meniere's (or inner ear problems) and find out which antidepressants are commonly used in these cases.

Aside from taking drugs to combat depressive symptoms, there are a number of psychological treatments available. These mainly being cognitive &/or behavioral techniques. The type of psychotherapy used would again be dictated by the symptoms of depression that are most prevalent and what the potential "cause" of the depression.

I have always said that antidepressants do not "cure" depression, but are only adjusting the concentrations of neurotransmitters in the brain to more "normal" ot "natural" levels. Antidepressants can increaase everyday functioning in a depressed person. In the end it is usually some sort of psychotherapy (or coming to an understanding of what caused &/or prolongs the depressive state) that "cures" one of depression.

Other potential treatments in your situation are electroconvulsive therapy (ECT or electroshock) or perhaps the newer transcranial magnetic stimulation (TMS). Today ECT is a much safer procedure than it was in the 1940s, 1950's, and even the 1960s. It is no longer the "One Flew Over The
Cuckoo's Nest" torture that resulted in brokens bones and burns. ECT is by far the most effective treatment for depression, especially treatment-resistant depression and is the recommended treatment in pregnant women and the old-old (person's over 75 years of age); especially those that do not respond to other, safer methods (eg. most SSRIs and psychotherapies).

The use of diazepam (Valiumª) in the lower dosages that you are taking, is not contraindicated in any of the antidepressants. A lowering of diazepam dose may be needed when using fluoxetine (Prozacª) or nefazodone (Serzoneª), as these drugs can inhibit the metabolism of diazepam (and certain other benzodiazepines: temazepam [Restorilª] and triazolam [Halcionª], for example.

I know that I haven't given any specific antidepressants that you could safely use, but I do not know enough about Meniere's disease to confidentally give you any examples. As I have said before, the choice of an effective antidepressant must also take into account the depressive symptoms that you are experiencing.

If no antidepressant is safe or useful in people with Meniere's there are also some other medications that may or may not help. Gabapentin (Neurontinª) and, probably, to a lesser extent because of a lack of scientific data, lamotrigine (Lamictalª) may be considered, especially of all else fail.

I hope that this is of some help. - Cam

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