— G.R., Arkansas Depression is associated with an increase in the amount and intensity of rapid eye movement (REM) sleep, which is the physiological state in which most dreams occur. There is some tendency for depressed people to experience more-distressing dreams than people who are not depressed; these usually reflect themes that are consistent with the worries and difficulties that accompany the depressive state. Although most depressed people do not report experiencing recurring nightmares or bad dreams, what you’re describing does not sound out of the ordinary; a sense of entrapment and powerlessness to solve problems is very common in depression. The answer to your question about whether your medication is causing or intensifying your recurrent dream can be partly found in your history. If the recurring dreams began after you started taking the medication, it is more likely that your medication is playing some role. Most, although not all, antidepressants reduce the amount of REM sleep you get every night and tend to “push” dream sleep into the latter part of a night’s sleep. Because we typically remember best our last dream (that is, the one that we experience closest to awakening), a medication that concentrates dream sleep at the end of the night can be associated with bad dreams or nightmares. Because you’re having these distressing dreams, it may be worthwhile to talk with your doctor about possible alternate medications. Although abnormal dreams have been reported as side effects of virtually all antidepressant medications, the ones that have less of a suppressing effect on REM sleep include bupropion (Wellbutrin, Zyban, Budeprion), Serzone (nefazodone), Desyrel (trazodone), Remeron (mirtazapine), and Surmontil (trimipramine). Aside from bupropion, these medications also have stronger effects than other antidepressants for treating insomnia. Over the years I have seen some people who report that marijuana helps to improve their feelings of depression and anxiety. The same is true for others who report finding comfort in alcohol and narcotics. These “home remedies” may have short-term benefits by lifting anxiety or hastening sleep. They may also transiently relieve some aspects of depression by stimulating a final common pathway involving pleasure centers in the brain. However, none of these drugs have proven anti-depressant effects, and regular use poses the real risk of dependence and other medical complications. Although I’m not an expert in California law, I also believe that this is not one of the approved medical uses of marijuana there, which poses the additional possibility of legal problems. Generally, drugs that have the potential to be habit-forming are not used as first- or even second-line treatments for depression, although the various neurotransmitter systems that they work through are now being explored in hopes of identifying new pathways for medications that will not be habit-forming. Q3. I was diagnosed with severe depression seven years ago. My doctor told me I needed to be on medication for one year. After the year, I decided to go off my medication, but my doctor wanted me to stay on it longer. He told me that if I stopped taking it and had another episode, I would have to stay on medication for life. Is this true? — Sally, Florida Depending on your age, “for life” could mean 80 or more years, and who really knows what our futures hold in this regard? The current standard of practice is to recommend ongoing antidepressant medication to prevent relapse or recurrence after the third lifetime episode of depression or when a person has had two episodes of depression within a five-year span. On occasion, such as when the depression was very severe or included a suicide attempt, such maintenance treatment is recommended after only one episode. In my practice, I prefer the term “indefinite” to “lifetime” and explain that this is a decision that the patient and I should review yearly. Q4. My brother is suffering from severe depression and is afraid taking medication will cost him his job. He is a long-haul truck driver and losing his business. He wants to work for someone else driving a bus or truck, but they won’t hire him if he is on psychiatric meds. He has no college and no other experience other than driving and just turned 53 years old. What are your thoughts for someone in his position? Certain medications have drowsiness as a side effect and can impair a person’s ability to stay alert. This, understandably, could raise both safety and liability concerns for a potential employer. But some antidepressants have no sedating effects whatsoever. Also, there are other treatment options that may be effective without the use of medications, such as cognitive-behavioral or interpersonal psychotherapy. One option may be to get started with psychotherapy and delay the decision to begin antidepressants until after being hired. If psychotherapy alone is not effective, your brother can talk with his doctor about trying an antidepressant that does not have daytime sedation as a side effect. Without appropriate treatment, his depression itself could impair his ability to work, so it is probably best for him to seek appropriate treatment and work with his doctor to ensure the treatment doesn’t affect his employability. Q5. My 89-year-old father just lost his wife (my stepmom) after 45 years of marriage. She died in a bed next to him in a nursing home, where he was recovering from brain surgery. She died of an overdose of medications that had been badly prescribed by their doctor. Now he won’t take his medications (aspirin and hydrochlorothiazide) because he’s afraid of the combination of the two. He’s being irrational about this, and I believe he is depressed (and understandably so). Could depression lead him to not take his medication? — Jane, California Depression is associated with lack of adherence to medication regimens, but so too are anger directed at one’s doctor and altered mental states following brain surgery. Although I don’t know enough about your father’s condition or the circumstances of your stepmother’s death to be of great help here, this sounds like a very sad situation, and I encourage you to talk with your father about his feelings of grief and possibly anger about your stepmother’s death. You will also want to make sure he lets his doctor know he’s fearful about his medications, and you should be with your father when he talks to the doctor.
