When Will My Meds Start Working?

Part 1— Antidepressants

Being a fan of medical and mental health research hasn’t prevented me from realizing that there are times when conclusions from studies constrain or even mislead clinical practice. One of those areas involves the timing of the onset of action of psychoactive medications. Patients often ask us when they can expect improvement to occur. Relying solely on the published research can give false impressions.

Virtually every Psych 101 textbook states that our conventional antidepressants (serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, tricyclics, monoamine oxidase inhibitors, and most others) take four to six weeks to work. This is wrong.

Several factors determine how quickly a medication can act on the brain or other parts of the body. The compound must enter the body, arrive at the target site, and be present at a high enough concentration to have an effect. Some psychoactive drugs exert change directly by binding to receptors and altering neuronal communication.

But for many drugs, those immediate chemical changes are merely providing a signal to tell the brain or other organs what to do, and that resulting cascade of effects may take days, weeks, or even longer to ramp up and materialize as changes in behavior or mood or cognition.

When a drug exhibits multiple effects on the body, each of these actions may show up at different times. For example, a vaccine might immediately produce soreness in your arm where the nurse injected it, and mild flu-like symptoms for a day or two, but it usually takes a few weeks for the vaccine to bolster your immune system and provide protection from viruses or other micro-organisms.

Paxil, a serotonin reuptake inhibitor, can cause nausea or loss of libido (direct effects) weeks before it helps with anxiety or depression (indirect effects).

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