has predictable main and side effects, though there is tremendous vari-
ability across individuals.
When I think about medications for depression, I first look at symptom
complexes, then confer with the prescribing physician about which med-
ication might be most effective in treating those aspects of depression.
Each of the five people I described at the beginning of the chapter had
some experiences, both positive and negative, with antidepressant medica-
tion. Let’s use them as case studies on how various antidepressant med-
ications might be prescribed.
Alonzo is actively sad, preoccupied with the loss of his wife.
He has lost his appetite and is having a hard time sleeping.
Following in a grand tradition of abandoned lovers, he begins
treatment by medicating himself with alcohol.Alcohol
The oldest psychoactive substance is absolutely the worst possible medication
for depression, yet it is the most widely used. The main reason for its popu-
larity is that it immediately treats all the symptom complexes that make
up depression, though badly.
As discussed in an earlier chapter, alcohol can cross the blood-brain
barrier. It’s absorbed directly from the stomach into the bloodstream,
and goes from there right into the brain. Alcohol works fast; it causes an
immediate, stimulating dump of dopamine followed by a relaxing flow of
GABA. Unlike reuptake inhibitors, which make transmitter substances
available for a longer time in the synaptic area, alcohol and most other
addictive substances weaken the walls of the vesiclesthat carry transmitter
substances, causing them to spill out into the synapse. Dopamine path-
ways lead right to the nucleus accumbens, the so-called pleasure center
of the brain. This feels good, but it uses up the dopamine quickly, so there
is less of it later on. The brain is designed to feel good a little bit at a time,
so that anything that makes it feel good all at once is bound to create the
opposite effect when the chemical is all used up.
Other substances are even better at causing transmitter dumps than
alcohol. Cocaine and amphetamine are at the top of the list. They cause
brain cells to pour out dopamine, serotonin, GABA, norepinephrine, and
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