Updated: Aug 14, 2020
A ton of questions came about after my last impromptu post about medications. Here are the answers to some of the top questions.
1. How do anxiety and depression meds work?
It’s no secret that there is a great deal that we still do not understand about the brain which is the source of our moods. What we do know is that certain chemicals are responsible for certain feelings. Now, I know for some that may be a trippy idea or feel like an oversimplification of the human experience but think of how the chemical of alcohol or other substances can change your mood and perception of things. So we know that there are certain chemicals such as serotonin and dopamine implicated in the feelings of well-being that escape the depressed person and those are some of the chemicals that are targeted by antidepressants.
Let’s take selective serotonin reuptake inhibitors or SSRIs which are a very widely used class of antidepressants. Serotonin is circulated in your brain by a constant release and reuptake. As the name implies, SSRIs inhibit the reuptake part, therefore making it so that you have more serotonin swimming around in your brain. The end goal is more serotonin so that you can feel better. So, the medication is not giving you serotonin because, at present, we don’t have a good way of getting serotonin to your brain. It changes your cell walls so that the serotonin that you already have, sticks around longer and in larger quantities.
SSRIs are only one class of antidepressants but the basic concept is the same with other medications. They all have the goal of optimizing the activity of the substances in your brain that are associated with stable mood and pleasure.
2. If a person's symptoms of depression and anxiety are in response to a traumatic life event, as opposed to a chemical imbalance, can medications still be an appropriate treatment option? If they are, how do they work under those circumstances?
Exactly where depression comes from is still not fully understood but we know there are factors that may increase likelihood of a depressive episode such as genetics, adverse childhood experiences and some adult traumas. However, there are some people who say to me “my life is great. My job is good, my kids are healthy. I have no idea why I feel so unhappy and like there is a dark cloud following me all the time.” So there isn’t always a direct cause of depression which is a common misconception. However, yes, sometimes a life event such as divorce or a pandemic can tip you over into a depression. You are not just sad or mourning as would be expected, perfectly normal and appropriate and not something you would try to treat or would even respond to treatment. The person is instead experiencing a syndromal depression with feelings of guilt, sleep changes, loss of interest in things, lack of desire to socialize, extreme anxiety, or feeling overwhelmed by everyday activities or just wishing they were dead. That is when an antidepressant can be helpful in dealing with the situation.
The idea that if your life is good, you won’t be depressed and if you have a hardship in your life you will automatically be depressed is a myth. That myth makes it difficult to understand how individuals who seemingly have everything. Celebrities for example can still harm themselves or struggle with mental health issues. If you are in the midst of a crisis and having a depressive episode, antidepressants can still help. A pill can’t fix your life of course but it can make you better so that you can better manage tough circumstances. The mechanism of action of the antidepressant would be the same in that instance.
3. How does the effectiveness work compared to those with chronic depression/anxiety?
The term chronic with respect to illnesses, implies that there is no cure, only management of the condition. Some examples are things like diabetes or hypertension. Depression is very curable with medication or a combination of medication, psychotherapy and lifestyle changes so I would not use the term chronic depression. That doesn’t mean that there aren’t people who have been depressed for years because they either don’t know what’s wrong or can’t bring themselves to take the leap of trying antidepressants.
The unfortunate truth is that almost all my patients come to me after years of being depressed. When they finally take medications and feel better, they realize that they have been depressed for years and say things like “I haven’t felt this good since college” and that person may be 30 years old. Antidepressants work the same for those individuals and with the same efficacy.
I will say that depression is an episodic condition. If you have one episode, you may have another. The more episodes you have, the more episodes you have. By that I mean, a person who has one episode may have another but may not. However, a person who has had 5 episodes, will almost certainly have another.
4. How long do most anxiety and depression medications take to start working?
Antidepressants do not work instantly. You need to take it consistently for a few weeks to get full benefit. However, that thing on the internet about 6 weeks does not refer to your average patient. That time frame really refers to studies testing the efficacy of a specific drug. When a drug is being tested, we don’t say that a drug has failed until a study subject has been on an adequate dose for 6 weeks with no benefit. That does not mean that everyone needs 6 weeks to see improvement. Most patients start to experience relief of some symptoms within 2 weeks of getting to a therapeutic dose and occasionally even sooner. That is still a long amount of time to take a medication while continuing to struggle emotionally, but the 6 weeks thing is incredibly discouraging to a lot of individuals because you can think, well if I’m not going to feel better for a month and a half, why bother?
5. Given that delay, should people experiencing depression and anxiety symptoms for the first time in response to this crisis still consider medications as an option, or should they try to wait out the current storm?
Yes there is a delay but it is still worth starting even in the midst of a crisis. After all, we know that exercise is good for you but does not pay off after 1 day or 1 week? No one would suggest that because there isn’t instant payoff, exercise is therefore not worth starting.
6. What symptoms may represent a need to consider medications?
Anyone who is wondering if they have depression, whether the cause is a current situation, or a childhood situation, or for reasons they don’t fully understand should consider having a consultation with a psychiatrist. A good reason to start antidepressants in the midst of a hardship is because even when the hardship is over, the depression may not be over. Most of us know someone who cannot seem to recover, even after years, from a crisis. We say of that person “ever since that divorce, Bob hasn’t been the same.” Meanwhile, the divorce was 10 years ago.
7. What would you want to say to someone who may be experiencing symptoms of depression and anxiety for the first time?
I meet people who are hesitant to take medications because of safety concerns but when I do a thorough history, I almost always find that they are self-medicating with excess food, drugs or alcohol or mismanaging their health in some way.
What I would want to say to any depressed person who is struggling but feeling like medication is “the nuclear option” is the following.
You don’t have to be suicidal or unable to function to be depressed. Most people don’t have the option of not showing up to work or not caring for their children or elderly parents regardless of how we feel. However, what I know as a psychiatrist is that you may still be in your office or in your marriage but the quality of your relationships or of the job you’re doing is not the same under the influence of depression. It’s like living life in black and white when you could be living in full color. Yes, you are walking, but you’re limping. The concept of a depressed person as a lonely person who is in a dirty robe, never leaving the house is just a myth. Brave and very accomplished people such as Michael Phelps and David Letterman have come forward and described their battle with depression and described how they dealt with depression at the height of their careers. So, yes, you can be working and doing and showing up and putting one foot in front of the other but something seems off. That thing could be depression.
I would also say that antidepressants are not addictive. I am frustrated with this misconception because it keeps people away from trying meds that may be life saving. There are other classes of psychotropic medications such as stimulants or benzodiazepines that have abuse potential but those are not antidepressants. It’s confusing because, yes, if a person takes a medication for a stretch of time and then stops abruptly, they may experience abrupt cessation syndrome which is not dangerous but can be uncomfortable. This can be confused with withdrawal but the solution to that is to taper off the medication whenever you are ready. Furthermore, the idea that medication will make you a zombie or change who you are is false. Depression changes who you are. If you are on the right medication and at the right dose, you will be more yourself. You will be whoever you are without depression.
Antidepressants are extremely safe. SSRIs for example have been around for decades, so there have been study after study confirming that they are safe and effective. But yes, some of them have side effects. Like anything in medicine, we weigh the risk of the treatment against the risk of the untreated condition. What we know about depression is that it can shorten your lifespan, increase your risk of cardiovascular disease, worsen outcomes when it comes to conditions such as diabetes and compromise your immune system. The cost of living as a depressed person and not having the full richness of life, not going for that promotion or not asking that woman out, or staying in that toxic relationship- those losses are harder to quantify but not less real.