Another in our series Nerdy Notes: Science in Story & Verse
You may have heard recent buzz about antidepressants being “overprescribed” or difficult to stop. Antidepressants are not habit-forming, but like other medications, decisions about stopping them are best made in partnership with a clinician who can help guide what’s right for you. Many people benefit from these medications, including some of the Nerds who share their experiences in this post.
Science and safety
SSRIs and SNRIs, selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors, the two most common types of antidepressants used to treat both depression and anxiety sometimes get bad publicity. Whenever people harp on the side effects of medications, I’m reminded of something I was once told by a physician I admire, “there is no free lunch in pharmacology.” That means that any medication can have side effects. There is no perfect pill or supplement that does only what you want with zero risk of unwanted effects. With that in mind, let’s talk about some of the critiques of these medications and why the critiques might be overblown.
Psychiatric conditions, including depression, anxiety, bipolar disorder, and schizophrenia are very complex. You might have heard about depression and anxiety being linked to brain chemicals and that SSRIs and SNRIs work by shifting brain chemistry to improve mood. SSRIs and SNRIs work in similar ways. Your brain communicates with chemical signals. The neurons (or specialized cells in your brain) are basically lined up in long rows with a gap, called a synapse, between them. The first neuron will release their chemical signals, and those signals will land on the second neuron. The second neuron reads the signals with a receptor, which is a bit like an antenna for specific chemical signals. Eventually, the first neuron picks up all the chemicals in the synapse and the signal goes away. Two of those chemicals are called serotonin and norepinephrine. It’s long been thought that serotonin and norepinephrine play a role in depression and anxiety. SSRIs and SNRIs are “reuptake inhibitors.” They stop the first neuron from picking up the serotonin and norepinephrine in the synapse, which keeps the signal going for longer, helping with the symptoms of depression and anxiety. There are other medications with different mechanisms of action used to treat depression and anxiety, like MAOIs (monoamine oxidase inhibitors, which stop the protein that breaks down serotonin and norepinephrine), but they’re not prescribed as commonly.
(Image credit: E. Wish)
Interestingly, it turns out that our concept of the chemical aspect of depression and anxiety might not be the whole story. Research suggests they might work to treat mood-related conditions in more ways than simply “balancing” brain chemicals. And we now know that mental health conditions are caused by many factors, including genetics and many other things happening in your body and life. For example, researchers are also looking at inflammation and how the gut microbiome might impact depression as well. All of that is to say that these are complex conditions that we still don’t fully understand and there is no one-size-fits-all approach to treatment. And while we may not fully understand all of the causes of disorders like depression and anxiety, medications like SSRIs and SNRIs are very safe and can be very helpful to people when appropriately prescribed and taken.
What about the side effects? Remember, there’s no free lunch in pharmacology, so all medications have some side effects. The most common side effects of SSRIs and SNRIs are nausea, decreased sexual drive (libido), dry mouth, headaches, increased tiredness or insomnia, and decreased or increased blood pressure. Each medication has different side effects and some are more common with some medications than others. That’s why psychiatric clinicians emphasize discussing side effects and working together to figure out what medication works best for each person. More serious side effects are possible if you take antidepressants with an interacting medication (such as opioids, triptans which are for headaches, or linezolid which is an antibiotic). That’s why it’s always important to make sure your pharmacy and your healthcare team know what medications you take and to check with them before taking anything new, including supplements or medications sold over the counter.
What about withdrawal symptoms if you decide to stop your medication? Antidepressants are not habit-forming but they can still cause bothersome side effects if stopped abruptly. So it’s best to get guidance from your prescriber. They can guide you on how to slowly decrease the dose to avoid side effects. Psychiatric and other clinicians will generally monitor you very carefully during this time period to ensure you are tolerating the decreases well. It’s possible for your moods to worsen during or after stopping an antidepressant so it’s good to check in with your clinician and to have a backup plan or support in place in case this happens. You can talk to your psychiatric clinician about how easy or hard it is to taper off medication.
Health Equity Alert:
Antidepressants are only one part of mental health care. But therapy and other support from mental health clinicians are often hard to access. The types of services available may also vary depending on where you live. A 2017 study showed that outpatient mental health offices tended to be in higher income areas whereas inpatient mental health services tended to be located in lower income areas. This suggests that those in lower income neighborhoods have less access to generalized or preventive mental health care like therapy. Another study looking at therapy use between 2018 and 2021 showed that people who were college educated and had higher income were more likely to work with psychotherapists than people with less economic privilege. The study also found that men were less likely to use therapy services than women, which is an important finding as men are more likely to die by suicide than women, though women are more likely to attempt suicide. These studies also show that folks in rural areas and kids also have a harder time accessing mental health care.
Our stories
Kenzie:
Unfortunately, the narrative that psychiatric clinicians and other prescribers are “pill pushers” who value profits over healing is still alive and well. It’s difficult to escape the feeling of stigma when this same narrative is echoed in church, school, and even youth mentorship settings, even when (as in my privileged case) you grow up in a household that is highly supportive of seeking professional help for mental health concerns.
Over the past decade, feelings of self-doubt would occasionally surface as I moved from one SSRI regimen to another in an attempt to find one that works for me. Was I being played by big pharma? Do I need to offboard meds entirely and simply try being stronger and more resilient? Then, as I progressed in my public health education: There really is historical evidence that Black women have been unjustly experimented on in the past; are my doctors experimenting on me right now? These questions stemmed from feelings of mistrust (and, to an extent, distrust) of both the healthcare system and myself. As a young adult, my priority became listening to my body more, trusting that I had expertise in my own needs, and being a firm self-advocate in voicing these needs. Taking a couple of minutes to do some pre-appointment planningtook away so much of the “stage fright” I usually felt when outlining my mental health concerns to clinicians. Soon enough, I was prescribed a medication that has been working for me better than ever. I can say with complete confidence that I am better off for having gone through the trial-and-error of identifying the best medication for me rather than trying to “tough it out” without professional support or relying solely on my own research.
But let’s talk health equity for a second. The stance of current Health and Human Services (HHS) leadership is that “Psychiatric medications have a role in care, but we will no longer treat them as the default.” Evidence shows that SSRIs can be highly effective first-line treatments for mental health (especially in severe cases). At the same time, it’s valid to desire a world where primary prevention – the type that sustainably enhances our sense of well-being in our homes, neighborhoods, workplaces, and government – is prioritized over medications. Know how we can create a world like this? By funding social welfare programs and supporting social policies that can remove all the economic and discrimination-related life stressors that induce (or worsen existing) mental illness. If the current administration genuinely wants to tackle America’s mental health crisis, they’d be wise to start with acknowledging root causes (one of their favorite phrases) and reforming unjust systems, not taking away the effective treatment options that are working for them.
Rebecca:
I was always an “anxious kid” but in college, the anxiety tipped over to OCD. The fear of infection took hours from my day and my therapist recommended I see a psychiatric clinician to start medications. I resisted starting medication for a long time because I felt like I should be able to control my thoughts, or fix myself, but going on medication allowed me to stabilize. Over the years, I’ve been on and off different medications. I’ve tried lifestyle interventions alone, including therapy, healthy eating, meditation and exercise. And, thanks to my OCD, I actually have years of data on myself that shows me when I feel the best. If I am consistent with exercise and healthy eating and taking my medication, I feel much better than any intervention alone. Everyone is different, but seeing that helped me realize that it was okay to take medications. I still get anxious but with tools I’ve learned in therapy and help from the medication, I am able to get through it.
Liz:
When I was newly postpartum with my second child, my days and nights were filled with what-ifs. I couldn’t sleep without worrying about what would happen if she stopped breathing and I wasn’t around to notice. I couldn’t walk by the stairs without envisioning myself accidentally falling down while holding her. Then, when she was six weeks old, she developed a fever and had to be admitted to the hospital for three days. When we got home my anxiety was so bad I was barely able to function. Finally, a dear friend reminded me that I didn’t have to try to power through alone. That I deserved help, and to actually enjoy these moments (though yes, of course, they’re also hard). She helped inspire me to connect back to a therapist, prioritize moving my body (which is key for my mental health) and I went on an SSRI. Eventually I started to actually enjoy having two kids, and the constant drumming of what-ifs, and anxiety, died down. I am so grateful that these tools existed, and that I was connected to them at a time I really needed them.
MK:
My first time being prescribed medication was when I was 18 after a sexual assault. I was left feeling broken physically and emotionally. While my body healed, medication helped stabilize me mentally so that I could do the significant healing work involved in trauma recovery with an amazing therapist.
Throughout the next 33 years, I have had periods of needing medication and therapy to restabilize. Pregnant with my second child and worried about bringing another child into the world who might have chronic illness, working on the frontline during the pandemic, losing my mom unexpectedly, worsening symptoms after my first COVID infection, the rollercoaster of perimenopause and the ongoing work of healing from trauma. Through the many transitions and challenges of living life fully as a caregiver and clinician, I have needed medication as part of my comprehensive approach to staying healthy.
I am lucky I have had access to a high quality mental health care team, which includes a psychiatric nurse practitioner who works diligently with me to make sure I am on effective medications, at the correct doses for my particular brain chemistry, for the right amount of time. I also have access to a quality inpatient psychiatric hospital when I have needed it, and a truly gifted LCSW-C (licensed clinical social worker) therapist. Together, these have been life saving. And I mean that quite literally.
As Kenzie noted in the Health Equity Alert, not everyone has the access I have had. And because of lack of access, people suffer. People die.
Right now, we need to do everything we can to advocate for expanding access, not shrinking it.
As an FNP, I bring my lived experience into the patient visit. I have patients who express concerns about taking medication to help regulate or support the neurotransmitters and hormones in their brain. Sometimes the questions are about side effects or how the medication works and those are more straightforward to answer. But sometimes it’s clear they are viewing their mental health through a stigmatizing lens. They express feeling shame or weakness. When this happens, I ask them to reframe their thinking this way: “Your brain is an organ, right? Just like your pancreas. If your friend’s pancreas didn’t make insulin anymore, would you be embarrassed for them if they needed insulin?” The answer is “Of course not!” And then I see an “a-ha” moment wash over them along with a wave of relief.
On days when I am feeling shame for how my brain works, I remind myself of the same analogy and it helps me face and dismantle the internalized stigma that we were all conditioned to believe, that having mental illness makes us bad or less than.
Medication is only one tool. But it is a critical one.
In my particular toolbox, I have 5 daily tools, plus weekly therapy. I call them the 5 Ms–medication, meditation, movement, merriment and music. (There used to be only 4, but then our incomparable content manager, Sandy, shared with me a Those Nerdy Girls Work ‘N’ Chill playlist on Apple Music one day when my other 4 Ms weren’t cutting it. I found that music, in fact, is a game changer for me.)
With this post, we are sharing our stories to highlight the importance of mental health care, to destigmatize mental illness, and to advocate for everyone having equal access to evidence-based care.
Share your stories and tools in the comments .
