Thinking calmly about anxiety medication

December 11, 2018 9:57 AM

I think I'd like to give medication a go, after years of trying to manage my mental health issues in other ways (yes, including therapy). I'm apprehensive, to say the least. I know the key is a good psychiatrist, but I have no idea how to evaluate psychiatrists. My prior experience with mental health professionals has ranged from actively negative to merely okay. How do I, a layman, discern whether or not a psychiatrist is competent and to be trusted?

I've dealt with mental health issues for years, and tried medication (Lexapro) exactly once. It didn't do anything (literally nothing, no side effects, positive or negative), even when I went up to the max dosage. My doctor warned me any other medication carried a greater risk of side effects, so I elected not to continue.

Now I am, frankly, at the end of my rope- side effects seem tolerable compared to the prospect of things continuing as they are.

I've been diagnosed with anxiety and depression, though I'm not sure of the validity of the diagnoses (one of the things that makes me skeptical of mental health professionals is how different the diagnoses they've given me are, from "it's all in your head" to "it's mild depression and social anxiety" to "it's major depression and GAD").

Over the years that I've dealt with this, I've gotten better at managing my mood- at kickstarting my interest in things, at not feeling worthless. But one symptom that I've been utterly incompetent at managing is my lack of productivity- I can't concentrate, I'm restless, and avoidance has been my default coping mechanism. Would medication even help with that?

When it comes to side effects, I'm most concerned about addiction. I'm not at all worried about issues with alcohol or libido- I don't drink and I'm asexual. Everything else seems concerning, but, again, not as concerning as the prospect of things continuing as they are.

Any advice you have would be useful. Thanks so much!

posted by anonymous to Health & Fitness (12 answers total)

I had anxiety (panic disorder) for years and struggled on by myself as my life shrunk and was compromised by avoidant and safety type behaviours. When I eventually told everything to my GP then I was put on an SSRI, citalopram. This made a massive difference and enabled me to change my lifestyle for the better (motivation for productivity, socialising and exercise). After a few years I reduced the dose and eventually came off. I had few side effects while on it (none really negative), while coming off had mild brain zaps and mood swings but passed quickly.

Please do try medication again, there's loads of different ones that work better for different people. They are slow acting so give them a chance though and don't change too frequently. Good luck
posted by JonB at 10:15 AM on December 11, 2018

(just to iterate more strongly - when I was unwell, my default answer to things was no - full of excuses not to do things. I lost friends and eventually my partner. I look back on those years as wasted to a large degree. Now my default is yes, I love trying new things and having adventures. Medication and lifestyle changes can be transformational)
posted by JonB at 10:19 AM on December 11, 2018 [3 favorites]

"I can't concentrate, I'm restless, and avoidance has been my default coping mechanism."
Yes, medication would definitely help with that, it helped me with that. Please keep trying medication until you find something that works for you, give yourself a month or more to adjust to a new drug, too. There are non-habit forming options as well as the ones you're probably thinking of that have addiction risk (such as benzos).

I also want to suggest getting an evaluation from an MD doing functional or holistic medicine because there are genetic and nutritional factors that have a huge impact on symptoms of anxiety and depression, as well as how your brain/body responds to various drugs. Take a look at www.genesight.com, a test you can take to suggest which drugs might work better for you - your psychiatrist can order this test for you if you're interested.

Also, consider reading up about the relationship between overmethylation and anxiety, and the MTHFR genetic variation. This is the one that comes to my mind at the moment because I have a family member who has it and is treating it, but there are definitely other nutritional deficiencies a physician can look for using bloodwork. Something simple like a dietary change or adding in a supplement could make a significant difference in how you feel.
posted by zdravo at 10:37 AM on December 11, 2018

Medication can be life-changing. Literally so; a complete change to how you perceive life. Things that used to seem absolutely impossible seem attainable, tasks that would seem immeasurably overwhelming are calmly resolved. Obviously this isn't true for everyone, but it was for me. Like JonB, I now view the time I spent clumsily fucking around, trying to self-manage with talk therapy and yoga and diet and exercise—not that there's anything wrong with those things—as someone who was trying to put out a housefire with teacups.

Anyway... this is going to be controversial, but... I don't have much of a relationship to the guy who prescribes my meds. He's my "white coat drug dealer". I pay him, he gives me pieces of paper, which I take to a pharmacist, who gives me drugs. That's how it works, and incidentally how I stay alive. When I walked into his office, I had a pretty good idea what drugs he was going to try first given my symptoms, because there are only so many first-line treatments for what I had going on, and he didn't surprise me. When that didn't work, we went to a second-line drug, also no surprises there. It worked. Now we have a very nice thing going where I make an appointment and pay him several hundred dollars every few months and exchange pleasantries, and then I get my slip of paper.

Doubtless there are people who have very involved clinical relationships with their psychiatrists/psychopharmacologists, but I wouldn't write the whole thing off if the person doesn't seem to be super interested in spending a whole lot of time going over the details of your condition. Bring notes with you on things you want to discuss, particularly side effects and new/changed symptoms. But I think it's typical for visits to be pretty perfunctory. Such is medicine in the US in 2018.

Also, plan on having to try several drugs until you find one that works. If the first one you try works for you—great! But that's not typical, at least based on most people I know. Commit to giving it 3 tries at least, so you don't get discouraged if the first one isn't a good match. For all we know about pharmacology, we don't know enough to predict with confidence which drugs will have exactly which effects on which people. It's a bit of a crapshoot. But it's still worth it.

But one symptom that I've been utterly incompetent at managing is my lack of productivity- I can't concentrate, I'm restless, and avoidance has been my default coping mechanism. Would medication even help with that?

Yes. I mean, YMMV of course, but yes. Yes it can.
posted by Kadin2048 at 10:48 AM on December 11, 2018 [5 favorites]

How do I, a layman, discern whether or not a psychiatrist is competent and to be trusted?

Here are some things to look for -

- When they talk about the pluses and minuses of various medication, do they refer to recent studies/scholarship or have they zoned out since medical school graduation?

- If you share a concern/worry about a specific medication or side effect, do they take it seriously or do they ignore/patronize you (i.e. if you say, "I've been gaining weight on this medication and it's concerning" or "I just saw this class-action lawsuit about this medication" it's a bad sign if they say "No you haven't, it's impossible that you could gain weight on the medication" instead of believing you, asking more questions and figuring out a plan.)

- Do they talk about other lifestyle changes that could be helpful in conjunction with medication?

And also I agree with Kadin2048, this is not like a therapist/psychologist where rapport, empathy, and a relationship are key. You are looking for a competent, conscientious professional; they don't need to be someone you'd want to hang out with, just someone who takes you seriously and is familiar with the current landscape of treatments.
posted by rogerrogerwhatsyourrvectorvicto at 11:11 AM on December 11, 2018 [3 favorites]

I finally found a good psychiatrist after quite a few questionable interactions. What distinguishes her from the others:

• She looks up relevant literature while we are in session;
• She listens to me. She remembers things about me. She genuinely seems to care;
• She knows her stuff: she's able to pull, from her brain, facts about chemical reactions in the brain, for example;
• She takes an entire half hour or hour with me, depending on what kind of appointment I've made, and I never feel rushed;
• She says things to me like "We will figure this out together" and "You do not have to suffer and we will work this out";
• When I've had a crisis (twice now) she has personally called me, after hours, after receiving my emails about said crisis (drug interactions);
• She gives me samples of drugs to try before prescribing them, when possible;
• She does not take insurance, which is unfortunate, but everyone else I tried did take my (very good) insurance and... they were terrible.

The psychiatrists I saw who did take my insurance did all kinds of weird things (my most memorable interaction was the one who wrote three drug names down on a used napkin and asked me to Google them and then come back to tell her which one I wanted!) I would suggest making an intake appointment and just seeing how you feel about your interactions with them. A lot of psychiatrists are gatekeepers for drugs; you should also be seeing a therapist and doing talk therapy in conjunction with medication. I actually found this psychiatrist through my therapist. Honestly, for me, being willing to see someone who did not take my insurance was the key.
posted by sockermom at 11:44 AM on December 11, 2018

My doctor warned me any other medication carried a greater risk of side effects, so I elected not to continue.
This is 10000000% not true. You have so many options, and how medication interacts with your body is different for every person. Every drug has side effects, it's a matter of what's manageable for you and what isn't but Lexapro isn't like, the only safe drug or something.

Also, SSRIs are not addictive, but if you are in a situation where a drug comes with a risk of dependence - don't dismiss that drug out of hand because of stigma surrounding "oh no I might become an addict". There's a lot of that and the most important thing is finding what makes you feel better, even if it turns out to be experimental or unconventional, or it's not an SSRI, or whatever. A good, competent psychiatrist is "on your team" so to speak, will look out for you, will consider the risks WITH you, so your only job is to get better. They will trust you and value your intelligence enough to keep you informed and provide you with accurate, even dispassionate, TRUE information, and treat you with compassion even if psychiatrists are notably a little cold a lot of the time.
posted by colorblock sock at 11:54 AM on December 11, 2018 [5 favorites]

I have been on various meds for depression and OCD for a while. here's what I've learned.
-SSRI side effects can be annoying.
-a good psychiatrist will listen to you and use "we" more.
-in the end you have to be your own advocate.
-wellbutrin name brand is better than wellbutrin generic.
-wellbutrin will lose effectiveness over time.
-keep a journal of your moods and look for patterns.
-listing the risks is part of how the psychiatrist avoids malpractice lawsuits.
-everyone reacts to meds differently.
posted by evilmonk at 12:21 PM on December 11, 2018

Some anxiety-specific drugs have a meaningful abuse risk, but careful management can mitigate that. Basically no one except maybe intractable epileptics should be on a daily dose of a benzo long-term, but many people benefit from having a small supply for use in emergencies (say, a few times a month). In fact, I've often heard people say that just knowing that the drug is available to short-circuit a panic attack helps them get over one without it--because they don't feel so trapped.
posted by praemunire at 12:41 PM on December 11, 2018 [1 favorite]

Lots of good answers here. Another question is, "would I feel comfortable discussing sexual side effects with this person?" You don't have to go into the messy details about your sex life but being able to discuss concerns like anorgasmia or finding that your libido thermostat has changed might be part of the process.
posted by GenderNullPointerException at 1:25 PM on December 11, 2018

Yeah, I can go ahead and judge that first doctor based on this: "My doctor warned me any other medication carried a greater risk of side effects, so I elected not to continue." That's just nuts.

That said, it does usually take several tries of different meds and dosages to get something dialed in. It's not a vote of no-confidence if they want to try different things. Anything that will do something will also have side effects.
posted by fiercecupcake at 3:00 PM on December 11, 2018

Meds made so much difference for me. Yes there are risks but there are also very clear risks, as you are experiencing, of going untreated.

Evaluating psychiatrists: Do you feel like they are giving you an option, or telling you to do something? (i.e., are you comfortable saying no to them?) Are they flexible about changing appointment schedules etc in case of crisis or unexpected issues? (my current one said to me a few days ago "you know you can come in any time, no questions asked" and it was so reassuring) Are they willing to refer out or recommend adjuncts (add therapist, MSW, whatever)?

I do agree with Kadin2048 that some psychiatrists can just function as med/ symptom managers, and you might need a therapist to serve some of these functions instead. But - and this is also specific to my situation and symptoms - I need a psych whom I can trust in order to manage my safety and that's fundamentally a gut-check kind of question.
posted by ahundredjarsofsky at 10:54 PM on December 11, 2018