How, exactly, do I get treatment for depression?
October 6, 2008 1:11 PM   Subscribe

After battling on my own for three years, I have finally decided that I need to seek medication for my persistent depression and associated overwhelming anxiety. Here's the problem: I have no idea what steps to take to get treatment. Can you provide me with a very detailed step-by-step map or script to follow?

Although I've been doing pretty well fighting this on my own - most people who know me don't know there is anything wrong; its not like I'm so depressed as to be nonfunctional - the stress of having to fight against this constantly is taking its toll, and I think its time to go on medication. The problem is, of course, that I have no real idea what I need to do in order to get medication and treatment.

My primary care "physician" is a big practice where I see someone different every visit, (and almost always a PA rather than a real MD) so there isn't one doctor I have a strong existing relationship with. Do I just make an appointment and say "I need anti-depressants" and walk out with a scrip? If so, that seems -- odd. Or will there be some string of tests? Should I try to find some different kind of doctor than my GP, or will I see my GP and then get a referral to some other MD?

With a "regular" illness I'd walk in and say "I think I have XX." or "I have XX symptoms" and there would be tests and the doctor would do the diagnosis and prescribe the appropriate thing or give me a referral and the specialist would diagnose and prescribe. Walking into a doctors office and basically dictating what treatment I need seems like a big reversal in the normal process.

Also, I have concerns about the potential side-effects -- in particular, I've known three people who had some pretty severe problems START after they started SSRIs -- one who had significant insomnia which led to hallucinations and ultimately a suicide attempt, one for whom long term SSRI use led to weight gain of more than 40 lbs and diabetes, and one for whom SSRIs led to migraines and hand and arm tremors. A fourth friend when through a year of trial-and-error hell while they attempted to find a medication that would work at all. Are there tests the MD can/will do to find out which of the multiple drugs on the market will best help with the fewest side effects? How exactly to MDs decide which drug they will prescribe?

Thanks for the help.
posted by anonymous to Health & Fitness (16 answers total) 14 users marked this as a favorite
Well, I always saw the same physician at the large family practice I went to. So I think you really need to have one dedicated doctor that you see. But yes, you would just call and make an appointment to discuss getting meds for depression and anxiety. Your doctor will want to monitor your progress, and will have you come in for follow up appointments to make sure everything is going well, or change you Rx if need be.
posted by at 1:21 PM on October 6, 2008

I would recommend seeing a psychologist first, and letting them talk to you, and decide what combination of therapy/medication would be a good place to start. Then have them call your doctor for a prescription if they think you need one, or at least be able to go to your doctor saying "my therapist and I think that medication might be the best way to treat some of my symptoms" (that's how I've done it in the past, anyway).
posted by Green Eyed Monster at 1:30 PM on October 6, 2008 [1 favorite]

This will vary a little bit depending on whether you have insurance and what you have. My insurance, for example, does not make me get a referral to see a psych. doctor. I can just go for a certain amount of visits and it will be covered. Figure this out in advnace because nothing makes you more anxious like unforseen medical bills if you're me.

step 1: figure out what your insurance will cover

step 2: either go to psych doctor [as yourself: do you want to consider talking therapy or are you really looking for meds, think about that to yourself a little bit?] or the doctor at your practice. Say something like "I've been experiencing anxiety and depression that's been getting in the way of me living my life because of X, Y and Z reasons (can't sleep, stage fright, crying at ork) and I'd like to do something about it. I've already been doing A, B and C (exercise, drinking less coffee, tea before bedtime, SAD lighting) and it's helped some but not much. I'm concerned about weight gain, and adverse affects with certain medications. Where do we go from here?"

Alter this to suit your specific situation but I think it's okay to talk about anxiety and depression as if you think you have them, but I don't think I'd say "I need this medicine" unless you're a little more certain. For me, at one point in my life, I had a doctor who was like "you're just stressed out" and I was like "yes, true, but I'm drinking every night so that I can get some sleep and I'd like to stop doing that. What can we do about this?" So not bossing him around but being clear what the problem was I was trying to solve and being firm.

Your doctor will probably ask you if you're having these sorts of symptoms so you may want to think about that before you go in and they'll help you tease apart which depression/anxiety symptoms are causing you the most trouble.

step 3: discuss your feelings honestly with your doctor but if you're pretty sure this is something that needs remedying, be forthright that you don't just want to "try harder" that you think it's time to do something medically about this. There are many non-SSRI alternatives to dealing with depression, so don't let that concern alone keep you from seeking treatment.

good luck, making the first phone call is the hardest part, but good for you for taking care of yourself.
posted by jessamyn at 1:50 PM on October 6, 2008 [2 favorites]

Here is a script to follow, but it's not the only one.

1. Call your doctor and say, "I think I'm depressed. Can you refer me to a psychiatrist who takes [Insurance]?" Bonus points if he can refer you to a psychiatrist who is positively disposed toward talk therapy in addition to/before trying medication.

2. Go to the psychiatrist. Be frank. If the psychiatrist recommends medication, he or she will probably recommend one in a small dose that causes minimal side effects (Prozac and Zoloft are common starters.) A good psychiatrist will want to be kept in the loop about your experience.

3. The first SSRI may not work for you. If you have weird side effects, like excessive sleepiness or the persistent feeling of growing an itchy mustache, or overwhelming obsessive thoughts, talk to the doctor.

re there tests the MD can/will do to find out which of the multiple drugs on the market will best help with the fewest side effects? How exactly to MDs decide which drug they will prescribe?
There aren't blood tests, or anything like that. If you have anxiety, your MD may prescribe an antidepressant that tends to do well with anxiety, for example. Different SSRIs have different tendencies, but they're only tendencies.

Good luck.
posted by chesty_a_arthur at 1:56 PM on October 6, 2008 [1 favorite]

When I was going through a rough patch, I called a mental/behavioral health clinic and asked for an appointment. When told that this was first visit, they went into "new patient" mode and had me come in to do paperwork and I remember taking a standardized test. Then I saw the psychiatrist who evaluated what I needed. Her diagnosis consisted of whether or not I needed meds or ongoing counseling or both.

So, yea, if your insurance will cover it or if you can afford it otherwise, I recommend calling a mental health clinic and asking for an appointment. My experience was that they took care of the rest.
posted by cabingirl at 1:58 PM on October 6, 2008

This obviously differs depending on your insurance, but you should start by calling up your primary care office and asking them to refer you to a psychiatrist who takes your insurance. They'll likely give you a list of names, and you may end up trying a few different doctors before you find one you really like. Trust me, if you don't feel comfortable with a psych. doctor, you're really going to have trouble getting better. It's worth the hassle to try a few until you get comfortable.

You may end up being referred to an office, where you'll have a psychologist who will see you for talk therapy, which is really important as an addition to meds, or as your primary treatment method. In that case, the office will likely have a psychiatrist who will see you for an evaluation and prescribe meds if need be. They'll start you with a low dose and counsel you to keep track of any and all side effects, many of which will go away after you've been on meds for a while.

Alternately, you can get yourself set up with a psychiatrist who will also see you for talk therapy, which can be nice because you will see them more often and they will be more informed about your situation, but also is a little more hit or miss because some psychiatrists aren't all that great with talk therapy.
posted by you zombitch at 2:12 PM on October 6, 2008

Make an appointment at the health care office. They will ask what the problem is. Tell them you feel depressed and ask to see a health care provider with expertise treating depression. Then go in and tell them what you told us. Say that you've tried to work it out, but feel that medication would help. They may refer you to a therapist, but will likely give you a prescription. In theory, with managed [sic] care, they will help you with a treatment plan, but managed care isn't, really.

It may take several tries to get the meds right. You can always come back to for more questions. Lots of us have lots of experience and opinions. I do recommend you add sunshine and exercise if you don't already get both. Goo dluck.
posted by theora55 at 2:13 PM on October 6, 2008

Most of this your question has been answered, but I think the side effects issue is worth addressing further. I went to my doctor with depression a few months ago (I'd already seen a psychiatrist for therapy in the past, and decided that wasn't enough). He started me on Prozac, which is common, and told me to double the dose after ... I forget if it was a week or two. Like a lot of people, I noticed about three weeks in that I had no libido, and related side effects, which sucked worse than I would ever have guessed, and I was even more depressed (I think not entirely related to the libido thing) than before. I tapered down (you generally don't want to start and stop antidepressants suddenly), and a week later was back to normal; the doc had been scheduled to see me every week, since the Prozac was pretty new, but said he'd squeeze in any patient with unwanted side effects. After a short discussion, he switched me to another drug, which I've been very satisfied with. It makes me slightly more anxious, but it isn't unmanageable, and I'm feeling a lot better.

Anyway - there's no way to predict which drug will work for you. We don't even understand all that well how these drugs do their thing. But I seem to recall my doctor telling me that 90% of patients are satisfied with either the first or the second drug they try.
posted by spaceman_spiff at 2:43 PM on October 6, 2008

Check around and see if your area has any kind of counseling referral service. These are groups of therapists who support the idea of shopping around before committing to a therapist. For a fee, you get seen by an intake person, who will create a profile of what you need and what your issues are, and then they will get back to you with 3-4 therapists you can see for an initial visit. If you don't hit it off with one of the three, they'll generally send you to two more. The cost is usually equal to one therapy session, so it's well worth it.

You will be better off if you are working with a therapist as well as taking medication, IMHO.
posted by micawber at 3:04 PM on October 6, 2008

I don't know which country you're in, but here's my experiences with the UK health system.

I was at home from university during the christmas holidays and was feeling pretty desperate, so I went along to the family doctor - who, I have say, isn't my official doctor, but is the one I tend to ask for because I rather like him. I had an ear infection or something, so we talked about that and then I panicked and blurted something daft like "how do you know when you're depressed and not just miserable?"

We talked for a few minutes, and then he gave me a questionnaire to fill out (how happy have I been feeling lately, do I feel like my favourite activities give me as much pleasure as they used to, how have I been sleeping/eating, and so on. Everything was on a scale of one to ten, and I just had to tick boxes.) He looked over my answers when I'd finished, looked slightly alarmed, and said I definitely sounded depressed, and did I think medication was the right choice for me. He gave me a month's supply of SSRIs, talked me through the potential side effects and the science behind them, and then very kindly said he'd write a letter to my official doctor in my university town to make the conversation with her easier.

He gave me this a few days later, and it was indeed very helpful. My doctor at uni was also very nice, and I went to see her every month for a year or so - she wouldn't give me more than a month's medication at a time. She went over a few other issues with me, we'd talk for a bit and she also encouraged me to see one of the university counsellors.

For what it's worth, I never had any major side effects with the medication - I was taking Citalopram, (also known as celexa or cipramil, among others) which I think is a common one to start people off on. I had a dry mouth for the first few days, and I suppose it could be responsible for some weight gain, but any other side effects were due to my own stupidity (SSRIs and alcohol are not a good combination).

While I know a lot of people have major problems with SSRIs, or even lots of minor problems, I personally give them most of the credit for me still being around. So.. if you think you need them, then persevere and don't be afraid to try a few different ones. (With a doctor's approval, and following their exact instructions - it's important with these.)

Best of luck, and feel free to send me a message if you'd like to know anything else, or want someone to talk to about it.
posted by badmoonrising at 3:43 PM on October 6, 2008

jessamyn has the answer best matching my experience. I'd also suggest looking into whether your employer has an Employee Assistance Program (ask HR or look around in the break room; there's usually a sign). They will provide you with a confidential referral to a health provider and you can go from there.
posted by desjardins at 4:35 PM on October 6, 2008

Standard advice is the Feeling Good website and books. Personally, I think that beating my depression with the help of David Burns (and some talk therapy and Prozac) saved my life, and Burns's techniques have stayed with me as maintenance.

The commonest treatment nowadays is cognitive-based. Basically, you are telling yourself negative things when hyyou think depressed thoughts, and you need to learn to argue back -- defense yourself -- against what you're thinking. "I'm worthless", for example. No you aren't -- you're worth as much as anyone and you have probably done a lot of good in your life. "I'm a failure." Well, everyone falls down once in a while. It just proves you're human.

Depressives are often also referred to group therapy. Don't resist it; I think that was the biggest mistake I made in my treatment.

Prozac is nowadays available in a form called Lexapro, but you might get a generic (fluoxetine), especially if you're insured. But the drug of first resort these days is always an SSRI, with the tricyclics and other drugs of old relegated to intensive care situations.

Go into your treatment as with any other serious health condition. Learn about it and determine to get control of it. Talk to your doctor if you don't think what you're doing is working. Let them know about side effects and any change in your condition, especially if you have thoughts of harming yourself. Oddly, this is something that can increase somewhat after someone goes onto a new medication, as you suddenly feel "capable" of following through with a plan. Know this going in and you're more likely to come out.

Good luck!
posted by dhartung at 4:38 PM on October 6, 2008

You mention overwhelming anxiety, but you fail to mention the exact type of anxiety. Sedatives can be a magic bullet, but they have the terrible downside of you becoming addicted. Be very midful of your decision on taking these.

Homeopathic remedys may be a good route to take for this. Though insurance is normally a bust on this.

Talking out your situation to a doctor, psychologist, counselor, peer; on a routine basis, (therapy), is a great way to process your experiences.
posted by captainsohler at 6:14 PM on October 6, 2008

Prozac is nowadays available in a form called Lexapro

No, it's not. Lexapro is a derivative of Celexa. I know because when Prozac stopped working for me, my shrink switched me toLexapro (this was very shortly after Lexapro was approved by the FDA). Different drug, different side effect profile.
posted by shiny blue object at 6:39 PM on October 6, 2008

But the drug of first resort these days is always an SSRI, with the tricyclics and other drugs of old relegated to intensive care situations.

Welbutrin (buproprion) isn't usually the first drug a patient tries, but it's definitely not a "drug of old", nor is it anything near "relegated to intensive care situations". It's an NDRI - norepinephrine and dopamine reuptake inhibitor.
posted by spaceman_spiff at 7:36 PM on October 6, 2008

I would check out this metafilter post. Especially the crazymeds site, will help you if you want to know what you're in for with the meds you've been prescribed.
posted by sondrialiac at 10:15 AM on October 7, 2008 [1 favorite]

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