Is my SSRI working? Too much or not enough to increase the dose?
October 4, 2013 4:48 PM   Subscribe

I was just prescribed Zoloft for anxiety and possible depression. After I've been taking it for 1, 2, 4 weeks or whatever milestones make sense, how can I determine whether it's actually working., and how do I decide whether a dose increase might help me more? I'm looking for specific challenges - exposure exercises, though experiments, daily logging maybe? - to attempt and compare with previous results to quantify my improvement.

I was prescribed Zoloft a couple of days ago for long-standing social anxiety worsened by (relatively) recent health problems, and possible depression secondary to the health problems and effects of intensified anxiety. My doctor told me to take 25 mg a day for about a week, then if it "seems to be work, but not enough" (whatever that subjectively means), to increase to 50 mg a day. I will see him again in 4 weeks.

My primary goal with this prescription is to substantially decrease my social anxiety to the point where I can cold-call one or more therapists and psychiatrists to get started with focused help; and to correct whatever part of my energy deficit might be caused by depression. Nothing points out that I have a problem like sitting on my floor, looking at a box under a table, and almost giving up on pulling it out because it's just too much of a hassle to reach and pull.

Eventually I want my first thought at nearly every action to not be, "Will someone notice that I [did X] and change their opinion of me negatively?" and avoid the hesitation and stagnation that creates.

So, I'm looking for small challenges to try out to test my avoidance, anxiety, motivation, lack of tolerance, and everything else that is messing with me, to determine whether the Zoloft is starting to work, and whether to increase my dose, or try for a different med.

Some examples of things that are varyingly difficult for me depending on my state of mind on any given day:
  • Dropping off outgoing mail, which has to be done in a small basket in the main leasing office of my apartment complex.
  • Making or receiving phone calls to/from people I don't know well - especially cold calls or to call centers where I could get any random representative.
  • Eye contact with people with whom I'm not currently engaged in well-defined conversation.
  • Being somewhere without an obvious obligation or well-defined transaction model, e.g. walking anywhere for exercise, especially if I pass the same person more than once; window shopping when there's a likelihood that someone will try to "help" me or sell me on something
Those types of things aren't just annoyances - the pop up in my mind as soon as I consider doing them and bother me enough to make me avoid doing them.

So I'm looking for small, atomic tests or challenges to gauge the ongoing effectiveness of my meds. Something that I can do toward the end of this week, and then the end of the month, to be able to say, "It hasn't helped at all yet," "It seems to be helping but not enough yet," or "It's working great!"
posted by mock muppet to Health & Fitness (13 answers total) 12 users marked this as a favorite
If I were you, I'd want to simplify this a bit. I'd do either a 0-10 rating for each day ("How much did my social anxiety affect me today, or keep me from doing what I wanted to do?"), or there's this mini-inventory for social phobia and anxiety:

[Rate the items] using a 5-point likert scale: 0 = not at all, 1 = a little bit, 2 = somewhat, 3 = very much, 4 = extremely.

1. Fear of embarrassment causes me to avoid doing things or speaking to people.

2. I avoid activities in which I am the center of attention.

3. Being embarrassed or looking stupid are among my worst fears.

I would give each item the 0-4 rating, then see how it changes each day, week, or month. Maybe I'd think about where I'd want my goal to be for each item (probably working up to 0 or 1 for each item at least five days a week?), and let that guide me to start with.

I would also say that once you get to the point where you're comfortable getting a psychiatrist, this decision-making about dosage should be their job. Monitoring yourself will be a huge help for that, and you should certainly collaborate with them about how you're feeling, but "figure out what dose works on your own" is a weird situation for your current doctor to have put you in.
posted by jaguar at 5:06 PM on October 4, 2013 [1 favorite]

If you have a smartphone, download a mood tracking app and have it ping you at set times every day. Or just do it online.
posted by munyeca at 5:21 PM on October 4, 2013

Mood tracking is a good idea. But honestly after about 1-2 months it was just clear to me that I felt better-- things were easier, I woke up on time, &c. Just be ready for thoughts like "why did this used to be so difficult? It's no big deal." Because if its working that's how it might feel.
posted by stoneandstar at 5:43 PM on October 4, 2013 [8 favorites]

Amen to the mood tracking apps/sites. They're the easiest thing I've ever used for this.

I also sometimes use the Beck Depression Inventory or something similar; there are certain bellweather questions that give me a really simple and quick way to assess how I'm doing. Like, a move up or down on the suicidal ideation question is a really big deal, so I basically have the two relevant ones (the second-best and third-best) memorized and just ask myself which one feels more true lately.

By the way, you should start noticing improvements in a few weeks, but it sometimes takes longer to get to where you're eventually going to be at a given dosage level. This isn't a poop-out thing, but more like the euphoria that comes with suddenly feeling significantly less awful, and then that euphoria dropping off again and realizing it's actually kind of tough getting yourself out of bed still.
posted by Fee Phi Faux Phumb I Smell t'Socks o' a Puppetman! at 6:11 PM on October 4, 2013

A very smart and practical psychiatrist once told me, "If it's working, you'll know." I've tried a lot of different anxiety meds at different times in my life, and I've found it's true for me.

If you can't really tell by the relative amount of anxiety you suffer before or while doing something, then try to estimate how much the activity "took out of you." How do you feel afterwards? When I'm very uncomfortable, it ends up making me feel tired and depleted. During a bad time, something like going to pick up a prescription feels scary and exhausting.

Thinking a lot is just part of having a lot of anxiety. If your meds start working, you'll probably notice that your mind is quieter and you do a lot less second-guessing about things you think and want.
posted by wryly at 6:12 PM on October 4, 2013 [2 favorites]

When I was in IOP (intensive outpatient) therapy, one if the things we did was a daily mood rating chart. It was a fairly extensive list of different aspects of mood and daily challenges and you would rate each from one to ten, and add up the total score. I think something like this would be really helpful to do every day. That way you can track overall progress, and see if your total scores increase, even though there will be ups and downs, gold days and bad days, you can see if the general trend is up. You can ask your doctor if they have something like this, or maybe create your own, that focuses on your specific issues. For example, maybe rate your social ability each day, stances of anxiety, and how severe, maybe certain daily goals, and if you attain them. I think this will really help you quantify if there is an improvement from the meds, and probably just be generally useful, and something to share with your therapist. I'm sure you can also find list like this online, or even an app.
posted by catatethebird at 6:21 PM on October 4, 2013

(On googling, I mostly found the NIMH chart, but I am thinking of a much more detailed and extensive one. Here's an example.)
posted by catatethebird at 6:33 PM on October 4, 2013

I don't know what you're like in real life so I can't say whether that's too complicated for you but that sounds too complicated for me. My job is cyclical so I knew that my meds were working when I was in the middle of a stressful time at work and I realized, this is Hard but I'm Doing Okay.

It's hard to see how dramatically my meds have improved my life because it's like night and day. Before meds, it wasn't unusual to have thoughts like, all of my clothes make me look fat and stupid, everyone who sees me thinks I'm a loser, I should call in sick. Now, I'm like, it doesn't matter, put on any clean clothes you own and go to work. So, I think you'll know when you know.
posted by kat518 at 6:47 PM on October 4, 2013 [3 favorites]

If I may make a minor suggestion: Hold off on measuring things for a couple of weeks. Come up with whatever measurement plan makes sense to you, measure yourself at your baseline (can't get the mail, etc.), but then don't measure anything else for a bit.

Here's why: If you are already anxious to the point of avoidance, you may not want to add an, "is it working yet?" cycle to your thoughts, especially if there's a chance that a few bad days would convince you it wasn't working at all. (A little like, if you've ever tried to lose weight, and weighed yourself too frequently, where the normal daily variations in weight suddenly seemed like failure.)

I would absolutely try some behaviors out: Why look, there is a store with people inside, I will stop in for a few minutes. Hey, I will get the mail now. Just the little things, with no pressure whatsoever, because you're not gauging the success of the med (or of yourself).

Then, in a month, go back over the list you typed up there, and ask yourself whether you've done any of the things you want to be able to do more frequently. If so, talk to your doc about it, and if not, talk to your doc about it; maybe a dosage increase would indeed be called for.
posted by mittens at 6:59 PM on October 4, 2013

Wait three weeks then come back to your question. For most people it takes that long to kick in.
posted by St. Alia of the Bunnies at 9:28 PM on October 4, 2013 [1 favorite]

Read this (and the associated informative blog here), this and this.

If you have any questions about any of these concepts please let me know or MeMail me.

Also, keep in mind that progress is never in a straight line. There are always dips in the road.

One other thing as well, when you're looking for therapists don't look for social anxiety as a bullet point. You want to find someone who deals almost exclusively with your problem. I started with a general therapist for some serious panic/anxiety disorders who didn't know what to do when I started having intrusive thoughts. Whereas my current therapist who is a zen master of anxiety and OCD immediately knew what I was talking about coming out of my IOP program.
posted by Talez at 1:58 PM on October 5, 2013

I've been on most of the SSRIs. Their effect comes on very gradually, so it's hard to tell when it's working. I'd give it at least 6 weeks or 2 months. Then, ask yourself, "How am I feeling? Any different?"

Your doctor will absolutely talk with you, but, again, don't expect that to be for a few weeks.

I've been on Effexor for a number of years. In addition to inhibiting serotonin reuptake, it inhibits norepinephrine reuptake. At least for me, it showed results quickly. If Zoloft doesn't work for you, you might ask your doctor about Effexor.
posted by KRS at 7:38 PM on October 5, 2013

For me the effects were definitely more gradual--when starting on SSRI's for the first time (which was just about a year ago) I definitely wasn't able to appropriately assess whether the specific things that were hard for me were getting any easier. But, one year later, I still marvel at the fact that for things I hadn't even realized were hard, now these things take literally no thought, and/or I actually enjoy them. (The enjoyment part is something I explicitly have worked on, and there is no way I could have gotten here without being medicated.)

These are some of the things: washing dishes; taking a shower; putting on jewelry (um, haven't done that in 10 years--I thought I just didn't like jewelry anymore); combing my hair; wearing a new outfit each day; noticing people on the street and feeling something outside of myself for them (e.g. liking something about the way they are dressed or are interacting, having empathy for a homeless person or a couple who is in a fight). Basically just feeling, instead of ruminating or worrying about the past or the future--just being in the present.

For me these changes did not happen in any kind of "instant" way--the improvements were much more gradual than I could have measured in weeks or even months. That said, my doctor put me on a very low "starter dose" with the same advice as your doctor gave you--"if you don't feel better, we can increase it". I just somehow "knew" that the beginning dose wasn't working--I simply didn't feel better. But I suppose the dose was at least enough to help me know that it wasn't enough, and do something about it.
posted by gubenuj at 10:50 PM on October 5, 2013 [3 favorites]

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