How do I get antidepressants?
August 13, 2014 3:06 PM   Subscribe

Who can prescribe antidepressants, who should, and how should I find/talk to that person?

I've been dealing with negative feelings about myself for a few years, and a few months ago I started to suspect I might really be depressed. I went to a therapist. I don't know if it's common, but I'm kinda Dr. Jekyll and Mr. Hyde about my depression, and anytime I saw my therapist, I would transform into Dr. Jekyll and be able to rationally and sensibly understand and explain how I felt and what I needed to do to change it. But outside of therapy, sometimes I'd become Mr. Hyde and contemplate suicide.

I don't think therapy is useless, but I just don't think it's for me. It's tremendously expensive (I'm not poor, so I don't qualify for any assistance, but I do have a small child, so money is tight) and I didn't feel (after a few thousand dollars) like I was getting anything useful out of it, possibly because of the dichotomy in my personality and the way I exhibit depression.

But it's getting worse and worse, and I've made a commitment to my wife to look into antidepressants. I suppose it's salient to mention that I have a family history of clinical depression that has required medication, so I think it's very possible that medication is the best solution for me. But I have no idea how to actually get any. I've broached the subject with my doctor, but she wouldn't speak of any medication before I explored therapy more fully. My therapist, when I was seeing her, also didn't believe in medication. Problem is, my doctor doesn't actually know what's good for me (she barely knows me) and throwing more money at therapy is not something I'm interested in at all.

So how do I do this? Do I need a new doctor? Do I need a psychiatrist? How do antidepressants work, from a prescribing standpoint? What sort of questions should I ask? I feel comfortable with the questions I should ask about the medications themselves and that I might have to experiment for years before I find a medication that works for me. But I don't even know who to talk to.

In case it matters, I live and work in LA, in the Valley.
posted by anonymous to Human Relations (17 answers total) 9 users marked this as a favorite
A general practitioner can prescribe them, or in a more complicated situation may refer you to a psychiatrist. You can usually go straight to psychiatrist depending on insurance requirements but it doesn't hurt to have a physical at GP to rule out issues that might causing be causing problems like blood sugar levels and thyroid functioning.
posted by tamitang at 3:11 PM on August 13, 2014 [1 favorite]

I've had antidepressants prescribed for me by my primary care physician -- three different PCPs actually, so I think it's pretty common practice. If your PCP won't help you, you might want to consider finding a different doctor.
posted by rabbitrabbit at 3:14 PM on August 13, 2014 [4 favorites]

I went to a psychiatrist's group office and had a consult with one of the doctors who does such a thing, and then was assigned to a psychiatrist who was able to diagnose and prescribe. Your GP can also do so, though some (like mine) prefer to refer you to a psychiatrist.
posted by xingcat at 3:14 PM on August 13, 2014

Unfortunately, insurance reimbursements are such that most psychiatrists are not going to be able to spend any more time getting to know you than your primary care doc. You'll get one 30-45 minute visit to establish care and then periodic 15-minute "medication management" visits after that for med refills, etc. That said, while any doc can prescribe antidepressants, psychiatrists are the experts, and are the practitioners in the best position to help you fine-tune meds, dosing and side effects for maximum effectiveness.
posted by killdevil at 3:15 PM on August 13, 2014

If your PCP won't help you, you might want to consider finding a different doctor.

My PCP won't prescribe antidepressants, but I find his reasoning solid, in that he's not one to specialize in that particular kind of illness, and prefers to refer to a specialist. So I don't know that having your PCP not prescribing antidepressants being grounds for finding a new doctor.
posted by xingcat at 3:17 PM on August 13, 2014 [1 favorite]

In the U.S., it's getting to the point where I feel like anon mental health questions should really specify their insurance situation. My advice for someone uninsured vs. someone with insurance but no mental health coverage vs. someone with a more rounded private insurance plan is really, really different right now.

If you're insured, you can (usually) look at your insurance company's online physician search, select for psychiatrists in your area, pick one, call their office, confirm that they're in-network, and set up an appointment.

If you have no or limited mental health coverage and are trying to limit your costs, you may want to either 1) call your insurance company and ask whether a psychiatrist visit will be covered after you've explored therapy as an option, or 2) call the psychiatrist's office and ask what out of pocket charges you'd be looking at.

As an anecdote, both PCPs I've asked about prescribing SSRIs have been fine with it. You can probably call up a new PCP's office and ask if that doctor routinely prescribes antidepressants, and if their staff are decent, I would hope they would tell you. Medication management through a PCP first is almost certainly going to be the cheapest way if your mental health coverage is limited or nonexistent.
posted by deludingmyself at 3:19 PM on August 13, 2014 [2 favorites]

Many GPs will prescribe antidepressants. I agree with tamitang that talking to your GP couldn't hurt anyway, because physical problems can cause depression - hypothyroidism and sleep apnea being two of the most common. You want to rule those out.

IME, where a psychiatrist comes in handy is in making sure you get just the right medication that you need. SSRI's work great for some people, but others respond better to a medication like Wellbutrin. Your doc should listen to your concerns about, for instance, sex drive or weight gain (two common side effects of SSRIs) and be willing to try different medications if the first one (or two) does not work out. Some GPs can do this but many want you to see a psychiatrist. It really depends on your insurance and your doctor. Good luck!
posted by Rosie M. Banks at 3:24 PM on August 13, 2014

Have you tried going back to your GP and asking if they'll prescribe something now that you've explored therapy more?

Also, I totally hear that therapy wasn't helpful for you and that it was too expensive (I've been in the same place myself), but it's also possible that therapist was a poor fit. Particularly if they didn't believe in medication at all, when your family history suggests it may well be helpful to you.
posted by needs more cowbell at 3:25 PM on August 13, 2014

Psychology (talk therapy) works well in tandem with psychiatry (medicine). These are two separate types of head doctors. Maybe your insurance pays for the medicine doctor visits and pills, then you pay a small amount for attending talk therapy at a psychology school clinic. The therapists are students in training overseen by profs, and it's incredibly low cost. Here's one. I simply Googled: Los Angeles Psychology School Clinic and there were several other links, too. (One thing is that suicidal thoughts may be out of bounds for them.)
posted by Jason and Laszlo at 3:32 PM on August 13, 2014

Get a different GP. Take this assessment and bring it with you. When you bring it up, preface your conversation by saying, "My Father, Sister and Aunt all have depression and I believe that I have it too. Here is an assessment that I took. I'd like to try medication to see if it can help."

My doctor had NO problems prescribing Celexa for me.
posted by Ruthless Bunny at 3:34 PM on August 13, 2014 [1 favorite]

I've broached the subject with my doctor, but she wouldn't speak of any medication before I explored therapy more fully.

This seems weird. That a GP may want to refer to a specialist is fine, but just refusing to talk about medication until you "explore therapy" seems strange.

I recommend starting with the GP (if she's in a practice, maybe try to see one of her partners). Tell the doctor you have been in therapy, but you continue to be depressed and your depression is worsening (describe your symptoms) and it is impacting your life in the following negative ways: foo, blah, etc. If you have thoughts about suicide, say so.* Say you would like to look at medical alternatives, and ask whether she is comfortable prescribing depression meds, or would prefer to refer you to a psychiatrist.

*This can be a scary thing to do, but it is really easy as a depressed person talking to medical professionals to downplay how bad you feel, especially if you're not feeling bad in that moment. Sharing that you have had suicidal thoughts helps them know this is a REAL thing and big deal. You don't want to overstate this and create concerns about your immediate safety (if they aren't warranted). They should ask if you have a plan, and if so if you have the components to put that plan into action. Thoughts of suicide + a plan + the ability to put the plan in motion should start to make a provider concerned about a person's immediate safety. Thoughts of suicide without a specific plan are concerning and need to be dealt with, but shouldn't trigger immediate safety concerns.
posted by jeoc at 3:44 PM on August 13, 2014 [1 favorite]

So how do I do this? Do I need a new doctor? Do I need a psychiatrist? How do antidepressants work, from a prescribing standpoint? What sort of questions should I ask? I feel comfortable with the questions I should ask about the medications themselves and that I might have to experiment for years before I find a medication that works for me. But I don't even know who to talk to.

Yes, you should see a psychiatrist. Psychiatrists are the people who will be able to diagnose you and who will be able to figure out the medical treatment options that are best for you. I *highly* doubt that you will run into any trouble with a psychiatrist when it comes to trying out antidepressants (which aren't particularly dangerous like sleeping pills are, and don't have street/recreational value like stimulants do, to name a couple other kinds of medication that psychiatrists also often prescribe but might be slightly more cautious about starting you on).

Did you specifically ask the GP for a referral to a psychiatrist? If not, you should. But even if your GP did say no or does say no, don't worry, because you don't necessarily need a referral from your GP to go to a psychiatrist -- depending on your insurance (do you have Kaiser? if so, this is definitely relevant), you could/should go through the behavioral health center by you instead of through your GP in order to get an evaluation and referral. If you don't have an HMO and therefore don't have access to a behavioral health center run by your insurance, than you should just look for a psychiatrist who takes your insurance. You don't have an ultra complex case, it sounds like, so while of course you want to find a good doctor, any competent psychiatrist is probably going to be just fine. You don't need to get hung up on searching out The Perfect Psychiatrist, at least not for now. Even if you end up deciding to pursue therapy (or workshops or any of that more holistic mental health care), you won't be getting that from your psychiatrist. Your psychiatrist will basically just be for the medication and related issues like getting the correct medical diagnoses (if appropriate/applicable).

When you speak to the doctor you're seeing about trying antidepressants (whether it's the psychiatrist or whether you go back to your GP once more to get that referral or to get the ball rolling before seeing a psychiatrist), tell that doctor that your [depression symptoms, aka, your low mood, fatigue, brain fog, suicidal thoughts, etc] are effecting your ability to function in daily life in that [you have trouble doing XYZ at work/home/with your child, etc]. Be specific about exactly what is going wrong and why that matters. If it's difficult for you to leave your house, if it's difficult for you to complete your work tasks, if your appetite or sleeping has changed, if you have stopped being able to care for your family members or home in certain ways, tell the doctor exactly what is happening, and that this is a *change,* and that it has reduced your *quality of life* and that you feel that you can't *function.* Those are all things that should get the doctor to pay attention.

I'm not really understanding what your GP's perspective is right now, because it is a much bigger deal to try to get by without medication when you need it (and if you think you need it, then you probably do need it) than it is to try medication and discover you don't need it. For what it's worth, if it turns out the antidepressants aren't useful to you or the symptoms you're experiencing don't turn out to be primarily depression after all, then you can just go off of the antidepressants again. I say that having been through that myself. It's not a FINAL AND LIFELONG kind of choice to go on antidepressants, though for many people antidepressants make their lives much better, and resolve or vastly mitigate the depression symptoms, and those people therefore don't *want* to and *shouldn't* go off of anti-depressants again. But there's no need to wait for some immense crisis before trying out an anti-depressant, and it's not as though, two months or a year or however long down the road, you will regret trying the anti-depressants because...well, for any reason. I mean, they're not particularly dangerous drugs in that they're not addicting or easy to OD on or anything, and even though going off of them can be a bit of a headache (maybe literally!) because they are fairly powerful medications, it's not really that big of a commitment.

I'm not sure about what you mean about not knowing what questions to ask, because if you know what questions to ask about the medication (things like, "how long will it take to get up to a therapeutic dosage?" "what kinds of side effects might I expect," etc), then I think you do know what questions to ask. If the antidepressants end up not working out for you -- because they don't actually impact the symptoms that are troubling you, or their side effects are too terrible for you, or whatever -- then it might be a good idea to talk to the psychiatrist and definitely/primarily your GP about what other (health) problem might be causing these symptoms. If at *that* point your GP still won't listen to you, then that is time to change to another GP.

(The reason I say that if it turns out that the antidepressants don't work and that the depression/depression-like-symptoms seem to be just a symptom of *another* physiological health problem, you should work primarily through your GP rather than through your psychiatrist, is that your psychiatrist is going to be on the lookout for and have the ability to treat *psychiatric* disorders specifically, so if you don't have a psychiatric disorder, they aren't really going to be able to help you and you're going to have to go back to the drawing board with the GP and subsequent specialists to investigate what is going on).
posted by rue72 at 3:45 PM on August 13, 2014 [1 favorite]

I didn't feel (after a few thousand dollars) like I was getting anything useful out of it, possibly because of the dichotomy in my personality and the way I exhibit depression.

This doesn't really sound like the issue is with "the way you exhibit depression" as much as it is that you were hiding salient information from your therapist. Have you been doing the same thing with your doctor? Sometimes people think they need to be "perfect patients" rather than being honest or truthful with their treatment team, and that can get in the way of getting appropriate care.

I think filling out some sort of assessment like the one Ruthless Bunny linked, making sure you're being honest on it (maybe run it by your wife, if you're comfortable doing so), and bringing it in to your doctor would be helpful. I also think that bringing your wife to the appointment, if she can go, would be very helpful -- a lot of signs of depression are more noticed by the depressed person's family and friends than by the depressed person.

In the US, about 80% of antidepressants are prescribed by GPs, so it's certainly common practice. If your doctor isn't being helpful, though, then seeing another GP or a psychiatrist (depending, as others have said, on what's easiest given your insurance) is probably your best option.
posted by jaguar at 4:06 PM on August 13, 2014 [1 favorite]

GP or psychiatrist, as mentioned above.

Unless you are contraindicated (long QT syndrome/family heart problems/epilepsy), and assuming you're accurately self-diagnosing "garden variety" depression (MDD NOS), you will almost certainly be first prescribed Celexa/citalopram.

If you have insurance, there is typically a provider finder on your website. Call and see who's actually taking patients.

There are a few psychiatrists left who also do talk therapy; if you want someone to have an in-depth understanding of your sitch, your best bet is to find such a person, do a couple/few talk sessions with them. Insurance will reimburse for at most 30 minutes of a med appt, generally, usually with an exception for initial assessment.

Ask about side effects, drug interactions, intended dosage scaling plan (you will almost always start at a lower dosage than you are intended to wind up at), effects of missed doses, likely time to see results, what plan B is if you don't see results with this one. The thing I like about my p-doc is that she generally takes a very conservative attitude towards med changes, and is generally very much in favor of tried-and-tested over new and shiny.

"Performing health" for the therapist is a very common problem. It can be useful, in fact, to expressly bring it up in the therapist's office as a thing you feel you have done in the past.

I am not a mental health professional, just a patient.
posted by PMdixon at 4:07 PM on August 13, 2014

I'm a doctor, so I can give you a little general background about physicians and the approach to depression.

Your GP's approach is unusual. Most primary care physicians are willing to prescribe antidepressants to their patients without any extensive exploration of therapy or a referral to a psychiatrist. To address the point made by xingcat's physician: primary care physicians, by definition, do not specialize in any disease process, but for common ailments like depression, should know enough to try at least one or two first line treatments and do an initial workup for it prior to referring you to a specialist. In fact, I would say most physicians have a reputation for being TOO wiling to prescribe antidepressants without much discussion about alternative treatment options or lifestyle changes. Perhaps your GP is responding to that sentiment and trying to show that they believe in non-medication options, and does not realize that your financial situation makes exploring therapy further prohibitive, or what the sense of urgency in getting this treated is.

To specifically answer your questions, there is nothing special about prescribing antidepressants, as they are not controlled substances. Any physician can prescribe them, and nurse practitioners or physician assistants can also prescribe them - generally the only people who will give you an initial prescription for a new medication for a chronic condition are either a primary care physician or the specialist(s) whose domain includes that disease, in this case, a psychiatrist. Some (very few, rural/with limited healthcare access) states do allow psychologists to prescribe medication, but I don't think California is one of them. Therapists also do not prescribe meds, although therapists and psychologists work in conjunction with people who can prescribe so that you can get your therapy and your prescriptions from the same office.

The fastest options when you can't get what you want from your primary care doctor are to either try again using a different approach (making sure to mention a history of suicidal thoughts although no current concerns about safety, specifying that further therapy isn't an option) or to ask for a referral to a psychiatrist. If you otherwise like your GP then I would take one of these approaches. If you don't really like your GP, then you can get a new GP and they will be likely to assist you with this issue, but that will take longer as many primary care physicians schedule new patient appointments several months out, and it sounds like you need help sooner than later - I can only assume if your wife is making deals with you about seeking treatment, your situation might be a little more urgent than the rest of your post makes it sound. Good luck! If at any point you are concerned for your own safety, going to the emergency department for an emergent psychiatric evaluation is a must.
posted by treehorn+bunny at 4:09 PM on August 13, 2014 [5 favorites]

Generally, antidepressants are the first line treatment.

I did therapy on and off for more than a decade, and while it might have helped me in some ways, it didn't help my depression. I finally went to a psychiatrist and he immediately gave me a prescription. I started taking it the next day, and two weeks later I felt better than I could ever remember feeling.

I say, fire your doctor, since she's just not on the same page as you. You can call doctors and ask how they feel about antidepressants before you actually go see them.

If I were to do it over again, I wouldn't bother with a psychiatrist. He gave me a prescription following the standard guidelines, and then tried to do therapy with me. Once again, the therapy wasn't helpful. My primary care doctor could have done the same thing.
posted by Renegade Duck at 5:18 PM on August 13, 2014 [1 favorite]

A primary care physician absolutely can prescribe anti-depressants. Or, if you're female, you can also ask your gynecologist - mine has told me that it's one of the most common topics she deals with because many women never see any sort of doctor outside of their annual pap.

It sounds like your current primary care physician is a bad fit for you, so you should seek out a new one anyway. Find a new one - I recommend an internal medicine physician rather than a general or family practice physician - and ask for an annual wellness exam. That is the exact type of exam in which you would bring something like this up*. All you should have to say is "doc, I am going through a really rough time right now, I've tried therapy and it isn't helping me so I'd like to give anti-depressants a try."

*part of the reason you should do it as part of an annual wellness exam (also called a physical) is that this usually involves bloodwork and it will be good for your doctor to make sure you aren't also suffering from any vitamin deficiencies or hormonal issues that may be exacerbating the depression. ALSO, annual exams are usually scheduled for much longer than a regular old checkin so your doctor should have plenty of time to discuss your needs with you.
posted by joan_holloway at 5:33 PM on August 13, 2014 [1 favorite]

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