You’ve tried many things to improve your mental health: journaling to soothe your worries, a yoga class or more exercise. You cut out caffeine and try to get more hours of sleep. Maybe you bought a light therapy lamp to prepare for the winter blues, but it still doesn’t seem like enough.
Now you’re considering medication to help manage your anxiety or depression. Taking that decision can feel like a big step, but it’s also fairly common, especially in the Seattle metro area.
According to a recent survey, about 1 in 5 adults in our area between the ages of 18 and 49 said they had used medication for depression or anxiety in the past 12 months.
The Pacific Northwest has a higher prevalence of mental health diagnosis than other states in the U.S., and there are many stressful events close to home and in the world — a tough economy, two ongoing wars, and whatever personal struggles you’re already facing.
While medication is not a silver bullet (and among experts, how it works and its efficacy is still up for debate), it is one option to help manage your symptoms.
Here are some questions to consider before getting started, and tips for what to expect if you’re navigating this journey.
First things first
“When you feel the need, talk to your primary care doctor,” said Dr. Tobias Dang, a psychiatrist and the medical director of mental health at Kaiser Permanente Capitol Hill Medical Center.
There are no hard and fast rules about starting medication. Experts agree that what matters is finding help early rather than waiting for symptoms to get worse.
In most cases, your primary care provider can prescribe medication, and it’s not necessary to see a psychiatrist. If you are experiencing more severe symptoms, like delusions or thoughts of self-harm, your primary care provider may refer you to a specialist.
In Washington, only advanced registered nurse practitioners and doctors can prescribe medication, not therapists or counselors. There have been efforts to create a new class of prescribing psychologists, though legislation hasn’t gotten off the ground in Washington. Five other states — including Idaho — have made these changes to help the behavioral health care workforce keep up with the demand for services.
Your provider will screen you for anxiety and depression and ask follow-up questions about how your symptoms affect your daily living. For example, are you having a hard time paying attention at school or work? Is your depression or anxiety making it hard for you to take care of your family or be present in your relationships? What have you tried so far to manage the symptoms?
People should also seek out care from a licensed therapist or counselor in order to maximize the effectiveness of the medication, said Dr. Lida Turner, the medical director for ambulatory psychiatry and chief of neuroscience at Swedish First Hill.
“The gold standard is therapy plus medications,” Turner said.
If you haven’t found a therapist yet, consider making moves toward that. (It may take a while to find someone who is a good fit or takes your insurance. The Seattle Times has a guide to help you navigate the process.)
Another question your provider will ask is if you have a family member that has done well on a certain medication. This might give them a starting point for you and help them gauge how comfortable you feel with medication.
There’s also research that shows how a patient feels about medication and their trust in their doctor can affect how well they respond to medication.
A 2006 analysis in the Journal of Affective Disorders, for example, found that the most effective one-third of providers had better outcomes with placebo medication than the least effective one-third of providers had with actual antidepressant medication — highlighting the power of a strong patient-doctor relationship.
The process
Finding the right medication and dosage can take some time.
“We don’t have a blood test or a brain scan that will tell us upfront, this is the right medication for this person,” said Dang.
Starting off then may involve trial and error — and patience.
Providers may start you on Zoloft (sertraline) or Lexapro (escitalopram), two of the most common antidepressant and anti-anxiety medications, because they’ve been around longer with more clinical research to back them up than newer medications.
Both are SSRIs, or selective serotonin reuptake inhibitors. SNRIs — serotonin and norepinephrine reuptake inhibitors — are a common class of medication used in treatment. There are other types like tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) that are used down the line if necessary.
How exactly these medications work is still fuzzy.
For decades, academics have known that depression and anxiety are not simply caused by low levels of neurotransmitters like serotonin or norepinephrine — there’s more to that “chemical imbalance” theory. Instead, a combination of more complex systems that include biological, social and psychological factors is likely at play.
But the simplified underlying theory is that the brain utilizes chemical messengers called neurotransmitters, like serotonin or norepinephrine. SSRIs and SNRIs bind to the receptors on the surface of neurons that receive and transmit these neurotransmitters — inhibiting or blocking the reuptake. This leads to an effect where more serotonin and norepinephrine is available, potentially improving a person’s mood after time.
Further research on the effectiveness of drugs like SSRIs is still needed, particularly when it comes to long-term results. But studies generally indicate they can have a positive impact, especially in cases of moderate and severe depression. An international study in 2018, which used results from over 100,000 participants and 21 commonly used antidepressants, found that all 21 medications were more effective than a placebo over eight weeks of treatment.
Turner, from Swedish First Hill, says the most important part is really educating patients about what to expect during the first few weeks when side effects can be a challenging hurdle for people starting medication.
“The reason why you get side effects is because those receptors are not just in your brain,” she said. They’re in other parts of your body as well, like your gut, which can lead to side effects like an upset stomach or constipation.
SSRI and SNRI side effects can also include headaches and changes in weight, libido or sleep, among other symptoms. In a 2021 study, 38% of patients experienced at least one side effect while on an SSRI antidepressant. If any of them are troubling you, check in with your provider.
Eliza Brink, a psychiatric nurse with Spruce Psychiatric Associates, suggests to her patients, “Take [the medication] with some food and be a little bit more low key if you can be.”
“Or start on a Friday, so you have the weekend knowing that most of the common side effects are going to get better.”
The medication may take several weeks to improve your mood.
“Tolerability is first and then seeing whether there’s a partial response would be second,” Dang said.
In some cases, your provider will up your dosage slowly over time to manage your symptoms. It’s best to stay on your medication and stay in touch with your provider. Stopping medication can lead to worsening of symptoms.
Turner recognizes finding the right medication can be an “uphill battle” especially for those who are already struggling with their mental health, but she says other medications can be used to treat side effects while your body adjusts.
“What’s important is for patients — especially in the medical system as it is right now — to be advocates for themselves,” Turner said.
