By Cassandra Roos
Through the media and elsewhere, misinformation about taking medications for mental health conditions remains concerningly widespread. Confusion, myths, stigma and fear make it difficult to seek help for the first time. Many people first seek help for their teenagers and children through pediatricians, and adults through primary care doctors. Primary care doctors may be ill-prepared to fully deal with mental illness, so it is important to realize that you may be first recommended medications through these channels but may need to pursue further specialized treatment. It is preferable to find a doctor in the psychiatric field, but primary care doctors are usually the starting point for most people.
Seeking professional help will most likely lead to starting on some kind of medication, depending on the severity of your symptoms, and this is not meant to categorize you as “mentally ill.” You haven’t “failed” to fight it on your own, rather you have succeeded in having the strength to admit and accept help. Try to ignore the rumor mill about the trials and tribulations of people who are “through with the industry” because of “trying everything” (extremely unlikely) or suffering “unbearable” side effects. This does not mean it will be your experience. In some cases, side effects do cause problems for patients, but often with dosage adjustments and ongoing monitoring patients experience more benefit from medication than without it.
Sometimes medication just allows someone suffering to get the support they need to get to the next step where they may or may not need ongoing medication therapy. Other people benefit from medication long-term and have a difficult time living without it, this is especially true for people with bipolar conditions. It does not have to be an all or nothing situation, and there is no reason to panic and think medication will be a lifelong ball and chain one must carry. Medication plays a very distinct role in treatment, and is most effective when combined with some kind of psychotherapy.
If you are suffering to the extent that you are considering seeking help, why not give medication a try like you would try a medication for any other condition? This may sound like a cliché line, but it does not make it untrue. Remember, you may not even need medication for very long or at all and that no situation is permanent.
WHAT AM I TAKING EXACTLY?
When you are prescribed medication, ask your doctor for information available to you. Make sure not to rely on online message boards and try to read about what medication you are taking from more reliable sources that vetted and contain research-based information on their websites. One great resources is The National Alliance on Mental Illness (NAMI) www.nami.org and you can access the page specifically discussing medications here https://www.nami.org/Learn-More/Treatment/Mental-Health-Medications. The National Institute of Mental Health (NIH) also has a comprehensive list of medications and their uses here https://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml. The American Psychiatric Association (https://www.psychiatry.org/ and The American Psychological Assocation http://www.apa.org/ are also helpful and reliable sources.
In general, anti-depressants will be given first to patients who exhibit symptoms of depression and anxiety, whereas mood stabilizers are most effective in treating bipolar conditions. Fast-acting, short-term medications called benzodiazepines may be prescribed for anxiety. It is relatively unknown that in the case that an underlying bipolar disorder is obfuscated by the depressed phase of the illness an anti-depressant can be dangerous and trigger a manic episode. This is why it is important to be monitored most when you are first trying a medication. Every case is different and your provider will help you find what will work best in your situation.
The term “antidepressant” is probably the most well-known term when people think of mental illness. Oversimplification of what an “antidepressant” is becomes problematic, because each class of anti-depressants is meant to target different functions of the brain and therefore work in unique ways. Antidepressants have many uses in the medical field including the treatment of pain, insomnia, seasonal effective disorder, ADHD, obsessive compulsive disorder (OCD), panic disorders, phobias, eating disorders, post-traumatic stress disorder, anxiety and mood disorders, and to aid in smoking cessation.
For minor, moderate, and major clinical depression, an antidepressant is recommended along with psychotherapy. Patients can begin on low doses at first to see how they adapt to the medication. Providers may not make this clear, but it takes 4-8 weeks for anti-depressants best treat symptoms. Patients often want to give up on a medication too early because it “is not doing anything” but antidepressants take some time to work.
Classes of antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin and noradrenaline reuptake inhibitors (SNRIs), tricyclic antidepressants (helpful with OCD) that block reuptake of serotonin, dopamine and norepinephrine, and monoamine oxidase inhibitors (MAOIs) and bupropion.
These medications slow the re-uptake of certain neurotransmitters in the brain that are being too quickly absorbed and this helps establish the proper balance of chemicals in the brain. Some considerations your health care provider will use to determine what kind of antidepressant to prescribe are: symptoms, age, health conditions, anticipated side effects and anticipated toleration of possible side effects, patient preferences, drug interactions, cost, half-life, etc. People who experience various stages of bipolar disorder may also be prescribed anti-depressants, but there is less room for experimentation.
Mood stabilizers have been shown to be the most effective medications to use in the treatment of bipolar disorder. Medications that have been empirically (results derived from research-based evidence) found to treat bipolar conditions can differ from medications used to treat depression. They also take 4-8 weeks to work at therapeutic doses.
Types mood stabilizers used for bipolar conditions and some names of these medications are: carbamazepine, oxcarbazepine, and lamotrigine. For patients diagnosed with the more intense Bipolar 1 disorder, only two medications are highly recommended for treatment, lithium* and valproate. A mood stabilizer differs from an anti-depressant because it is meant to address the extreme elevated highs as well as the severe lows associated with the condition. Anti-depressants are also used for patients with bipolar disorder, but not always as effective. Some mood stabilizers are used in epilepsy and are anti-seizure medications, but are effective for both conditions.
OTHER CLASSES OF MEDICATION
There are other classes of medications including anti-psychotics, benzodiazepines, stimulants (for attention deficit disorders), and other medications are used on or off-label (not originally intended for that use) to assist in easing anxiety or aid in sleep. Anti-psychotics are used to treat a wide variety of mental health conditions. More recently, newer anti-psychotics, known as “atypical antipsychotics” are given to non-psychotic patients to aid in the treatment of symptoms when mood stabilizers and anti-depressants are not effective enough.
IMPORTANT WARNING ABOUT BENZODIAZEPINES (Xanax, Valium, Ativan, Klonopin)
Benzodiazepines (commonly known types are Xanax, Klonopin, and Valium) are highly addictive and sedative, likely to be abused, and can be dangerous when mixed with other substances, especially alcohol. Mixing alcohol with these medications will cause blackouts. Please be very careful if you or your child is prescribed a benzodiazepine. It will work faster than an anti-depressant or mood stabilizer and appear helpful (or to be the only thing helpful because it is fast-acting) but this class of medications can be very dangerous. More and more doctors are reluctant to turn to benzodiazepines for treatment although the effect on symptoms are immediate, there is less long-term evidence that they treat the underlying condition, and these medications usually impede long-term patient progress.
Contrary to popular rhetoric, nobody will force you to stay in treatment or judge you, most professionals are here to help you and work through your problems with you. When you are at a low point, it is difficult to advocate for yourself. As you get better, it is important to do small things to help get the best treatment possible. One example is to write a checklist of topics you want to discuss with your provider, especially due to current time restraints placed on prescribers. Your doctor is still human like you and cannot read your mind.
If you are afraid to try medication that is okay, just consider it as an option that may help you or someone you know get better exponentially faster than they can without it. It is unfair and potentially dangerous to simplify hearing about someone’s experience of trying many medications as useless or blame it on the failures of the field of psychiatry without trying to analyze why the medications that did not work were not appropriate to a patient’s symptoms or diagnosis. For example, if someone is not properly diagnosed with bipolar disorder until the symptoms are clearly present later in life, then it makes sense that earlier medications given to treat the patient’s symptoms may not have worked or only worked for short periods of time as the cycle of the illness progressed. Medications are not meant to eliminate a mental illness, but work to address symptoms and help the patient work towards stability.
It is frustrating that psychiatric treatment can involve so much experimentation, but as with any complex medical issue, no treatment will ever be proven 100% effective. Changing medications over time, even when they may have previously worked for you, is not always a reason to give up completely. There are a wide range of options if certain medications do not work for you. Feeling frustrated with trying medications that don’t work or result in delirious side effects does not mean that your provider has failed, that the field of psychiatry has failed, or that you are an outlier who does not respond to treatment. Do not be swayed by bombastic voices that may make you think that. Sometimes a medication may not seem like it worked, but it is uncertain to know how much worse the situation may have been without it. Most of all, every situation is unique, and trying different medications until you find what works for you is frustrating. Starting medication for the first time does not have to be a crisis in itself. Many people do not have to stay on medication for very long. With the amount of research out there today you can try to learn as a patient and if you have the capability to advocate for yourself or find someone who can help you do so, you will be much more empowered and better able to cope with your situation.
Sources and for further research go to:
For Further Information
The American Psychiatric Association https://www.psychiatry.org/
The American Psychological Association http://www.apa.org/
National Institute of Mental Health https://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml
National Alliance on Mental Illness https://www.nami.org/Learn-More/Treatment/Mental-Health-Medications
Treatment of Major Depressive Disorder:
Treatment of Bipolar Disorder:
New Research on Depression in Teenage Girls:
Anti-depressants triggering mania:
Peet M. “Induction of mania with selective serotonin re-uptake inhibitors and tricyclic antidepressants.” Br J Psychiatry 1994; 164:549-550.
Use of atypical antipsychotics with antidepressants and mood stabilizers:
Nelson JC, Papakostas GI: Atypical antipsychotic augmentation in major depressive disorder: a metaanalysis of placebo-controlled randomized trials. Am J Psychiatry 2009; 166:980–991.
Pediatrician Participation in the Treatment of Mental Illness: