Well, welcome back to another episode of your
favorite pharmaceutical podcast, Your Mom on
Drugs. My name is Josh and I am the son. And
I'm... Jenny and I'm the mom. And welcome to,
I think this is episode 16. And today we're going
to be covering a topic that we haven't covered
before. And I don't think anything related to
mental health, which is the topic of SSRIs, which
stands for selective serotonin reuptake inhibitors.
That is a mouthful. But I've got some friends
who take SSRIs and I think a lot of them are
like, Why do I take these? Do I need these? And
what are the side effects? And so that got me
thinking. I was like, well, I've got a perfect
family member who I love dearly and is very smart
who could probably answer these questions. So
for anybody who's thinking about going on SSRIs
or going to a psychiatrist to prescribe them,
we hope this episode will kind of help inform
you so that you can have an informed discussion
with your primary. Not your primary, your specialist
health care provider, right? Yeah, I'm thinking,
yes. I mean, there could be a primary care provider
that prescribed them too. They're not just designated
just for a psychiatrist to prescribe. Okay. Well,
cool. Well, so let's delve into the world of
SSRIs. So, Mom, do you want to kind of give us
a brief overview of what they are and what they're
for and how we got here in this moment? Yeah,
I'm going to start first of all, and again, we'll
get to this as we move on in this discussion,
but SSRIs are used for a variety of different
indications, but I'm going to start first of
all with depression because that's a... That's
where they started as far as when they got approved
for use. And so let's first of all talk about
depression as far as an illness is concerned.
It's really a serious debilitating disorder for
those that have been diagnosed with major depressive
disorder. And despite a lot of different treatment
options, depressive disorders are difficult to
manage. And there's a lot of reasons for that.
One is that you can have high relapse rates despite
being treated for them. You can have unwanted
adverse. adverse effects from your therapy. You
could have co -occurring mental or physical conditions
that also add to compound that disease state.
And you could also delay your treatment if you're
like, you know, there's been definitely a stigma
associated with mental illness for years. And
I think that we're breaking through that a bit,
but there is still that stigma. So it does delay
people going to get help for mental illnesses.
I thought this was very fascinating. And in the
1950s, there was clinical research with antihistamines,
you know, those drugs that we take for allergies
and cough and cold. Shout out to our former episode
on allergies. There you go. Phenothiazines. Phenothiazines
are drugs that are used in mental health disorders,
primarily for schizophrenia. And then there's
other. And then so we've got. antihistamines,
phenothiazines, and medications that were used
to treat tuberculosis of all things. And this
is how we got our first antidepressants used
because they are discovered because they found
that although they were being investigated in
these particular areas, they found that the agents
that were being investigated actually worked
to help with depression. Oh, interesting. So
it was kind of an accident. It was kind of an
accident. Sometimes that's how drugs are found.
I know. So the drug class tricyclic antidepressants
is one that's used to treat. treat depression.
And so imipramine is one of those tricyclic antidepressants
and it was found through this mechanism. And
another drug class that is used to treat depression
are called monoamine oxidase inhibitors or MAOIs.
And so there was another agent that came out
of there, out of that initial research that was
discovered for depression. The tricyclic antidepressants
really target norepinephrine, one of our neurotransmitters.
and the monoamine oxidase inhibitors actually
target epinephrine, norepinephrine, and dopamine.
And we're not going to really talk a whole lot
about those agents. We'll just kind of skirt
around them. But I just wanted people to be familiarized
with those drug classes that are also used to
treat depression. I like that. Are we going to
do a basic overview of just kind of basic neurobiology
just for folks out there who... maybe are we
gonna like what a basic neurotransmitter is like
what does that do Yeah, I'm going to let you
do that. Because in that research also, they
also found that serotonin is also implicated
in depression. So we've got a lot of different
neurotransmitters that are implicated in depression.
So before I get into the prevalence of depression,
why don't you... Actually, let me do the prevalence
and then we'll skirt into talking about the...
Well, let me give a brief overview first because
I just think it'll set the stage. So we're throwing
a lot of terms at you. things like norepinephrine
serotonin dopamine and you've maybe the audience
has heard of a lot of these chemicals thrown
around i think people associate dopamine with
like the pleasure neurotransmitter or hormone
and then serotonin is like the feel good or like
social and um If you really take it back to,
if you look inside of your brain and even in
your body, there are these certain types of cells
and you have hundreds of types of cells in your
bodies that do different jobs. Just like if you
have a company, you've got a lot of different
people that do these jobs. So the job of these
cells called neurons, they're a lot of them.
Most of them are in your brain. Then you also
have them all over your body. We distinguish
between the central versus the peripheral nervous
system. The central nervous system is your brain
and your peripheral is like, All over your body,
like how you can feel things in your fingertips,
for example. Or your toes. Or your toes. Heads,
hands, shoulders, knees, and toes. So if you're
thinking like, okay, if I stub my toe, then how
does the signal from the toe get to my brain
to be able to perceive, hey, I just stubbed my
toe. And that is. used by, they're mainly electrical
signals. And the signal is passed between cells,
kind of almost like a yarn of string, where you
have certain knots that are basically the connections
on the string. And where those knots are is essentially
not, it's not really a knot in a neuron, it's
a space. And we call that space the synapse.
And so when one nerve wants to send a signal
to the other nerve that's to the next to it,
there's a gap in between. So it's thinking, shoot,
I got to cross this gap and I don't know how.
So for some reason, biology invented this mechanism
of sending these things called neurotransmitters,
which essentially carry a signal from one nerve
to another. And depending on the type of nerve
and the type of signal, it'll either send dopamine,
serotonin. GABA. There's a lot of different types
of signals. And based on the concentration of
this signal, meaning how much serotonin you have
or how much GABA you have, it'll either excite
the next neuron being like, oh, I want to tell
this message to the next neuron. Or it'll be
like. don't tell this message to the next neuron.
So we call them excitatory or inhibitory neurons.
And depending on what type of neurotransmitter
you're dealing with and how much of it you have
in a certain amount of time, you will send a
very strong or long lasting or weak. So whenever
we're talking about things like neurotransmitters,
literally thinking about it like a game like
telephone that you played in kindergarten where
it's like I'm telling you a secret, then you
tell the next person. And that signal is going
from one area of your body or one area of your
brain to another area of your brain. And that's
just going to basically carry a signal. So just
wanted to set the stage for that. So when you
listen to Dr. Seltzer talk about neurotransmitters,
you have this kind of idea in your mind of how
these signals are being sent. Okay. That's a
great explanation, Josh. And so I'm just, I'm
really, we're going to talk about other disease
states, but I'm really just giving a lot of the
main details about depression since it's going
to be the one that we. deal with a lot. So the
lifetime prevalence of depression has been estimated
to be about 15%. And this is for unipolar depression.
And when I say unipolar depression, that means
that you don't have the manic component of bipolar
disorder associated with it, but it's just major
depressive disorder. And about 4 % of the population.
worldwide experience depression that's about
300 million people i never knew that's where
bipolar came from where it's like you have the
depressive symptoms but then you also have the
manic yes so it's just called unipolar depression
yeah Oh, interesting. So bipolar is almost kind
of a form of depression, but with a manic state.
Absolutely. And again, I am not a psychiatrist
and I'm not a pharmacist that specializes in
psychiatry, but I believe in patients with bipolar
disorder, they spend a lot more time in depression
than they do in mania or hypomania and stuff.
But those episodes do definitely happen and that's
how they get characterized differently. That's
really interesting. I've always wondered where
the term bipolar comes from. Makes a lot of sense.
Females will be affected with depression twice
as much as men or males. And interestingly, over
the years 2005 to 2020, depression rates in 18
to 25 -year -olds had doubled. Do you think that's
due to – I'm sure we're just speculating. Do
you think that's just due to – better diagnostic
or just like, or maybe, you know, you think,
I mean, it was before the pandemic, you know,
cause that definitely caused some issues with
younger people and stuff. But I mean, life just
gets harder, you know, and stuff. And may I,
you know, and I, you know, definitely different
than when I was a kid, you know, and stuff. So
I don't know if that's, you know, with you, the,
all the whole social media, you know, trend,
you know, with, you know, I don't know if that
amplifies, you know, like, you know, I've got
to get this many likes and not, you know, I'm
not accepting. I don't know if that really, that's
only speculation on my part. I'm just more wondering
is like, if we see more of it and you said that
there was a bit of a social stigma, I think there's
been always a social stigma around mental health.
I know you've dealt with that personally of just
like, even when I remember you got in that car
accident and people were just expecting you to
get back to work. you know, really quick. It's
like, yeah, whatever's in your brain, like you
just got to get messed up. You got to get over
it. And like, you don't treat it like a broken
leg. It's for some reason we, we haven't approached
mental health the way we do physical health until
recently. Yes. I think behavioral changes make
us feel uncomfortable. You know, it's a lot different
than if somebody has high blood pressure, you
know, so that's a really good point. Yeah. Yeah.
You can have a really pleasant cancer patient,
but a really unpleasant bipolar patient. Yeah.
Even if they're really healthy. Yeah. Interestingly
and sadly, about 10 % to 15 % of patients with
depression will also attempt suicide. And anxiety
peers up or accompanies depression in about 50
% to 75 % of patients. So it's not uncommon to
have a patient that both has depression as well
as has some sort of anxiety disorder as well.
So like I've talked about, depression is a more
common mental illness. And there are different
factors that may contribute to depression. You've
got some genetic factors. So if you have a blood
relative with depression, you would be more likely
to have depression. Biological changes. If you're
taking a particular medication or you have certain
medical problems, they can contribute to developing
depression. We've talked about cancer patients.
When you're facing potentially mortality, that
could trigger having depressive episodes. And
so that's very realistic. Environmental issues.
So if you use alcohol or drugs, that can contribute
to depression. And psychological issues. So if
you've been abused, if you've had a traumatic...
life event or a traumatic event that can also
contribute to a depressive disorder. So there
are actual clinical definitions for all the mental
health disorders. And it's in a book called the
DSM -5. It stands for the Diagnostic and Statistical
Manual of Mental Disorders. So DSM, yes, DSM
-5. And the five stands for the fifth edition.
And so you can pull up this resource and it will
tell you in specifics and very much detail the
criteria for getting diagnosed with a particular
mental health disorder. Because mental health
disorders are... You know, we can think we're
depressed or we can think we're anxious, but
then it goes away really quickly, you know, and
stuff. Because you're having a bad day, you know.
Yeah, I feel like that's probably the hard and
sticky thing about mental health disorders is
that the line between normal behavior, quote
unquote, versus a disorder can be quite blurry.
Like you said, I've definitely been in a temporary
depressive state, as you know, as my mother.
And it's like. But then, yeah, with enough time,
you're able to kind of get out of it. But when
you're in that mode of feeling depressed, it
is hard to imagine that you're going to feel
any better. And so it's got to be really interesting
to look at a patient and see them going through
these symptoms and wondering, is this severe
depression? Is this minor depression? Like you
said, I imagine it's also good for codifying
this stuff for insurance reasons, right? So like
at the end of the day, it's like, okay, I need
this list of criteria and I know it's a bit fluid,
but at the end of the day, I've got to call it
something so that I can justify the intervention
I'm going to prescribe to this individual, right?
Right. And too, I think a patient's going to
get to the point where it's like, I can't handle
this myself. Typically, depression, you have
to have at least five or more symptoms out of
this whole long list of symptoms. It could be
that you're feeling really sad or that you don't
have an interest in daily activities, that you
have changes in your sleep or your eating patterns.
And they're there almost every day and it has
to last for at least two weeks. And so it causes
you to have impairment that you just want to
not. participate in life anymore. And you also
have to get, this is another reason I think you
go to a healthcare provider is to make sure that
it's not due to some other medical disorder because
depression sometimes can mimic other disorders.
So then you've got a label per se, you know,
but you're not, you don't get the label so that
somebody could say, oh, there goes that oppressed
patient. But it's like, okay, now we can figure
out if you want to do something about this. Now
we've got some. we've got some avenues in which
to tackle this particular condition. So. That's
a good point. It's like, it's someone who, you
know, you might have high sodium and it's just
like, you need to know that you have high sodium
so that you can do something about it. And then
maybe potentially become a person with normal
sodium levels in your blood. But like, no one's
going to say there's a high sodium person. They're
just going to say, this is a, hopefully a temporary
condition or a temporary state that we can help
you get through. Right. And just speaking to
anybody who's going through depression or anxiety,
I've been there. And it really, it's such a perverse
feeling because you would think that when you're
depressed, you would want to get help and you
would want to do the things that make you better.
But actually you want to do all the opposite
things to make you better. So when you're feeling
this way, the hardest thing in the world to do
is actually to do the things that make you better,
which is to get help, talk to friends, exercise.
And we're going to talk about all this stuff
later. I know it feels so dark. I've been there.
I've been there. Like, I just wish I didn't feel
this way anymore. And you probably will for a
bit, but that's why it's really good to seek
somebody else who's not feeling the way that
you're feeling so they can kind of like be your
eyes for you and like let you know that there
is a lighter side to this. Because even like
six months ago, my mom can tell you I was going
through tough stuff and I was, oh my gosh, I
was so sad. And just being here now. so light.
It's pretty amazing. I would want to tell my,
my, my former self six months ago, like it's
going to be okay, but you really don't feel that
way in the moment. Yeah. Well, so we talked about
the fact that one of the, and the reason that
we're talking about serotonin we're targeting
serotonin today, as far as one of those neurotransmitters
that is uh, targeted as far as treatment and
depression is because we're talking about selective
serotonin reuptake inhibitors. So let me give
you a little tiny bit of a background about serotonin.
Like Josh said earlier, serotonin is one of the
chemicals that can carry messages between nerve
cells in the brain and throughout the body. And
like he also mentioned too, that normal levels
of serotonin can produce focus, emotional stability,
calmness, and happiness. So serotonin is a good
neurotransmitter to have. you know, higher levels
of. One of the theories as far as why depression
happens is that these neurotransmitters, serotonin,
norepinephrine, and dopamine. are decreased.
And so that there's some sort of, it was called
the monoamine hypothesis. And so it was used
for a lot of years. I think 50 years was kind
of like, and researchers are always looking for
new things per se, but that kind of stuck for
a while. There are some newer research ideas
going out around now as far as why depression
happens. And so, yes, these neurotransmitters
are. are implicated and are targeted in the definition
of depression, but it may not just be that they're
in lower concentrations, but it could be that
they're not used effectively. It could be that
they are produced in an inefficient manner. There's
a lot of different theories as well, too. So
I don't stand before you stating that we know
the exact mechanism why depression happens, but
we do know that these neurotransmitters are involved.
So the selective serotonin reuptake inhibitors
were, so like I mentioned earlier, the earlier
antidepressants, monoamine oxidase inhibitors
were shown to inhibit monoamine oxidase. And
monoamine oxidase has an effect on... dopamine,
epinephrine, and norepinephrine. So it increased
their concentrations. And tricyclic antidepressants
also showed that they blocked the reuptake of
norepinephrine. So then that meant that you've
got more norepinephrine, epinephrine, dopamine
in your synapses to operate. Yeah. Just to clarify
that point is like when your cell, when your
neuron is done sending a signal, it just recycles
that signal, the serotonin or norepinephrine
back into the original. neuron that sent the
signal. But if you block the way for it to get
back inside and it stays in that space, which
we call the synapse to go to the next thing,
then the concentration of that will be higher.
Therefore you increase that in the synapse. So
by blocking it or, you know, the reuptake inhibitor,
quote unquote. in the name ssri meaning that
less of that serotonin will get taken back up
by the original cell and it'll stay in that synaptic
cleft which we call that space in between or
the knot on the yarn as i alluded to earlier
and you'll get a stronger signal right right
so in 1960 in the 1960s eli lily which is a pharmaceutical
manufacturer they showed that molecules could
also effectively inhibit serotonin. So then that
led to the birth of selective serotonin reuptake
inhibitors. And the first one was a drug called
fluoxetine. And actually it was in 1988. Is that
Prozac? It is Prozac, yes. So with the development
of the selective serotonin reuptake inhibitors,
the usage of antidepressants increased five -fold
between 1988 to 94 and then the 2015 to 2018.
It increased five -fold because of SSRIs, because
they have a better adverse effect profile than
tricyclic antidepressants and monoamine oxidase
inhibitors. So, like we talked about, SSRIs inhibit
the reuptake of serotonin. So, you've got, like
Josh said, there's more serotonin in the synapse
to be utilized to send that signal. And remember,
serotonin causes a more calming feeling and lifts
the mood and makes it feel happier. So, in depression,
it's going to work to help with that particular
aspect of that disease. Oh, let me just give
a little caveat. I'm sorry. This probably sounds
like all over the board. But there are selective
serotonin reuptake inhibitors. There are also
a couple of medications that are called. Serotonin
and norepinephrine reuptake inhibitors. So that
implies they're SNRIs. So that implies that they
also will block the reuptake of norepinephrine.
And I believe they have a little bit of an effect
on dopamine as well, too. So there's a couple
of agents like that. So they're still blocking
serotonin, but they're also blocking norepinephrine.
And we'll get to those names in just a minute.
The selective serotonin reuptake inhibitors have
fewer effects than the TCAs, which are the tricyclic
antidepressants, or the monoamine oxidase inhibitors,
which are MAOIs, because those agents have antihistaminic
and anticholinergic effects, and especially the
anticholinergic effects can cause things like
urinary retention in men, especially if they
have enlarged prostates and they already have
issues with that to begin with. So that can be
uncomfortable. You can have dry mouth and it's
harder to pee. It's harder to pee. So, or you
can have dry mouth, that type of things. And
tricyclic antidepressants are also associated
with having different types of cardiac dysrhythmias.
So the larger doses that you've got that to be
concerned about as well too. MAOIs have a lot
of drug interactions with them as well too. And
you also have food interactions with them. So
they just became, they're just more complicated
and it's just more, you have to watch out more
for how you - It is more restrictive in your
lifestyle. It's not that you can't use them.
And we'll get to that when we talk about the
adverse effects in a minute, but just that they
do have more adverse effects associated with
them. And as you famously say, if there are no
side effects, then there's no effect. There you
go. Because something's going to happen in your
body. So if you're going to alter the concentration
of neurotransmitters in one area, unfortunately,
it's not a very specific thing. So it's going
to go to your body and potentially do something
else as well. Right. You just have to understand,
is the trade -off worth it? I forgot to mention
too, there's now a newer third kind of class
of drugs that also affect serotonin. They are
the SSRI serotonin 1A receptor partial agonists.
So they not only are they reuptake inhibitors,
but they actually also serve as kind of a partial
agonist on the receptor. So I believe that that's
going to like enhance the production of serotonin.
You know what's a great serotonin 2A agonist?
Psilocybin. Do you know what that is? I do, but
what is that? It's the ingredient in magic mushrooms.
Oh, no. No, no, no. No, son. No, no, no. No,
no, no. Yeah, we could have a whole podcast on
that. Oh, Lord have mercy. Please, no. For some
reason. So this could be a whole tangent, but
I might even cut this out. But it's like. I remember
my mom and I had a discussion of this when we
were in France. And I see no difference in something
like that because it's just a drug and it's activating
a certain receptor. Yes, but it's not, you can't,
the dose is not regulated. And so you could end
up getting really sick, you know, and stuff.
It depends because if you're just taking mushrooms
willy -nilly, I totally agree. Yeah. But now
you can isolate psilocybin. They've done clinical
trials on this. Um, and you're trying to figure
out the dose that gives you the proper benefit.
So there, I promise you there are actually clinical
trials. I believe you. I believe you. So if you
find this, this, you know, fungus, please do
not, you know, promote this. It's not FDA approved.
You know, I agree. I'm not, I'm not, I'm not
saying don't do it. Um, you just gave people
like new ideas and stuff. I'm like, that might
not be good. What I'm saying is that it's mechanism
of action. is, uh, it's a, it's a serotonin to
a agonist, meaning that one of the reasons why
it feels so good to take this substance, which
I have taken, you know, just for record, it's
like, is because it acts very strongly on, on
these receptors. So anyways, it involves serotonin.
That's the whole, the whole thing. So if we have
this drug or this, this fungus that essentially
could provide us this compound that we could.
find the proper dose for it. I said, you should
see the look on my mom's face. She's just thinking
that I'm this huge drug. Well, I remember you
talking about that. It's like, it's like, like
it took you a day to get over taking it the first
time. Well, it has a very long half -life in
your body. And like you said, if you just take
a mushroom cap, you don't know how much you're
taking, which is the huge risk. Yeah. Um, luckily
it's an, it's a biological organism. So you're
not really like. really having to deal with people
messing with it you know what i mean like if
you take something like um gosh lsd or um uh
what's another ecstasy um which is mdma like
potentially that can get laced with other chemicals
and that's actually been a lot of the things
associated that cause people and the fentanyl
and you know yeah people will put fentanyl in
mdma and heroin they're just packing it in yeah
so but you can't really do that with a mushroom
which is nice um so um anyways we're getting
off topic yeah really okay yeah okay well anyway
okay there you go okay so um and Let's get and
getting back on target. So I just wanted to just
give just kind of a just a brief list of all
of the different indications for which SSRIs
are used. Again, I'm going to do it in. alphabetical
order. This is not necessarily, because not all
of the SSRIs are approved for all of these indications.
So we've got bipolar major depression, so fluoxetine
or Prozac is indicated for that. Bulimia, interestingly,
is also a Prozac indication. A generalized anxiety
disorder has several of them, Lexapro, Paxil.
and then the SNRIs, duloxetine, which is Cymbalta,
and venlafaxine, which is Effexor. Generalized,
oh, I just said that. Major depressive disorder,
all of them except for fluvoxamine. Fluvoxamine
is an older SSRIs, and it's only indicated for
obsessive -compulsive disorder. We also have...
the SSRIs that have been used in menopausal vasomotor
symptoms as well as premenstrual dysphoric disorder.
And they've been shown to help women to be able
to stabilize their emotions as they go through
those points of life. Like when they're pregnant?
Well, no, no, no. Menopausal, so when you go
through menopause, you can have a lot of crazy
hot flashes and stuff like that. I don't know
how to turn that off, Josh. It's my phone downstairs.
It's my phone. Thank you. Women have, you know,
hot flashes and mood changes and stuff. And so
SSRIs have helped to stabilize that because some
women can get it really significantly and it
really affects their quality of life. I mean,
we all can have it, some worse than others. Pre
-menstrual dysphoric disorder is the same as
like when women are going to have their menstrual
cycle each month. Some of them get really bad
emotional symptoms that go along with them. And
so to stabilize that, then they can take a drug
that is helpful with that. And that's primarily...
Prozac, Paxil, and Zoloft have been shown to
work in those conditions or in that particular
condition. SSRIs have also been used in panic
disorder, and they've been used in social anxiety
disorder as well as if you have... Fluoxetine
has also been FDA approved to be used in treatment
-resistant depression. So you've got, you know,
like, you know, it's a variety of different mental
health issues that these SSRIs over time have
been found to be safe and effective to be used.
Like Joshua alluded to, and like we've talked
about, there's pretty much... not really a medication
that you can take that doesn't have adverse effects
associated with it. And so SSRIs can touch a
lot of your different biological systems, gastrointestinal,
and some patients that can cause a decreased
appetite. So you may lose a few pounds when you
take them. You can have, you know, the typical
nausea, vomiting, diarrhea, but they're not,
it's not like a daily type thing, but it's just
some patients may struggle with that. You can
have central nervous system effects like drowsiness
or dizziness. You can have some cardiovascular
effects like palpitations, like your heart beats
a little faster, but it's not like the tricyclic
antidepressants where they really do have cardiac
dysrhythmias associated with them. One thing
that can happen with... uh ssris is something
called that you they can cause a lowering in
your sodium concentrations which is not always
great you feel pretty you can get feel pretty
sick when your sodium levels drop sometimes you
can get low sodium if you've had like a uh a
gastrointestinal illness, you know, so your fluids,
you get dehydrated and stuff. But this is a condition
also that's associated with SSRIs called syndrome
of inappropriate antidiuretic hormone, which
is, it means that the hormone vasopressin, which
is your antidiuretic hormone, gets increased.
And so what that means is that you are not able
to get rid of fluid as much out of your body.
So think about it. If you have if you've got
you've got a beaker or a glass of of of water
and you put some salt in it. And so you've got
this concentration of salt and water in it. But
let's say you add more water to it. So now your
salt concentration is a lot less than that cup.
That's what happens inside of our body with this
condition. And so it can be. serious. And so
it's more likely to occur in elderly patients,
those that are taking diuretics, which are those
drugs that are used a lot of times for blood
pressure that cause you to pee a lot out. And
then it also could happen with people like I
talked about that are dehydrated or whatever.
So you just have to just know about that and
to be able to use the drug wisely and stuff.
Yeah. I think a lot of times people associate
sodium with table salt and then having high sodium,
which can lead to high blood pressure right um
but for anybody who remembers their basic cell
biology um and if they didn't i'm going to remind
you that there every cell in your body has this
thing called a sodium potassium pump which essentially
is you exchange sodium and potassium so that
you can create a kind of an electric gradient
to provide energy for the cell so that things
can come in and out of the cell so sodium is
just an essential element that your body needs
and all of your cells need in order just to just
function and luckily your body is an extremely
fine -tuned machine that usually regulates that
balance really well but like mom said too much
of it can cause a certain too low of it can cause
a certain condition. If you don't have enough
sodium, you're not going to be able to pump as
much back and forth between those cell membranes.
So it can lead to a lot of these. A lot of things,
muscle cramping, I think, nausea and vomiting,
feeling weak. You feel sick when you have a low
sodium. You clear too much from your body, like
mom said, especially along with these diuretics.
Yeah, like mom said, as you get older, more things
can break down. And so you just need more medications
to counter a lot of those things that are happening.
And some of those drug interactions can be a
little tricky, which is why it's good to have
a good physician or pharmacist who can help you
out with that. You're tailoring your dosages
for these medications for the specific patient.
Other adverse effects associated with SSRIs are
you can have a little agitation, but it's not
like in 50 % of patients. One thing that we need
to note is that in antidepressants, it's been
shown in clinical trials that suicidal thoughts
increase in younger patients, in kiddos, and
in young adults. So you've got to be... cautious
about that they may need the antidepressant but
they just need you they've got there's needs
to be an awareness of suicidal thoughts and those
and there may be other treatments uh non -pharmacologic
treatments we'll talk about in a little bit that
may be more useful in those patient populations
um initially at least anyway um and another interesting
thing is because serotonin like josh said is
in all cells it's also in your platelets and
um you and and so um you can have some blood
effects adverse blood of blood effects from taking
ssris and not this is not a common this is infrequent
and rare but your platelets might get depleted
of serotonin because you've got the remember
we've got the inhibitor blocking and it's not
it may not be getting to all the places that
it's supposed to be getting to so if you have
If your platelets don't work properly, remember
we use platelets to help clot our blood, like
if we cut ourself and stuff. And so if you don't
have that working correctly, then you could have
increased bleeding risk. And it's okay if, I
mean, you know, we can see the external times
when we cut ourselves, like if we like slice
our finger with a knife, but we could also not
be able to see things that are happening inside.
Like, and so one of the big... problems could
potentially be gastrointestinal bleeding that
you can't necessarily see. So you just, you know,
so again, it's just, it's not a common thing,
but I'm just making people aware that that has
been seen with this particular drug class. Also
too, if you are taking a drug that also increases
bleeding risk, like an anticoagulant, it's not
that you can't take these two medications together,
but you just have to be cognizant of what's going
on. Yeah, that's a really good point. Two other
things I want to talk about as far as adverse
effects. This is probably one of the bigger complaints
of taking SSRIs and that they have effects on
your sexual function. And that is, there's been
some interesting thought as to why that happens.
It might be because your mood is kind of more...
flattened per se than where you were before,
but sometimes it might make you not feel, it
may dull emotional pain, but it may also. flatten
out your more excitement type and joy field type
things and stuff, which may have an effect on
sexual function because of all what goes on in
a sexual relationship. But that's just part of
it and stuff. And I apologize, but I don't know
the whole mechanism behind serotonin and sexual
function. Yeah, it's a good point. I mean, it's
like, because you also mentioned too that it
can affect. fluid retention in the prostate,
right? Which could potentially cause - No, those
are tricyclic antidepressants. Oh, sorry. So
not any of the - Yeah. Yeah. I mean, that makes
a lot of sense, but it is definitely an issue
that goes along with these, some more than others.
So again, if it's happening with one of your
particular SSRIs, then you could switch to another
one and possibly, you know, yeah. And it's, it's
really patient dependent and patient specific.
Yeah. It's almost kind of like, is it affecting
the software or the hardware pun intended, but
it's like the, the idea is like, yeah. And it's
like, yeah. It'd be like, yeah. If you can't
get aroused, right. But maybe mentally, or is
it, actually physically right um you're right
it probably does depend on the patient right
and so it could be it can be a reason why people
don't want to take ssris yeah but it doesn't
happen in 100 of patients but again it's just
something to be aware of and one other thing
that's really important as well too that because
these are serotonin selective serotonin reuptake
inhibitors there's a rare but potentially fatal
reaction called serotonin syndrome that can occur.
And it happens to, and it's due to serotonergic
overactivity. So if you have too much serotonin,
then you can have nausea, vomiting, excess sweating,
dizziness, facial flushing, mental status changes,
elevated blood pressure. So it's serious. So
if you started having any of those feelings,
you would need to contact your healthcare provider
immediately. One other thing that's noteworthy
about SSRIs, pretty much other antidepressants
as well too, is that you want to taper them off.
You don't want to abruptly discontinue them or
you might trigger a withdrawal syndrome. So if
you're starting to feel better. Quote unquote,
if you're feeling less depressive symptoms, you
might think, I don't need this SSRI anymore.
And somebody might want to go off cold turkey.
Or the other way. This isn't working. I want
to stop it. But if you've been taking it for
a month, you still need to taper off the dose.
Yeah, so just key is to taper no matter what.
Okay. That's good advice. One other thing I want
to mention as far as adverse effects compared
to other agents are concerned. So tricyclic antidepressants,
like I said, they used to have, I'm not used
to, they have cardiac dysrhythmias associated
with them as well as these anticholinergic effects,
which can cause, you know, scratch a dry throat
or urinary, urine retention, that type constipation.
But because there can be an increased suicidal
risk with depressed patients, people have been
known to use tricyclics to try to overdose on.
And because of those cardiac effects, they can
get really sick and they can kill themselves.
So it's just something to be aware of. Yeah,
that's a good point. Also, another famous MAOI
or monoamine oxidase inhibitor is cocaine. And
one of the bad things about cocaine is that it
can arrest your heart. And one of the reasons
why that is, is because of the same reason as
the tricyclics and things like that. Right. And
the other thing about MAOI inhibitors is that
they can also interact with foods like these
foods that are high in tyramine. So you're talking
about avocados, bananas, beer, and cheddar and
aged cheeses. And they can interfere and they
can increase, they can, because the monoamine,
oxidase inhibitors are increasing concentrations
of norepinephrine and epinephrine and dopamine
in your synapses. I believe that these agents
also can increase norepinephrine with this interaction.
As well as there's a lot of other foods that
interact as well too. And there's other medications
that also can interact. So you need any medications
that increase serotonin or norepinephrine, using
them together can make you really sick. So you've
got, there's a lot of contraindications for use
with MAOIs. That makes sense. And like anything,
the dose makes the poison. It does. So just depending
on your diet and obviously your ability to digest
and metabolize certain things, it's obviously
going to be patient dependent. So you're just
going to kind of notice this as you take this.
Your pharmacist will probably counsel you not
to be using particular medications or eat particular
foods. But you do have to be careful. Over time,
you might be able to figure, well, I can do this
amount of cheese, whatever I can have. a fourth
of a beer, you know, but it just, it's not like
he, like Josh said, it's really patient dependent.
I know a lot of people when they hear the side
effects on pharmaceutical commercials, they're
just like, oh my gosh, that's so much. And I
think, I guess I would love for you to speak
to the idea of like, I think sometimes a lot
of side effects can scare people off. I think
a lot of people might think that this is always
going to happen. Like when you take this drug,
like these things are going to happen. So would
you mind just kind of giving a brief overview
of when side effects are discussed, like how
they were discovered in the first place and then
why they're mentioned? Well, when you do clinical
trials for a medication, one of the things that
has to be evaluated is safety. as well as efficacy.
So we certainly want the medication to work,
but we also want it to be safe. And so you're
looking for adverse effects that could potentially
be deal killers. And so they're going to capture,
you know, all kinds of things because they're
looking at all of your organ systems to see whether
or not the drug is going to have an adverse impact
on those. And so then not only do you look to
see what... potentially can happen, but then
you also quantify it based on how many people
did this actually happen in. And so in package
inserts for medications, or you can look things
up online for particular medications, you'll
oftentimes see it associated with different percentages.
So adverse effects are that you'll list the most
common adverse effects, but then you're going
to list some rarer ones as well too. The pharmaceutical
manufacturer is required to disclose that information
just so that patients know that. Here it all
is, you know, and stuff. Now, no, it does not
mean you're going to get every, nobody's going
to get every single adverse effect that's listed
in a package insert. But there could be some
that are just more common for people. Like, for
example, if you take an antibiotic, maybe you're
going to feel a little upset stomach. And we
may all feel that. But it doesn't mean we stop
the antibiotic. We're able to get through it
or whatever and stuff. So, but you just have
to know that they are, and I did not include
percentages for all these adverse effects I just
talked about. a lot of them are really not common.
You know, maybe, you know, the decreased appetite
might happen in 20 % of patients and stuff, but
it doesn't happen in 100 % of patients. All those
adverse effects did not happen in 100 % of patients.
There's scales as far as how frequently they
happen. Usually you'll target the ones that are
more common and then you'll go down to, we start
looking at the ones that are less common if somebody
starts complaining of something and you'll think,
I wonder if this medication. can cause this as
well too. And so then you start looking for that
as well. It almost makes me think it would be
a really interesting, just like the way that
we compare the drug to a placebo to determine
its effectiveness. It would be interesting to
compare the side effects between placebo and
the drug of interest. Oh, they do. Yeah, what
I mean is that would be an interesting percentage
to have in the insert. I don't know if that's
actually in the insert. They do. Because like
if you have 20 % of people complaining of nausea
in one group. And then 20 in the other. Right.
And so if you have the opportunity. You can always
find a package insert for medications if they're
not a brand name drug anymore, you know, that
they've gone generic. You can go to the Food
and Drug Administration and there's a drug section
there and you can actually pull a package insert.
So you can just Google the generic name of the
medication and package insert and you can find
it. And if you go to the adverse effects section
of a package insert, you'll see a table there.
And they're oftentimes comparing it to placebo.
Sometimes they're comparing it. to other drug
treatments. It just depends on what the medication
is. A lot of times with the adverse effects table,
it's not, there aren't enough numbers of patients
to do statistical analysis on them, but you can
see the numbers for yourself to see like, oh,
there were 22 people in the treatment group and
20 in the. other groups so this is not necessarily
roughly the same cause and effect as far as this
adverse effect is concerned that's a great point
to bring out as well too josh so yeah it's unfortunate
that you have to do a little bit of extra leg
work just because i know for legal reasons they're
just going to try to mention that these people
had side effects I just get the sense, and I
could be completely wrong, that most people think
they're just very scared off of certain medications
because they hear the side effects. It's a common
trope of like, oh my gosh, the side effects are
longer on a pharmaceutical commercial. They absolutely
are, yes. And I know they need to be, but at
the end of the day, it's like, well, if it's
just a 1 % extra risk, then I'm willing to take
that risk to potentially lower my depressive
symptoms compared to placebo by... You know,
60 to 70 percent. And I think, you know, you
know, when I was growing up, we definitely didn't
have those kinds of commercials and stuff. But
I think it just it informs patients now. So it
gives you more material to go to your talk to
your doctor with or your health care provider
with. You know, it's like I heard that this causes,
you know. blank or whatever and you're like and
they can say well you know what it only happens
in 0 .1 percent of patients you know and stuff
so so they can help put some perspective on it
as well so when you listen to all those commercials
with all those adverse effects that's a really
good point yeah and i think if you're ever looking
for a drug insert it's usually either just uh
paper that's inside of the the it can be on the
bottle or a lot of times when you go to your
pharmacy they will staple that information on
the outside of your bag and so that has a lot
of the adverse effects associated with it but
if you go to like um let's say we go to um vibrid
which is one of those um s i believe it's an
snri but i could be completely wrong on that
let's I'm completely wrong on that. It is one
of the SSRI 5 -HT1A receptor partial agonists.
So you go to the Vybrid. And since it's a newer
medication, you can pull up Vybrid. And you can
go to the top and it'll say prescribing information.
And you can click on that and you'll pull up
the whole package insert. Okay, cool. That's
good to let people know if they want to be more
informed. Some light reading before you go to
bed. Yeah, light reading. You can find out the
mechanism, all the clinical trials. Think about
how much you can learn. Yeah, a lot of information.
So we'll move into, now that we've talked about
all these adverse effects, now we'll talk about
treatment adherence, which means like. you know,
will you continue to take your medication, you
know, and stuff. So, I mean, there could be a
variety of reasons why you don't want to continue
taking the medication. Maybe you've had an adverse
effect or you feel like it's not doing anything.
But there's a couple of reasons or there's a
couple of ways that patients with the mental
health disorders can be encouraged to stay the
course with their treatment. And it could be
that you have a great relationship with your
healthcare provider or that your attitudes about
treatment are understood and that you really
feel like you've been heard as far as how you
feel. And that you are also, as the patient,
involved in the treatment decision as far as
what gets done. Please remember that even though
the mechanism of an antidepressant, today we're
talking about SSRIs, can happen pretty quickly,
the clinical effects from that chemical reaction
will take several weeks to be seen. So you have
to be patient with the effects of an antidepressant.
And so don't, after two weeks, don't say this
isn't working. You've got to give it several
weeks to see what happens. That's just, it used
to be that some of the older antidepressants
took months. So with the SSRIs just taking weeks,
it's a lot better than in past times. But you
do have to give it some time to have effects.
And so don't be tempted to discontinue your medication
when you're not seeing what you want. Give it
at least a month. I've got, and so all those
treatment, I mean, all those mental health disorders
that we talked about that SSRIs are used in.
There are a whole lot of different treatment
durations for how long SSR should be completed.
Things like premenstrual dysphoric disorder are
going to be more sporadic. Maybe a woman needs
to take it just around the time of her menstrual
cycle every month, or sometimes they may need
to take it all the time. It just depends on the
patient. The vasomotor menopausal symptoms, maybe
it's temporary because menopause doesn't usually
last really severely forever, but in some women,
it does. And so it's going to be patient -specific
as well, too. You may need help, you know, for
a longer time period. Bulimia, the recommended
treatment duration is nine months to a year,
but again, that's patient -specific, and they
may need it longer. Post -traumatic stress disorder
is another reason to take SSRIs, and you may
need to be treated for up to a year, but it could
be longer. It depends on the patient. Same thing
with general... anxiety disorder, obsessive compulsive
disorder. You may need one to two years after
you go into remission. Panic disorder, same thing,
may need up to 24 months of treatment. Major
depressive disorder. You may need eight to 16
weeks of acute treatment, but then you may need
at least 24 months of therapy as you stabilize
and you may need it longer. And with depression,
major depressive disorder, what's been found
is that if you So there could be certain conditions
that could cause you to have a second bout of
depression. And the more bouts of depression
you have, the more likely you are to have another
bout of depression. So it's a disease that can
be frustrating, you know, as well, too. But we
do have a lot of things to be utilized to help
patients manage that particular disease state.
So you may have antidepressants continued in
patients with depression for longer time periods
just based on that tendency for that particular
visiting state. Josh also alluded to this as
far as self -care in depression. And this is
particularly in depression, but I think that
it could be applied to other things like generalized
anxiety disorder, panic disorder, or post -traumatic
stress disorder as well too. you want to keep
doing the things that you like to do. Even though
it feels really hard, you want to do that. And
you want to stay connected with your friends
and family instead of isolating because what
you want to do is isolate. But you have to force
yourself to say yes to that person who's calling
you and says that they want to go have coffee
with you. Exercise on a regular basis, even if
it's just a short walk. You know, get out there
and get your heart pumping. It does tend to help
you feel a little bit better. You want to do
regular eating and regular sleeping habits. You
want to kind of try to cut down on your alcohol
and any type of use of illicit drugs because
they are also associated with a perpetuating
depressive state. I think if, yeah. Stepping
in there is this, okay, so if we're thinking
about these mental health disorders as an imbalance
of certain neurotransmitters or chemicals in
your body, and you are seeking to restore that
balance, there are many ways to do that. essentially
you are the sum of a lot of these chemicals in
your brain to do these behaviors. And a lot of
times I'll be 38 on Friday. And a lot of times
I've been doing these behaviors for 38 years.
So when you are doing these interventions, you
are essentially just trying to change who you
are as a person. And there's, we could go into
a whole another category on this, but The main
goal of doing anything differently is to try
to change your brain state. So the way I like
to think about mental health disorder and using
things like SSRIs is that when you are in a bout
of depression, whether it be mild or severe,
I call that like the fog of war. You are lost
in the fog. You basically feel like, I don't
know where to go. I don't know where up, down,
left, right, or is. I'm just going to sit still
and do nothing. And the forest could even be
a round full of enemies or full of maybe even
on fire. And you literally don't have enough
information to move. And so you sit still, which
is probably the opposite of what you should do,
depending on your circumstance. What I think
SSRIs are is the lifting of that fog, depending
on the population. of the person that you're
in. And then when that fog is lifted, you then
get a little bit of extra information to be able
to make different decisions. And if you are a
cognitively, I'm going to say this, I'm going
to try to say this in a sensitive way, like a
cognitively prepared person, meaning that you
have good, you have self -esteem, you've got
good social skills, you have ability to cope
with bad things happening in your life, then
you'll be able to navigate out of that forest
because you have the skills and you've just lifted
your depression to kind of trap you in. If you're
a person who has maladaptive strategies, even
if you lift that fog of war, you might just run
towards the fire because that is what you know.
There are people born in this world who are addicted
to pain because they see pain as just a way to
signify that they're alive. Or they go towards
abuse because they've associated abuse with love.
And the reason I'm saying all this is because
this is a good way to think. SSRs aren't going
to solve your problems. They're a tool to help
lessen symptoms. And if you're really looking
to change your life in a way that's going to
be pretty profound, one of the ways that's been
really shown is... cognitive behavioral therapy,
which is essentially a long -term, it's a long,
basically a long -term intervention with something
like a psychiatrist or a therapist or a counselor
that potentially just investigates the stories
that you're telling yourself and the narrative
patterns that you tend to fit in. And then you
basically question those narratives. And then
you essentially are asking yourself, do I want
to keep doing this? Because I think a lot of
people don't think the reason I'm depressed sometimes
could be neurochemical. But a lot of times it's
because we repeat behaviors and we're on a cycle.
It's like if you are a mountain climber and you
are constantly jumping from mountain to mountain.
And then you slip and you break your leg. And
then you go back to mountain climbing the same
exact way. Of course, the probability of breaking
your leg is still just as high. But if you do
it with safety gear or maybe you're like, maybe
I should be a hiker instead of a mountain climber.
And then you might still break your leg, but
the probability of breaking your leg is going
to be a lot lower. So I say all this is like
SSRIs and these drugs are amazing, but they're
not cure -alls. They're really just ways to help
you see beyond the forest when there's a fog.
But if you really want to have profound behavioral
change, things like cognitive behavioral therapy
and even things like exercise or social engagement
with other human beings are really good ways
to reset your neurochemistry so that you can
have a quote unquote. um, better adapted way
of living in this life. So just, uh, well, and
we're going to move into that. One other thing
that I wanted to, that those are great points,
Josh. Um, and what we're going to talk about
that a little bit more in just, just a second.
I just need one other thing to say. Um, sometimes
patients with depression can have suicidal thoughts.
And if that is the case, instead of just sitting
in that by yourself, you need to call a friend
or your healthcare provider, or there are suicide
hotlines. And there is somebody on the other
end. of that phone that really wants to talk
to you. So you don't want to do that alone. You
want to remember that although you feel like
that nobody cares about you, that's usually,
that's almost never the case and stuff. So you
want to make sure that you reach out even, you
know, and hopefully you've got a friend system
or a family system around you that they are aware
that something really drastically is changing
you and they're going to reach out to you as
well. That's really well said. Okay. So Josh
was just talking about cognitive behavioral therapy.
One of the targets for treating depression is
what we call remission. So that means that you've
got a 70 % improvement in symptoms. That's how
remission is defined. And so not only have medications
been shown to be utilized and effective in treating
depression, but also psychotherapy has been shown
to be effective as well too. And there are different
types of... of psychotherapy josh just talked
about cognitive behavioral therapy i thought
one of the one of the ways that it was defined
is that you've got what they call cognitive distortions
and so you tell yourself i fail at everything
and so they're going to help a therapist a psychiatrist
that's going to help you really investigate that
statement and see is there really truth to that
or not and help you get a right perspective on
how you're thinking about your own personal life.
Another therapy that's used is called interpersonal
therapy. And in this particular therapy, a therapist,
a counselor, a psychiatrist will focus on one
or more of several interpersonal situations that
may relate to initiating or sustaining depression,
such as if you've got a significant interpersonal
conflict. or there's a role transition, or there's
grief, or you've got a social skills deficit,
they'll talk about that and help you. And they'll
also include awareness training in that as well,
too. There's also psychodynamic therapy. This
is focusing on interpersonal relationships and
unconscious feelings, desires, and strivings,
and thoughts, and that they help to treat these
symptom disorders and stuff. And then there's
family therapy as well, too, if you've got issues
going on with family. In refractory cases of
depression, you've heard of things like electroconvulsive
therapy, where you actually do get shocked. And
I don't have all the ins and outs of that, but
that has that again, that is not. That is not
the first thing we go to. That is the last thing
we go to. There's also something that's newer.
It's called transcranial magnetic stimulation.
This is kind of fascinating. It's non -invasive,
but you use magnetic pulses that will help target
specific areas of your brain to help you get
better. And then there's a newer medication that's
used. derivative of ketamine, which is used actually
as an anesthetic and it's used for pain. But
there's a newer one called esketamine or Spravato.
And it has actually been used to help patients
that are refractory in their treatment for depression.
And they're not sure exactly of the mechanism,
but it may involve another receptor called NMDA
in our synapses and stuff. So one of the questions
that Josh asked me when we prepared for this
was, how do antidepressants compare to psychotherapy?
Remember, one of the things too that we want
to remember is that In a plan for treating depression,
it needs to be a collaborative plan. So what
that means is that the patient needs to be involved
in choosing how they're going to get managed
in addition to the healthcare providers and maybe
family members as well too. Because if the patient
is not buying into this, then they may not do
it. So there is evidence that shows that In mild
to moderate major depressive disorder, actually
psychotherapy is recommended by guidelines over
pharmacotherapy or medications. With medications,
you potentially have adverse effects. And so
if you have psychotherapy, you don't really have...
adverse effects per se, except for having to
face a particular situation that can also, you
might consider an adverse effect as well too,
but it's not induced by a medication per se.
Yeah, the adverse effect is crying in front of
your therapist. Yeah, there you go. But you know
what? That's healthy. It is. If by chance psychotherapy
is not something that you can afford or commit
to, medications can also be used in mild to moderate
depression. When you get to the moderate and
severe cases of major depressive disorder, antidepressant
medications are recommended and they're often
recommended alongside or in concert with psychotherapy.
So trials and research has shown that these treatments
are additive so that you get antidepressants.
So Josh talks about that fog lifting, but then
you've got a psychotherapy. mechanism that you're
using that helps deal with those things that
you're having to face and may help you face them
in a healthier way. So there are some limits
to psychotherapy. Cost is going to be one of
them because they're usually not covered by your
insurance plans. There might be some insurance
plans. If you've got a more robust insurance
plans, they can be covered by them. But not all
people are going to have that luxury. So it could
be something that you need to just have to figure
out whether or not you can include it in your
budget. Yeah, it's one of those interesting things
where therapy is more qualitative than quantitative
because it's like. when you're feeling better,
like they try to correlate it to a scale, you
know, like mom said, like you have 70%, you know,
of your symptoms reduced, but someone has to
give you basically a questionnaire. Like, do
you feel like this? Do you feel like that? And
I can even tell you like week to week, sometimes
that questionnaire will be different depending
on my day. Um, so a therapist, like one of the
best indications that your therapy is actually
working, it's actually the only indication that
therapy is effective is do you feel. that your
therapist has your interest at heart. That is
the only predictive measure of a therapy actually
working, which is kind of crazy to me. So this
idea of like, that's gotta be very troubling
for insurance companies. I think a lot of people
like to rat on insurance companies and pharmaceutical
companies because they do wanna make a lot of
money, which is fair, they do. And there's a
lot of perverse incentives there. But at the
end of the day, it is so much easier to codify.
and associated with clinical trials than something
like therapy. And I'm hoping that we'll catch
up to this. We'll have more clinical trials associated
with cognitive behavioral therapy and these other
therapeutic modalities because it's changed my
life. But there's never like you get 10 therapy
sessions and then you see this reduction. It's
very random. It's very patient -specific. It's
very patient -specific and you never know when
your breakthrough is going to be. And so it really
does behoove you to kind of keep going and pulling
on a thread. But like mom said, that can be very
expensive. You know, sometimes therapy can be
160 to $300 a session. And if you don't have
that type of money, then it might be better to
stick with the medication. And I think too, that
I think a therapist and you as a patient need
to recognize when you're done. Because you don't
want to become dependent on the therapist to
help you do life. They should be professional
enough to know when to set you free, per se.
It's kind of like a parent. Yes, it is. Absolutely.
So, so you don't want to have this like, Oh,
I've got to, I've got, I've got to go see my
therapist because I can't do life without them.
That's not going to be healthy. Now, initially
you may feel like that, but, um, but then there's
going to be a time when they're going to have,
hopefully a good therapist is going to give you
the skills that you need when you're alone on
a Saturday night, you can still cope and do life.
Yeah. That's really well said. Yeah. You can
get addicted to a therapist. Like you get addicted
to a drug. Yes. Yeah. Yes, you can. whole goal
is to do it on your own right that's scary but
you got to do it on your own Another limitation
of psychotherapy is like the logistics. If you're
working, unlike Josh who gets to pick his hours
and when he decides to work, other people had
to work, you know, according to a time frame.
And maybe you can't get off, maybe you can't
go to your appointments because it's too far
away or you don't have freedom in your work schedule
to do that. Or maybe you live in a more rural
area and you don't have quality therapists in
your area. That could also be an issue as well
too. it could be that you're a lot more reluctant
to go talk to somebody than just take a medication.
So those can sometimes be limitations to promote
or pursue psychotherapy. But they are really
effective therapies, especially if you don't
have really severe depression. And for sure,
in severe depression with medication along with
it, there's evidence that you do get better.
We have a few kind of, we always end, we always
kind of wrap up or go to the end of our podcast
each week with looking at what we call myths
or maybe a little bit of untruths associated
with misconceptions. So we've got our list for
our antidepressants this week as well. So our
first, since we're talking primarily about SSRIs,
the first myth is that antidepressants like SSRIs
just increase serotonin levels. And that really
is partially true. They do that, but there are
other antidepressants that can also affect other
neurotransmitter systems and that you also may
desensitize serotonergic receptors. So there's
a lot of all kinds of things that are going on
in managing depression other than just... making
sure that your serotonin levels are increased.
So you want to make sure that your mind is broadened
as far as how they work. This was an interesting
one. Antidepressants like SSRIs can change a
patient's personality. And if you've been living
in a state for a while and you start taking an
antidepressant, you may recognize that you are
doing life differently, that you do respond to
things differently. Because the antidepressant,
like an SSRI, is helping to relieve those depression
symptoms so that you maybe don't feel sad or
hopeless all the time anymore. But they're not
designed to change who a person is. But a potential
antidepressant adverse effect is what we call
emotional blunting. And what I mean by that is
that you could feel less intense emotions. You
feel maybe a little flatter because while it
dealt with the emotional pain and helps to make
that not be so dramatic in your life, it also
may also take away some of your enjoyment. And
so it appears to occur in about anywhere from
4 % to 60 % of patients that take an SSRI. And
so... you, in order to deal with that, um, and
it could be due to interference with reinforcement
learning or, um, and, and so, um, yeah, as far
as what, what I mean by that is that, um, it,
if we, if, you know, it's like, if I love chocolate
and, um, I, I, and I love Diet Coke. Um, and,
but if the the sensations that i get from eating
chocolate or diet coke are are reduced i might
not want to do that as much and so that's what
i mean as far as um reinforcement so the more
i drink diet coke the more i drink it you know
or the more i eat chocolate the more i want it
but it's like if this is flattened a little bit
then you don't do that so you don't want to do
those things as much so yeah it's a question
you really have to ask yourself because i'll
have friends who will tell me I really appreciate
your joy of life. I am a person, as my mom knows,
has very high highs, but I can also have very
low lows. I feel things very intensely. And it
has a cost. And some people might want to not
feel that way anymore. They might want to feel
more level. And maybe chocolate doesn't taste
as good, but hey, at least I don't get... extremely
existential sadness. Um, so it's, it's just one
of those things that you just going to have to
ask, like personality is a really interesting
topic. You know, it's like, yeah, what makes
you, you, and, uh, can you mute some of those
parts of yourself to enhance part of the others?
And, um, there's a lot of ways to do that. Um,
and not just drug wise, even exercise or music
you listen to, or going for a walk, or it's like,
we all do things that I'm sure we've all had
this experience where we hang out with different
people. And they bring out different sides of
us. And it doesn't mean that our personalities
change. It just means that different parts of
us are enhanced at that particular moment. As
far as this emotional blunting is concerned,
there are things that can be done. Maybe it's.
maybe you're taking a higher dose than you actually
need. So the dose could be reduced. Or a different
antidepressant class may help, even though, you
know, I'm not saying, maybe it's a tricyclic
that you need, you know, instead of an SSRI,
if this is really causing a lot of issues and
stuff. So you just have to play around with it
and stuff. Another myth is that antidepressants
like SSRIs are addictive. Absolutely not. They
don't produce cravings or compulsive disorders.
But remember, an SSRI has to be tapered down
off when it's discontinued and not abruptly stopped,
or you could have some withdrawal symptoms that
could look like a withdrawal symptom from taking
illicit medication. Another myth is that antidepressants,
we've kind of alluded to this, like SSRIs are
a quick fix or a rescue medication. And it is
not a quick fix. Treating a mental health disorder
is a longer treatment process than treating an
infection with an antibiotic. And so you need
to give it time and you need to give permission.
You need to allow permission to give it time
to help you feel better. I wonder if a great
tool for that would just be do like a little
basic journal of just like, how am I feeling
today? So that you can look back over time. And
just because I'm sure it's just hard to like
be objective with your feelings because by definition,
they're very subjective. Absolutely. About how
you feel about the world. I even will feel that
way if I've journaled and I'll look back and
be like, oh my gosh, I can't believe I felt that
way. But I did. And then it's just a really nice
reminder that you can get through it. And that,
yeah, that better days hopefully will be able
to come. Right. And then the last one is that,
and this can definitely happen. Well, antidepressants,
I tried them in the past and they don't work.
So they're not going to work in the future. But
we have so many different antidepressants. And
within a class, one might work better for a patient
than another one. So you cannot. That's a total
lie. So if something didn't work in the past,
then there's an option to try something else
that could work better in the future. So make
sure that you give it a chance if you're really
struggling with depression or other mental health
disorders that, you know, there may be a way
that you and your health care provider can come
up with a plan and a medication that could work
for you. Because it could have been that when
you took it in the past, the dose was too low.
Maybe you just needed, this is a situation where
you needed to bump up the dose rather than bump
it down. Or maybe you took it too short the last
time. You didn't give it enough time to work.
Or maybe you were only taking it as needed. That's
never going to work. Because if you only take
it on every, you know, on Mondays of every week,
it's not going to work. You know, so if you've
got to take it consistently and stuff, kind of
like a blood pressure lowering medication. Anyway,
so to wrap up, I think some of the concluding
statements I would make about this topic is that
serotonin's role in the pathophysiology of depression
and other mental health... has been observed,
and it's also being refined, trying to understand
it more clearly. And the reason we refine and
want to look at it more clearly is so even maybe
newer medications that are more targeted can
be designed or that they also have less adverse
effects. SSRIs have been shown to improve. treatment
of depression and they've also been shown to
be effective in concert with psychotherapy psychotherapy
has also been shown to be used alone but it's
also been shown to be additive effects with other
antidepressants to help patients with depressive
disorders and I believe I didn't look into psychotherapy
with other mental health disorders but I'm sure
that you could find effect for them with PTSD,
post -traumatic stress disorder, or anxiety disorder
as well. Yeah, like PTSD, SSRIs in particular,
were not shown to be as effective as maybe psychotherapy.
But something like OCD, they worked well in concert
together. Interestingly enough, exercise. With
anxiety compared to an SSRI was comparable. I
would agree there. And there was a potential
bias there because there was a large dropout
rate in the exercise group, which makes a lot
of sense. You're forcing people to exercise.
So maybe the potential, the people who were left
behind were the people who just really wanted
to exercise and they got the benefit of it. So
there's always kind of that selection bias going
on, but I thought it was really interesting.
Yeah. That they were comparable. There's a lot
of different options out there. And again, whether
you're using drugs or whether you're using behaviors
or talking to a therapist, you're always altering
your brain chemistry because you're literally
doing things differently than you did before.
Right. And I think that's the key here is if
you're in a tough spot, the only way to get out
is to try something different. And it's like
the most counterintuitive thing in the world
because there's something so satisfying about
staying sad. When you're sad, you want to listen
to sad music. You want to watch sad movies. There's
something like you almost like want the resonant
frequency of sadness to linger. You want it to
echo. But if you – I think it's good to do that
for a little bit. But then at the end of the
day, like is this what I want my life to be?
And most of the time the answer is no. So just,
yeah, you just got to break out. And if it's
really severe, I would definitely recommend going
to a psychiatrist and talking about antidepressants
and to see if they can help lift that fog of
war. Yeah. And let me leave our audience with
this last just reminder that if you have been
prescribed an SSRI, please do not abruptly discontinue
it because it can make you feel really sick.
That's really well said. Well, if you're feeling
sad, we hope that you've made... We made you
a little bit happier today. Or gave you some
tools, you know, to help, you know, maybe go
in a different direction. Yeah. Yeah. So go for
a walk, talk to a friend, and just remember that
you're worth living this life for. There you
go. And so until next time, my name's Josh. And
I'm Jenny. And this is another episode of Your
Mom on Drugs. We'll talk to you next time. Bye.
Thank you.