Still, I can’t imagine this spin instructor popping off the cap of a bottle of Zoloft in front of 30 sweaty strangers.
It’s not a perfect analogy: We now know that depression is perhaps infinitely more complicated than the comparatively well understood fix for type 1 diabetes of replacing missing insulin. But it still makes the point so clear it nearly punches you in the stomach: We wouldn’t judge someone for treating a physical illness with medication, so why do we judge someone for doing the same for a mental illness? Diagnosing depression can be just as challenging as treating it. (Do you experience any of these nine surprising depression symptoms?)
I’m confident we’re (slowly) moving away from this stigma, but we’re not quite there yet. Whether it’s because a person on antidepressants doesn’t necessarily “look” sick or because we simply don’t understand the benefits antidepressants have to offer, it’s obvious we need more honest discussion of these meds and whom they work for and how. Considering the most recent data available suggests 11% of Americans over the age of 12 take an antidepressant—and that was in 2008!—we owe them a little more compassion and understanding.
In an attempt to help make things clearer and help us all be even just a little more accepting, here are a few things only people taking antidepressants truly understand.
Antidepressants are not a cure.
Depression is thought to be a noxious combination of genetic, environmental, and psychological factors that leads to profound feelings of sadness, hopelessness, pessimism, irritability, and fatigue, among many other possible symptoms. Antidepressants, the medications most commonly used to treat depression, affect a number of brain chemicals called neurotransmitters, which are thought to be involved in regulating our mood. While meds can make a drastic, sometimes lifesaving improvement in how a person is feeling, antidepressants don’t always mean the end of bad days—or even meh days, for that matter.
Freelance writer Lynn Shattuck, 41, likens antidepressants to her contacts. “I’m super-nearsighted; I need contact lenses to see,” she says. “Antidepressants aren’t a happy pill; they just clear the fog for me. They help clear my vision and enable me to be able to see a little more.”
She’s been on and off meds to help manage depression and anxiety for 2 decades. “My antidepressants are just one tool in my toolbox,” she says. “I don’t think any one thing for someone with depression is necessarily the answer.”
For Rob O’Hare, 34, an actor, comedian, and web producer who also happens to be my dear friend, antidepressants haven’t made negative thoughts vanish, but they’ve helped speed them along. “Without medication, I might feel devastated,” he says, “but with medication, I won’t feel awful, and then the feelings will pass—and that’s actually a drastic improvement!” He was first diagnosed with depression in 2003, and while he recognizes that he still harbors negative thinking patterns, “they have a chance to get better now with medication.”
You don’t have to be on them forever (but you might be).
It can be tempting to take antidepressants for a month or two, feel like you’ve improved leaps and bounds, and figure you no longer need meds, says psychiatrist Michelle Tricamo, MD
, an assistant professor of psychiatry at Weill Cornell Medical College in New York. “That’s not something we want to see,” she cautions. “Just like you want someone to finish the whole course of antibiotics to prevent relapse, we don’t want anyone to prematurely discontinue antidepressants, either.”
Typically, Tricamo says, your doc will want you to be relatively symptom-free for about a year before you talk about stopping the meds, she says, to make sure the changes in how you’re feeing are going to stick. What’s even more important than how long you’ve been on antidepressants is that you don’t try to go off them alone. A doctor can help you expertly taper your dose to wean you off with as few withdrawal effects as possible (we’ll get to more on withdrawal later).
After that weaning period, some people might carry on drug-free. Antidepressants can function like that ever-illusive perfect face wash that clears up your acne after a few weeks and you’re set, O’Hare imagines. “But for someone like me, depression is chronic,” he says. “I just have to manage it.”
If you do stay on them forever, it’s not because you’re addicted.
Shattuck says she was constantly establishing timelines in her head for when she’d be able to ditch antidepressants. It took years for her to come to terms with the fact that she might take them for the rest of her life. “I believe this is part of my genetic makeup and something I need,” she says.
Her attitude is key in understanding long-term antidepressant use: People who benefit from the meds are taking them because they still provide those benefits. There’s no high, and there are no cravings, Tricamo says. Antidepressants can cause withdrawal, which is probably where this misconception came from, she says, but it in no way means you can’t stop using them.
It’s not always an easy decision to start taking them to begin with.
There are critics out there who say antidepressants (and heck, countless other meds) are simply overprescribed. But the process of beginning antidepressants doesn’t start with some haphazardly written prescription. Docs frequently recommend therapy first, Tricamo says, which can result in significant improvements for many people with mild to moderate depression.
When she’s considering who might benefit from meds, Tricamo evaluates how much depression interferes with a person’s daily life. “If adults are unable to get to their jobs or leave their homes or can’t support themselves, these might be times to use a medication,” she says.
Some people still have hangups about starting meds, even if therapy hasn’t helped. “The biggest internal battle was the idea that I should be able to feel better by myself,” Shattuck says. “If I just did enough therapy or herbs or whatever, I could treat myself naturally.” Such defeating self-talk, she says, is a nonstarter because “depression is, in and of itself, a distorted way of thinking,” she says. “It makes it really, really challenging to get yourself out of that on your own.” We wouldn’t suggest that a person with a broken leg should simply pull herself up by her bootstraps.
Tricamo emphasizes the importance of working through these concerns and making the decision to try antidepressants a collaborative one. “They’re the ones taking the medication, after all,” she says of her patients. “You can’t force them, and since you’re not there to give it to them every day, you might not even know if they’re taking it.” Thoroughly explaining the risks and benefits can help a person understand why meds are important and how they might help. “If you don’t get them to buy in to treatment, treatment is going to fail,” she says.
Side effects can be harmless or hellish.
Anyone who has seen one of those horribly cliché staring-out-a-window-while-it’s-raining TV commercials for antidepressants knows that the accompanying long list of potential side effects is equally horrible. Many of them, like weight gain, insomnia, nausea, low libido, delayed or vanished orgasm, and diarrhea, to name just a few, sound entirely unpleasant.
Certain meds come to have a reputation for one side effect or another, but there’s no real way of knowing what you might feel when you start one or how long the side effects will last. Nausea, headaches, or a jittery feeling usually vanish within the first couple of weeks, Tricamo says, but weight gain or a dampened sex drive might be harder to cope with. “Unfortunately, it’s something we can’t really predict.” Side effects aren’t based on the dose of the med or really anything else measurable or adjustable, she says, although they are likely to be worsened by drugs or alcohol. While the unpredictability is certainly frustrating, it shouldn’t be prohibitive. “We can switch antidepressants, and we usually do find one that isn’t so harmful in these ways,” she says.
“It’s kind of a guessing game,” O’Hare says. He ended up in the emergency room after what was likely an allergic reaction to Lexapro when he first tried it in 2003. He’s since tried a handful of others with varying rates of success: Cymbalta and Wellbutrin both made his depressive symptoms worse, he says. Effexor made him feel something he can only explain as “medicated.” He gained weight on Remeron, but describes the experience as feeling like his body was no longer his own. He’s currently feeling some improvements on Prozac and is about to visit his psychiatrist for the first time in a month.
He’s stayed away from any antidepressants thought to mess with libido. He guesses everyone has their own threshold for tolerating different side effects. Some weight gain might not bother one person while it’s a deal-breaker for others, for example. “If a drug was going to diminish my libido, then I just wasn’t going to deal with that,” he says. “Among the drugs I haven’t taken are some I haven’t taken for that reason.”
But you’re not about to become a zombie.
The idea that antidepressants totally change your personality is understandable, Tricamo says, since they are tinkering with your brain. The persistent “I won’t feel anything” fear, however, is unwarranted. “Antidepressants are designed to help you return to your former demeanor,” she says, not transform you into some always-up or totally-out-of-it new you.
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“There’s some need to preserve a sense of your own identity or some kind of self-integrity or a version of yourself that being medicated might alter,” O’Hare says of this hesitance some people have to taking antidepressants. Of course, if you do feel like meds are “flattening” you, talk to your doctor, who can likely suggest another option.
There’s usually some trial and error involved before you find the right one.
When Shattuck first started medication, she went on Paxil and had horrible nightmares. Zoloft gave her heart palpitations and sent her anxiety through the roof. But just because one antidepressant makes you, say, sweat profusely, doesn’t mean they all will; it’s worth giving a few a try if nothing feels quite right at first, Tricamo says.
Even if you try one and feel nothing—no uncomfortable or dangerous side effects, but no real improvement either—don’t give up. With dozens on the market, odds are the first one isn’t the right one, O’Hare says, and frankly, it could take years to find one that helps. He was so frustrated by his experience with one drug in 2014 that he decided he wouldn’t try anything for a while. “I didn’t want to go through that hunt,” he says.
The process of starting a new antidepressant over and over again isn’t ideal, but it’s worth it to him. “It’s hard, but when you have major depression, after a while it’s just not worth being unmedicated or untreated anymore,” he says. “It’s so worth it to not feel the way you do when you’re suffering through major depression.”
Stopping or switching can be a Process with a capital P.
If only it were as simple as filling a new prescription. To avoid those aforementioned withdrawal symptoms—which can include anxiety, irritability, dizziness, headaches, muscle aches, and chills—doctors carefully and methodically wean patients off antidepressants when it’s time to stop or change meds. Shattuck says the last time took about a month to gradually taper her dose with her doctor. She felt flu-like fatigue, was more tearful than usual, and had what’s come to be called “brain zaps,” a feeling likened to an electrical current momentarily pulsing through the brain. Some people notice the effects of tapering almost immediately, Tricamo says. Some lucky others have no problems whatsoever.
Yes, yoga, meditation, and getting more sleep can help. That doesn’t mean antidepressants don’t.
Tricamo has a patient whose mother continually tells her she should quit the meds and take up yoga and meditation instead. There’s (probably) nothing wrong with any of the lifestyle tips offered up by your neighbor, your uncle, or that blogger you follow on Pinterest—but that doesn’t mean antidepressants are out. “Maybe she should be doing yoga and meditation, but that doesn’t mean she shouldn’t also be taking Zoloft and going to therapy every week,” Tricamo says. In fact, all these tools might work better together, if antidepressants are the “contact lenses” that clear the fog so you can actually get yourself to the yoga class.
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Even if people mean well, this “just try yoga instead!” mentality is rooted in stigma, Tricamo says, against both psychiatric illness and its medical treatments. As long as there’s reason to believe there is a biological basis for mental illness, however, there’s reason to believe there is a biological treatment to go along with it. “If you have asthma and you can’t breathe, are you going to try to just meditate through it?” she asks.
O’Hare does his best to tolerate this kind of advice because he knows his friends mean well. “I’m not about to criticize my friends for whatever bits of helpfulness they’ve thrown my way,” he says. “I’m grateful for any and all of it, even when it is repetitive or bullshit.”
You can maybe even safely take them while pregnant.
Starting or growing a family can be a tricky decision for anyone, but women who use antidepressants have an extra layer of complication to decode. Questions about how antidepressants might affect a developing fetus have long been up for debate, and the most recent news is the meds don’t seem to have lasting cognitive or behavioral effects on children born to moms who use them.
Know what does leave a lasting impact on the lil guys? Moms who are depressed. “My midwives kept saying it’s not just the safety of my unborn baby that we had to consider but my safety and mental health,” Shattuck says. She stayed on antidepressants during both her pregnancies, a decision she calls “the most difficult part of my journey” with depression. Her son, now 6, and her daughter, almost 4, are both healthy. “They didn’t go through any of the scary things you find if you Google ‘antidepressants during pregnancy,’ ” she says with a chuckle. She was wracked with guilt, though, a feeling she doesn’t imagine she would have had if she had needed meds for, says, diabetes at the time. “A lot of people have to take medication during pregnancy for physical ailments,” she says. “I don’t know if I would be as hard on myself as I was about antidepressants.”
Sure, there’s a lot we don’t entirely understand about how they work. But they work.
You’ve likely heard the relatively straightforward theory that depression is caused by an imbalance of the neurotransmitter serotonin in the brain. If that were the case, drugs called selective serotonin reuptake inhibitors (SSRIs), which work by keeping more serotonin available in the brain, would obviously be an easy solution.
Unfortunately, it’s pretty clear today that depression is a much more complicated story than that: Serotonin’s not the only neurotransmitter involved, for starters, and we still don’t entirely know how antidepressants actually work. We know depressed people’s brains look different on imaging tests, but “we don’t necessarily have all the answers from science yet,” Tricamo says.
Whether we prescribe the meds, take them, or know someone who does, we’d probably all be more comfortable if we did have more answers. Antidepressant-bashing critiques range from there are too many people on them who don’t need them to they don’t work at all and patients only benefit from a placebo effect. “There are significant questions we should be asking about who needs antidepressants, why doctors prescribe them, and how the insurance industry approaches mental illness,” Maura Kelly wrote in the Atlantic in 2012. “But that, of course, doesn’t mean that antidepressants are dummy pills that have no real effect; and it’s crucial that depressives—many of whom are suspicious of medication—realize that.”
Shattuck is just glad they’re even an option. “Until really recent history, people didn’t have access to medication that could help them if they had depression,” she says. “I’ve come a long way from thinking, ‘Why can’t I do this on my own?’ to a place where I’m thankful I live in a time where it’s not quite as stigmatized and there’s access to help.”