Friday Q&A: On How Long to Take Antidepressants; Aging & Acceptance; Shame at the Doctor's Office, & Sleep.

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It’s Friday Q&A time! Click here to submit your questions for future posts!

The first question (about how long to take antidepressants) is free to everyone. The remaining questions (about aging; managing shame; and sleep) are for paid subscribers.

Photo by National Cancer Institute on Unsplash

Let’s dive in.

QUESTION #1

I have used antidepressants for many years to treat my anxiety and mild depression. I asked my psychiatrist recently if this is safe to do over decades, and her answer was that I can take a smaller dose “if I want to.” Later I was frustrated by the complete lack of answers. Months, years and decades go by and nobody ever seems to question if the antidepressants are still needed. What do you tell your patients? -Laurel

Dear Laurel,

This is a great question. The duration of treatment with anti-anxiety or anti-depressants depends entirely on the person and situation.

Let me explain.

When prescribed appropriately, medications like Prozac, Lexapro, and Zoloft can help reduce suffering and improve patients’ quality of life. But they are not a panacea. They are not a substitute for making appropriate behavioral, chemical, and/or environmental changes that drive or trigger the patient’s symptoms.

Take, for example, a patient whose depression stems from a toxic relationship and/or from alcohol abuse. This person might benefit from an antidepressant medication, but the best “medicine” would be to thoughtfully and strategically extract themselves from the relationship and to quit alcohol as able. In this case, the job of the psychiatrist (or internist) is to help the patient — mentally and physically — and to add support with medications and from therapists, AA, support groups as needed.

Assuming the patient was able to make these behavioral, chemical and social changes, we might be able to then taper the medication dose — or discontinue it altogether — if the patient was no longer experiencing depression symptoms. Without alcohol (which itself is a potent depressant), with less stress at home, and ideally with an improved set of coping tools, medication might not be needed at all.

That said, this same patient might still experience symptoms of depression despite the absence of alcohol and the presence of healthier social relationships. Not all depression symptoms are rooted in habits or are malleable. Some are more hard-wired. In this case, medication might still be appropriate and necessary. Perhaps the dosage could be reduced if the patient were to add an exercise program and more time outdoors, but this would be a chapter-by-chapter decision in the patient’s larger life story.

At the end of the day, anxiety and moods are informed by the integrated sum of our genetics, brain chemistry, everyday behaviors, relationships, and intake of substances (from alcohol and sugar to supplements and vitamins) — plus the robustness of our coping tools.

Managing symptoms of depression and anxiety is highly nuanced. It requires a heavy dose self-awareness and honesty about our own lives, active problem-solving where we’re able, and asking for help, early and often. Sometimes that involves taking medication. Sometimes it requires facing hard realities about our lives and our stories. Sometimes it’s both. Regardless of route, mental health includes accepting support (social, emotional, behavioral, and/or pharmacological), being open to change, and regularly re-assessing symptoms over time.

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QUESTION #2

For seniors, losing vision, hearing and other abilities can be distressing and isolating. How do I tell my wonderful internist that I’m not necessarily looking for solutions (although I welcome her advice!) and that her support and understanding is what I need most? - Anonymous

Dear Anonymous,

I hear you loud and clear! A doctor’s impulse is to make a diagnosis and fix problems, but what patients often need most is to be seen and heard — and then to be reassured that their complaints aren’t worthy of alarm.

Of course reassurance from a doctor must be rooted in facts. For example, I wouldn’t reassure a patient with heart failure that their chest pain was “nothing to worry about” without ordering an EKG and lab work first.