Should You Be "On" Something for Anxiety? 💊

Sometimes you don't need Prozac—you need a divorce. Sometimes you don't need more yoga—you need Lexapro.

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If you’re looking for a virtual street fight, read the comment section of the recent New York Times article, Kennedy Starts a Push to Help Americans Quit Antidepressants. This topic is HOT—not just because of our political situation but because roughly 1 in 6 American adults takes an SSRI. And just like that, the medical voices and wellness influencers were back in their corners.

One side: SSRIs have saved millions of lives! This agenda is more about politics than it is about patients’ wellbeing! The other side: SSRIs are overprescribed! Medication shouldn’t be the default plan for anyone with anxiety and depression symptoms!

The thing is BOTH SIDES HAVE VALID POINTS. Arguing about the legitimacy of SSRIs as a tool in the proverbial toolkit for mental health problems is merely a distraction from the more important issues facing people who suffer from anxiety and depression.

Let’s talk about my patient in her mid-50s who recently came into my office, blood pressure newly elevated and lab work showing prediabetes. When I asked about her life, she described months of constant fear about divorcing her husband, even though it’s what she knew she needed to do. The anxiety was making her sleepless and restless and unfocused at work, which only impaired her ability to move forward with the decision. And so the cycle persisted.

By the time she came to see me, she had her question ready: Should I be on something for anxiety? The way she framed the question signaled she was both open to medication and somewhat familiar with the idea.

Had I been in a hurry, the easy move would have been to take her question at face value, write the prescription, and move to the next patient.

But the real answer to whether or not she “should” be on anti-anxiety medication is, of course, it depends. The answer hinges on a whole stack of other questions hiding beneath the surface—questions she needs to ask herself first (with me to help her elicit them as needed). Questions like this:

• How much of my anxiety is related to my habits and the situation I’m in—versus things that are out of my control?

• What in my life can I actually move the needle on—my breathing, my sleep, having an honest conversation with my spouse?

• What am I most afraid of, and how would I cope if “the worst” happened?

• How well calibrated is my fear to the facts of the situation?

• If this anxiety has taken on a life of its own despite my attempts to mitigate it, might a medication help me as part of a broader plan?

That last one matters a lot. Because her default question—should I take an SSRI?—didn’t get the job done. The better question is what role could an SSRI play in a broader strategy to manage my anxiety?

As you probably know, some anxiety is normal, even adaptive. The burst of adrenaline we experience before taking a risk can help focus the mind. But anxiety that is persistent and negatively impacts our health or quality of life should be addressed like we would any other health problem—with curiosity about where we have agency and where we need support. Not every anxiety problem warrants medication. It’s an option on the table, but it’s not always the move. Medication earns its place when an anxiety problem can’t be improved by lifestyle, habit, or situation alone, or when it’s severe enough that we can’t afford to wait for those changes to take hold.

For some patients, the answer is no medication at all. Sometimes you don’t need Prozac. You need a divorce. Sometimes you don’t need Lexapro. You need an honest conversation with your spouse or to get more sleep to take a break from alcohol. Sometimes therapy, sleep, movement, and a little time outside are the whole intervention, and they get the job done.

And sometimes you do need Prozac. There is no amount of breath work that pulls a person out of panic attacks that won’t quit. Sometimes you do need Lexapro, because depression hasn’t budged despite the steps tracker and the protein and the sunrise walks. Medication, for many people, is the thing that makes the rest of it possible.

It turned out that my patient needed a small dose of Zoloft. Not as a sign of personal failure or because she lacked willpower, but because she needed a biochemical tool to help her break a cycle of worry and avoidance and fear. She needed a bump in her serotonin levels to create distance from the feelings of panic and then incessant loops of What if thinking. It turns out we don’t always have control over how we think and feel. Admitting that—and asking for the appropriate help—is a sign of strength.

Back to the headlines. This is the very question they are debating: Should this woman—and millions of people like her—be “on” something for anxiety?

This isn’t even the right question, because the conversation about the role of psychiatric drugs doesn’t happen at the level of good or bad, more or less. It happens one patient and one doctor at a time.

The question the Secretary of Health and Human Services should be asking isn’t are SSRIs overprescribed? (They probably are. So is just about everything else, in 15-minute appointments without continuity.) The more pressing questions are: Who is there to help the average person figure out what role a medication should play in their health? Who is asking them, what problem are you trying to solve? Who has the time, the training, and the permission to surface people’s actual problems, ask better questions, and take the answers seriously?

Because right now, when someone walks in anxious, they get a few minutes with a doctor who (through no fault of their own) barely has time to get through the person’s lab results, much less ask about how anxiety is shaping their life. Then they go home and ask ChatGPT. ChatGPT suggests they have an “official” anxiety disorder when, in reality, they may simply have the ordinary experience of being alive in the modern era—or it recommends yoga when what they really need is a formal psychiatric assessment. And they are no better. They are sometimes worse. And the conversation about whether to deprescribe SSRIs entirely misses what it would take to make the prescribing—and the not-prescribing—appropriate in the first place.

Health isn’t about having all the answers. It’s about asking better questions—of yourself, and of the people responsible for your care.

Right now, in this country, we have run out of people whose job is to help you ask them.

That, more than any debate about a class of medications, is THE problem.

Did I mention this already? 😆 I’m starting a book club!

Join me this summer for the official Beyond the Prescription Book Club. It’s open exclusively to Substack readers and gives you early access to the book. Sign-ups are open in May only.