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This post is a continuation of “The SSRI Experience,” written to demystify the experience of being on an SSRI—a medication that helps with depression as well as anxiety. Many people have hesitation about going down this road, so I wanted to put a typical experience out there that is representative of a common therapeutic response to this class of medication. We will continue with John, our prior fictional/summary patient. Here’s what it’s like:
Tired but Wired
To recap, John is a 35-year-old married male who works as an engineer. He had a lifelong tendency to overthink, get stuck thinking, and sometimes overreact. He would overreact internally, in the form of catastrophic thoughts that would scare him sometimes, and sometimes externally, by being short-tempered and impatient, often critical of his family as well as his colleagues at work.
He performed at 130 percent and expected the same of everyone around him. As stressors mounted, he began to have trouble making decisions and would often “feel too much, both good and bad.” He felt somewhat tired but wired. He was concerned about not being able to sleep more than six hours per night and was often tired, but unable to nap.
Despite ongoing therapy, it became apparent that his frustration and stress were more pervasive than at work alone. While the tools he learned helped, he continued to feel and react to too many things, big and small. He eventually spoke with a psychiatrist and was started on escitalopram—with the trade name Lexapro.
Feeling Smug – Week 6
The first 30 days on escitalopram went like this. Most of the side effects had gone away within the first 1-2 weeks, and by week 3, John felt at peace. He had slowed down just enough to be patient, happy, and in the absence of mental noise, more productive.
Six weeks since starting, his libido returned from 40% below normal to about 10% less than usual. He felt the major benefit to mood and reactivity was well worth this small side effect. His moods went from being as low as 3/10 to about a 6-7/10 on average. His weight remained unchanged. His sleep felt a little deeper, but was still in the 6- to 7-hour range due to waking a bit too early.
Annoyed at Being Annoyed (Again?) – Week 8
By week 8, at the continued low dose of escitalopram 5mg (it goes up to 20mg), John began to feel some irritability return.
For the past 2 months, he had the amazing ability to see annoying, stressful issues without letting them overrun his life and thoughts. He always read about “watching your thoughts, going by in a river,” but for him, historically, that river was always a torrent, and he was often drowning in it. While the SSRI worked, he would still feel and react, he just would not obsess, and that felt like a superpower. He made progress in his therapy because it was easier for him to move off from issues. Rather than being obsessed with the past, he found it easier to put that same energy into positive thinking towards the future. Because he was less “buffered out,” or working at peak capacity, he had more love and patience for everyone around him, and even those who did not know he was on meds (sometimes it’s interesting to see what friends notice on their own) noticed a positive change.
Unfortunately, eight weeks after starting his SSRI, some of his old symptoms began to creep back. He became more annoyed at things, partly bothered that he was able to be annoyed again, and after a week or two of this, decided it was time to speak with his doctor.
He was not as bad as he had been prior to the escitalopram altogether. He was still doing better, but bothered that he had backslid maybe 30 to 40%, and was afraid this would continue. Back to catastrophic thinking, he feared he was becoming immune to this medication and would end up untreatable. Not much had changed in the way of stressors; everything just became a bit louder again and started to hurt more.
More Medication? – Week 9
His doctor mentioned to him that this was not uncommon, and indeed he was on the lowest dose of escitalopram (5mg). Everyone is unique, and everyone’s optimal dose may differ. His doctor wanted him to increase to 10mg. With hesitation—as anxiety can make all decisions hard—he agreed. He was now taking two small pills each morning, and continued to exercise, work, parent, and see his therapist once every other week. He did feel some side effects that were not unfamiliar, some minor nausea in the mornings, maybe a very mild headache, and some minimal vertigo. Within a week, these mild effects were gone.
Back to Zen – by Week 10
Yes! It worked! Right back to that sweet spot where things were before. Again, John was able to “sit and watch his thoughts float by the river.” The torrent of feelings had subsided. No, he did not become a zombie. He had simply gone from driving 130 miles per hour through life to still speeding along at a cool 80. Things were definitely still getting done. He still reacted and noticed what bothered him, but instead of being stuck on the pain, he could focus once again on solutions. Thinking forward not backward, and having some inner patience to think before reacting, was a superpower indeed.
Sustained Serenity and Charting the Course – Week 16
John expected the higher dose of 10mg to fade in benefit like the 5mg dose did. It didn’t. The benefits lasted. With less of his brain worried about things that were beyond his control, especially in his therapy, he was able to focus more on where he could make a difference—and how. The serenity prayer, known to many, captures this wisdom:
“God grant me the serenity to accept the things I cannot change, courage to change the things I can, and the wisdom to know the difference.”
For most of his life, this felt like Pollyannaish nonsense. Just like watching the river of thoughts—good luck when it’s a torrent and you are drowning. For most of the past four months, he had not been drowning. Most interestingly, he began to forget what drowning—ahem—anxiety felt like. It was a thing of the past, like a movie you remember watching, but nothing about. Kind of like a dream. He remembered it was rough before, as a thought alone. The feeling felt foreign now.
John, being an engineer, was tracking his moods and anxiety this whole time using an app called Daylio. His categories (from high to low) were zen, normal, tired/low, anxious, sad and anxious. The graphs that would previously bounce and dip into anxious or tired and low (and rarely sad and anxious), had changed to solid stretches of zen and good. Feelings of cold hands and heart-pumping adrenaline were gone, along with endless dark, obsessive loops. Tired/low days would still rarely occur, mainly when he got to sleep too late, and he realized just how much fatigue can impact mood, even on an SSRI. But those low days were now few and far between, and he had the data to back it up. It helps to mood chart because you will always forget how things were, and later on, how things are, right now. Moods tend to diffuse, and how you feel now (good or bad), you might think you’ve always felt. That’s why mood charting and journaling are essential, especially for the skeptic.
Lowering Meds and Yoga – Week 17
While the side effects had been minimal, and libido eventually returned to 95% of normal, John did also realize he had gained some weight. Many people fear this side effect. Five percent weight gain is a true possibility with some anti-depressants, and that is what he noticed as well.
Time and time again, he felt the benefits of this new state of mind far outweighed any side effects. Given how long he had felt good, and the therapy that had reinforced his positive frame of thinking, he thought it might be time to test out a return to the lower dose of 5mg, and requested his doctor to make the reduction.
It is essential for any patient to never make such changes without speaking with their doctor. It is also essential to note that John decided to lower his meds not because of the weight gain, but simply to see if his new toolset and mindset could continue to work on less medication.
I have often found that people with long personal histories of depression and anxiety, and long family histories of the same, tend to continue to need meds and do worse off them. For anyone considering lowering psych medication, it is important to look at the pre-existing biology and genetics before doing so. For people with strong family histories, or severe anxiety or depression with a history of suicidal thoughts or hospitalizations, this should be done slowly and with extreme caution, if at all.
For everyone else, I use the yoga example. Sometimes with the help of an instructor pushing on you, you can reach and touch your toes. Once you know how it feels, it is easier to work towards that goal on your own. Psych meds can be similar. If the support structure is in place, you can slowly back off meds, and see what is possible with what you have learned. We are capable of state-dependent learning. Just make sure the risks are low, and there is great supervision and guidance throughout the process.
To be continued in the next SSRI experience post.