Hi I'm Dr. Tracey Marks, a psychiatrist, and I make mental health education videos.
Today's video is based on a viewer question from Trey, who says, Dr.
Marks, I'm not sure if my antidepressant is working or not.
When I take it, I feel numb.
I'm glad that I don't feel sad, but I don't like feeling numb either.
Is this how I'm supposed to feel?
Thanks, Trey, for your question.
The quick answer is you're not supposed to feel numb.
Emotional numbness is a side effect and not a therapeutic effect.
Most antidepressants treat depression by increasing the levels
of certain neurotransmitters associated with mood, like
serotonin, norepinephrine and dopamine.
When serotonin is elevated there, it's a feedback
mechanism that can suppress dopamine levels.
This reduced dopamine level
can make you feel apathetic, like you just don't care anymore,
or it can make you feel unmotivated or reduce your emotional reactivity.
With this reduced emotional reactivity, you may not feel sad,
but you don't feel all that happy either.
And when something happens, you don't feel like you can fully express yourself.
And for some people, this can be very distressing
because they feel like a robot.
And just as Trey said, the sadness and the hopelessness may be gone,
which is a good thing.
But you still don't feel normal when you experience
something that you would ordinarily enjoy.
You feel held back like you can't fully express or experience the joy.
We can see this emotional numbness or apathy with any dose
of anti-depressants, but we tend to see it more with the higher doses.
Wellbutrin is the only antidepressant that enhances dopamine with no effect
on serotonin, so you shouldn't get that same emotional dullness with Wellbutrin
if you experience the dullness on a serotonin antidepressant.
Sometimes you can make it go away by reducing your dose just a little.
So for example, let's say you were taking escitalopram
brand name Lexapro at a dose of 40 milligrams.
If your doctor reduces the dose down to 30 milligrams,
you may notice a lifting of this emotional flatness
and still have a therapeutic benefit of the antidepressant.
Sometimes your doctor may add just a little bit of bupropion
brand name Wellbutrin to your selective serotonin
reuptake inhibitor to offset the dopamine suppression effect.
Some people can't tolerate both of these medications together,
but for some people it's a nice combination.
Here's another situation of how the medication should
or should not make you feel.
I've had people who were going through a really tough situation
ask me to prescribe them something that will make them feel like a zombie.
So that they don't feel anything.
When I get this request, I usually say there is nothing
that I can prescribe that will allow you to zone out
and coast through this hard time and then check back in when it's over.
The medications just don't work that way.
So how do they work exactly?
How aren't you?
Depressants improve.
Depression is not fully understood, but they do have multiple mechanisms
of action.
Traditionally, we understood anti-depression sense
to work by increasing levels of serotonin, norepinephrine and dopamine,
the fixing the chemical imbalance theory.
This is what I learned in resonance Z 24 years ago.
The current antidepressants do increase these neurotransmitter levels,
but more recent research suggests that antidepressants
also work by promoting neuroplasticity, which is the brain's ability
to change and adapt.
This includes the formation of new neural connections
and the strengthening of existing ones, a process often called neural rewiring.
They do this by increasing the protein brain derived neurotrophic factor,
which supports the growth of new neurons
and strengthens the connections between existing neurons.
The third way that antidepressants exert their effect is by reducing
inflammation in the brain.
Increased inflammation is associated with depression.
All of these processes take time, which is why
you don't get instantaneous results when you take an antidepressant.
For most of the antidepressants, it takes about 4
to 6 weeks to see the full effect of a given dose.
But side effects can show up immediately.
Things like nausea or feeling tired
can happen after the first few pills,
and then some people can feel better
just from the act of putting a medication in their mouth.
We call this a placebo effect.
Our minds are powerful and sometimes you can feel more hopeful
and improved simply because you know that you are taking something
that is supposed to do something positive.
Not everyone has this kind of response,
but if you find yourself feeling outstanding
after one or two doses, it's probably a placebo effect.
So what would a therapeutic effect look like?
To gauge this, you need to know what your target symptoms are.
Target symptoms are the specific symptoms that are most problematic
or distressing for you.
It's the things that are not right that are part of your depression.
Your doctor may help you identify these by asking what's different about you?
Because part of the treatment for the doctor is to monitor your target symptoms.
So let's say for you, you can't enjoy things.
Everything feels hard.
You're easily overwhelmed.
You feel angry all the time.
You can't focus on anything and you have trouble falling asleep.
That's five things If you combine the overwhelm with things being hard.
Chances are you do have some other symptoms, like low energy or appetite
changes.
But these five are the ones that stand out the most in your mind.
These are the symptoms that you're going to watch for to see how much they improve.
It's good for you to write these things down so that you can keep up with them.
Many times
I will see someone for a follow up appointment after starting a medication
and they can't remember how they felt a month ago.
They may say, I don't feel any better.
Then I start asking about their target symptoms.
I don't call them that, but I'll look at my notes and I'll say things like,
Are you crying as much as you were when you feel overwhelmed?
And the person may say, Well, not as much as before, or
I think I only broke into tears once since I saw you.
Then I'll say, When was the last time you yelled at someone?
And they may say, now that I think about it, I haven't yelled.
My partner still gets on my nerves, but I keep it to myself.
And so on it goes.
And by the time we get through the symptoms, the person realizes,
Gosh, I guess I am better, but I still feel bad.
This would be considered a partial response,
and that's a reasonable response after only being on the medication
for a short while, and especially if you're still on a low dose.
But what if you're on a pretty good dose and you've been taking that dose for 4 to
5 months?
Then you want to review your target symptoms and see what's still a problem.
But even more important is to look at the intensity of the remaining symptoms.
Remission of symptoms does not always mean that you'll be symptom free.
You may still have occasional sleeping problems
or you still may not have that much patience.
But how much are these left over symptoms
getting in the way of your relationships, work or school?
A realistic outcome from taking medication is that most,
if not all, of your original symptoms decrease in intensity to the point
where they're easy to ignore or distract yourself from
so that you can maintain your usual level of functioning.
In other words, you're not looking for all of them to disappear.
If they do, that's wonderful.
But that's not the usual. Think about it.
If extreme irritability is one of your depression symptoms,
do you really think that you'll never be irritated again?
You will.
But if you're not depressed, the irritability doesn't creep into your
every thought or caused you to explode on people all the time.
So some of these symptoms are on a spectrum from normal personality
based reactions to life on one end of the spectrum
to all encompassing destructive thoughts and behaviors on the other end.
For more information on depression nuances,
watch this video on minor versus major depression
or this other video on why antidepressants can make you feel worse At first.
Thanks for watching today. See you next time.