If we use antidepressants to treat anxiety,
why do they make you more anxious at first?
That's what I'm gonna answer today.
I'm Dr. Tracy Marks, a psychiatrist,
and I make mental health education videos.
This video is based on a viewer question.
This problem of antidepressants making you feel worse
can happen whether we use it for anxiety or depression.
With depression,
you can feel even more depressed after you take it.
But if you keep taking it, that effect tends to wear off.
The problem is more pronounced though with anxiety.
Taking it can make your anxiety spike
and even make you feel worse
than before you took the medication.
So why would we even use this medication to treat anxiety?
Because the effect is usually transient,
meaning it goes away after several days.
But for some people it may persist
and then they have to stop the medicine,
but it usually still goes away.
That's the usual tendency.
Why does this happen?
Researchers from the University of North Carolina
identified another pathway in the brain
that gets activated with serotonin.
Serotonin activates one pathway that helps mood and anxiety,
but it also activates another pathway
that increases the brain chemical
corticotrophin releasing factor,
also called corticotrophin releasing hormone.
This hormone is normally secreted in response
to a stress or a perceived environmental threat.
This activates the body's fight or flight response
that is intended to protect you from a threat.
But when there's no real threat to respond to,
you experience that adrenal response as anxiety.
So what they found is
that serotonin can trigger the stress response
through the corticotrophin hormone release.
This finding has led to a new research direction
to find a drug that can block this hormone
during the initial phase of your treatment
until you get fully onboarded with the antidepressant.
Now there's still a lot of unanswered questions about this.
Like why doesn't this happen to everyone?
In practice, we tend to see this more of a problem in people
who are prone to anxiety and less in people
who have depression without anxiety.
So do people with anxiety have a lower threshold
for tolerating the hormone release?
Another question is what makes it go away
after you've been on the medicine for awhile?
Well, one possible answer is
when you start an antidepressant,
the first thing that you experience is side effects
of the medication if you have any.
So when I see a person a month after starting the drug,
I usually ask, did anything bad happen?
Because usually the side effects like nausea
or stomach issues, or even activation like not sleeping well
or being energized, which is different from anxiety,
these are the things that you see at first
and they usually taper off.
The benefit that get of reducing your depression
or anxiety comes later
as the medication reaches a steady state level in your body
and starts to have its therapeutic effect.
So one explanation for the transient effect is
that once the medicine kicks in,
the beneficial pathway
that's being activated overrides
the negative anxiety producing pathway.
So what do we do about this?
The main thing in treating anxiety is
to start low and increase slowly
to reach the therapeutic dose
or the dose as expected to work.
And we call this titration.
Your doctor could start you on Zoloft, for example,
and then titrate your dose from 25 milligrams up
to a target dose of 100 milligrams.
So if you wanna use fancy words with your doctor,
you can ask what will be my titration schedule?
The answer could be something like start at 25 milligrams
and increase by 25 milligrams every two weeks.
Keep in mind every time you increase the dose,
it could aggravate your anxiety.
So one way we deal with this is
to prescribe a benzodiazepine or benzos, for short,
like clonazepam or lorazepam to reduce your anxiety
and make the titration period smoother.
Then when you're fully onboarded with your medication,
your doctor would taper you off of the benzodiazepine
and you would remain only on the antidepressant
to treat your anxiety.
The benzos only work for the anxiety feeling
and not the worsening depression that some people can have.
Sometimes the effect of feeling overstimulated
from the antidepressant doesn't go away.
And in this case,
you may need to discontinue the medication.
How long you deal with it is an individual decision.
But I'd say about a month should be long enough
to know if it's gonna go away or not.
Also if the activation interferes with your sleep
or creates daily panic,
you probably don't wanna put up with it
for longer than a week or two.
If it happens with one medication,
you can try another one
and it may not happen with the other medication.
So it's not a given that it will happen.
One more thing about this,
all of the antidepressants
increase serotonin except buproprion.
Does this mean that you don't get this problem
with buproprion, also called wellbutrin?
Not exactly.
Buproprion has its own issues
with increasing activation through the dopamine system.
It's great for increasing motivation
and preventing the apathy and blunting
that you can get with the serotonin agents.
I did a video talking about emotional blunting
or dullness with the antidepressants.
So buproprion avoids this,
but it also has a stimulating effect
that can increase anxiety and make you feel agitated,
irritable, or interfere with your sleep.
And these effects are usually seen soon
after you start taking the medicine
and don't get a lot better if you just keep taking it.
But it is dose dependent.
So lower doses may not do it as much as higher doses,
like 300 or 450 milligrams.
That's it.
Thanks for watching.
See you next time.