Thank you for existing, and for Ask's habit of suggesting therapy. October 16, 2011 10:12 AM   Subscribe

I decided to take the common advice AskMeFi gives and seek therapy (again) to get my SSRI's changed.

I've been having problems with depression, and my SSRI's (prescribed by my regular doctor) stopped working. I foolishly tried upping them on my own, and had really bad results. (FYI, too much Zoloft/Sertraline can cause major aggression and rage.)

I searched this site to see if anyone's had similar experiences, and found a lot of useful information. It made me realize that I really needed to seek therapy rather than go back to my regular doctor for a medication change.

So, I found a new therapist last week, and she changed my medication at the first appointment. I'm on day 2 of Celexa and I'm amazed at the difference. I feel so much better. Haven't been this happy in longer than I can remember. My new therapist seems great, and I'm going to see her again tomorrow.

So, thanks, Mefites, 'cause not only did I find some really good information about SSRI's in the archives, it also encouraged me to seek therapy again.
posted by luckynerd to MetaFilter-Related at 10:12 AM (53 comments total) 12 users marked this as a favorite

Glad things were helpful for you.
posted by jessamyn (staff) at 10:15 AM on October 16, 2011


I wish therapists were covered in the same manner as GPs. I can see my GP all I want, but my insurance covers only 6 visits to a therapist. That's not long enough to form a relationship or even a level of trust, so my GP is my defacto therapist.

Glad things are working out for you.
posted by cjorgensen at 10:32 AM on October 16, 2011 [2 favorites]


Yay! I'm really happy AskMe was the resource you needed.

I love Metafilter. Even while I'm having the occasional disagreement with a user or one of the mods, I feel like you all are my extended family (and half the time I realize you're right and I'm wrong). So Metafilter gives me my shmoopy fix, like this post, and the occasional reality check I need to keep my head straight, too.

It's a dessert topping! It's a floor wax!

And yeah, I agree with you, cjorgensen. I'm happy (and lucky) to have decent insurance, but I think the US gets a big F on mental healthcare across the board. My therapist doesn't even take insurance, but he's the best, so I suck it up for sanity's sake.
posted by misha at 10:45 AM on October 16, 2011 [1 favorite]


Glad you're doing better, luckynerd. Fuck depression.

cjorgensen: "I wish therapists were covered in the same manner as GPs."

Oh, me too. My extended insurance covers two visits and that's in Canada.
posted by deborah at 10:58 AM on October 16, 2011


Glad to hear it, and good for those answerers who helped out - I'm useless at this sort of stuff and respect enormously those of you who take the time to give good advice.
posted by Abiezer at 11:13 AM on October 16, 2011 [1 favorite]


Boo-yeah, fuck that depression! Brilliant.
posted by angrycat at 11:32 AM on October 16, 2011 [1 favorite]


Funny, I was on an anti-depressant 10 years ago and it was awful. Far worse than the disease it was treating. So I avoided them for a decade.

Then I was reading some random threads on the topic, went to my GP, and have been on Wellbutrin for the last month and a half and it has been so great. I can't believe the number of problems that went away.

So let me add my thanks.
posted by munchingzombie at 11:42 AM on October 16, 2011 [4 favorites]


Glad it's working out for you guys! I'm on a combo of Pristiq and Nuvigil and am soooo glad I am. (This is after going through Lexapro, Welbutrin, Effexor and Cymbalta with varying levels of not workingness with all of them.)
posted by NoraReed at 12:00 PM on October 16, 2011 [1 favorite]


I can see my GP all I want, but my insurance covers only 6 visits to a therapist.

In most cases, I thought the Mental Health Parity and Addiction Equity Act of 2008 meant that visit limits for mental health benefits could not be any more restrictive than medical/surgical benefits in most cases.
posted by grouse at 12:01 PM on October 16, 2011 [1 favorite]


I am always so heartened and proud to see people reaching out to ask those questions--about depression or meds or therapists or what have you. Having the wherewithal to even ask about help, to advocate for yourself to pursue that help, and continue following through with getting that help isn't easy, and yet it can be so difficult for the people closest to someone who's depressed to understand why it's so difficult for him or her to "just" go see a therapist or a doctor.

This community truly provides a supportive and understanding environment to people who are in that difficult place, and it's so valuable to have the flood of "I went through it and came out safely on the other side, and here is how I did it" stories to inspire other people to go forward even though it feels awful or scary or impossible.
posted by so_gracefully at 12:02 PM on October 16, 2011 [4 favorites]


:)
posted by ThePinkSuperhero at 12:09 PM on October 16, 2011


In most cases, I thought the Mental Health Parity and Addiction Equity Act of 2008 meant that visit limits for mental health benefits could not be any more restrictive than medical/surgical benefits in most cases.

I think what ends up limiting most people's access is the diagnosis. In CA, there are only a very specific handful of "parity diagnoses": http://www.dmhc.ca.gov/dmhc_consumer/br/br_mentalhlth.aspx

One problem that might arise is if a person has experienced sort of low-to-medium depression all their lives, with no big spikes or more serious periods of depression, etc., they would get a diagnosis of Dysthymic Disorder, which is NOT a parity diagnosis even though it's arguably as clinically "serious" as Major Depressive Disorder. Some private practice mental health providers will put a lot of effort into discussing this whole thing with you if you're using your insurance to pay, and explain the process of putting a diagnosis on record and what effects those diagnoses might produce in the longer term. Some private practice mental health providers will also work a little harder than others to try to ensure that a client has access to MHPL's provisions.
posted by so_gracefully at 12:11 PM on October 16, 2011 [3 favorites]


Glad to hear it.
posted by the young rope-rider at 12:34 PM on October 16, 2011


I have to admit I haven't checked in a while either. I've had the same insurance through the same place for 11 years, but that doesn't mean it's the same insurance as when I signed up. It may cover therapy now.
posted by cjorgensen at 1:18 PM on October 16, 2011


Sometimes the stock answer is the best one. I'm so glad it worked for you.
posted by patheral at 1:18 PM on October 16, 2011


cjorgensen, the law changed starting in 2010 for calendar year plans. It might be worth checking.

Thanks to so_gracefully for the more general explanation.
posted by grouse at 1:26 PM on October 16, 2011


Can we all bookmark this post for the next time someone complains about AskMe giving any sort of medical advice? I've gotten similar encouragement from the site and I bristle every time someone wants to shut down this resource.
posted by Durin's Bane at 1:59 PM on October 16, 2011 [5 favorites]


Askme was the exact thing I needed for my medical question.

I asked my doctor and got reassurances that everything would be fine and go well. I asked my surgeon and got medical speak and descriptions of the procedure. I watched videos on the internet and watched them cutting-into-a-woman's-face-and-cauterizing-the-wound-and-there-was-smoke-coming-out-of-her-face-oh-god!

I felt a lot better about it after posting that question.
posted by cjorgensen at 2:08 PM on October 16, 2011


What kind of therapist can change your medication?
posted by Danila at 3:02 PM on October 16, 2011


If I stop taking citalopram for 72 hours, I'm promptly reminded why I should never stop taking it.
posted by Trurl at 3:12 PM on October 16, 2011 [1 favorite]


What kind of therapist can change your medication?

A psychiatrist. Is this not true where you are?
posted by jessamyn (staff) at 3:17 PM on October 16, 2011


My goodness, askme works, we've all been so mistaken, we should reinstate the helpfultherapueticaskmeexpert thingy immediately.
posted by sgt.serenity at 3:25 PM on October 16, 2011


Or a psychophamacologist.
posted by Splunge at 3:26 PM on October 16, 2011


"I wish therapists were covered in the same manner as GPs."

I somehow get between 10 to 12 visits with my therapist, paid for by the government. And I've got a GP to prescribe me my SSRIs. I'm glad you're feeling better! I'm feeling great too! Thank you, Lexapro!
posted by Lovecraft In Brooklyn at 3:34 PM on October 16, 2011 [1 favorite]


On average, SSRIs do not start to have significant effects for several weeks. 2 days would be an almost unbelievable period in which to notice any effect.

Just saying.
posted by spitbull at 3:38 PM on October 16, 2011 [3 favorites]


Celexa/citalopram has that immediate and noticeable effect. Really.

Very happy for you, luckynerd, and thanks for letting us know.
posted by Gator at 5:31 PM on October 16, 2011


A psychiatrist. Is this not true where you are?

I never think of psychiatrists as therapists because they don't do much besides diagnose and dispense medication. I guess when I think of therapy I think of talk therapy, and that's how I read it when people in AskMe suggest seeing a therapist for personal and interpersonal problems. If people are getting talk therapy/counseling AND medications from the same source I was interested in finding out what that source might be, because I find having to regularly go to different professionals to deal with the same problem to be a barrier. This is especially so if the therapist and the psychiatrist aren't really working together.
posted by Danila at 5:36 PM on October 16, 2011


When I suggest it I mean it as either/or. With meds, you can start to see your problems more clearly, which is where a therapist helps. OTOH, perhaps therapy can help on its own. Its very individual.
posted by Lovecraft In Brooklyn at 5:49 PM on October 16, 2011


Celexa/citalopram has that immediate and noticeable effect. Really.

Not according to its prescribing literature (and hence clinical evidence) it doesn't.

Placebo effects are of course not chopped liver. But the difference between zoloft and celexa is not that significant.

I'm glad that the op feels better. Really I am. But it isn't likely due to changing meds, other than backing down from overdoing the zoloft. Not in 2 days.
posted by spitbull at 6:27 PM on October 16, 2011


Not according to its prescribing literature (and hence clinical evidence) it doesn't.

According to a review in the journal Drugs:
Therapeutic effects can be apparent within 1 week but the full effects take 4 to 6 weeks to develop.
Someone would have to go back to the original studies published in 1986–1987 to see whether they specifically looked at whether there were effects in any period of less than 1 week.
posted by grouse at 6:52 PM on October 16, 2011


Can we all bookmark this post for the next time someone complains about AskMe giving any sort of medical advice?

I think that's way too reductionistic in this context. A person telling her/his own story about getting through a difficult struggle with depression is vastly different from the people who chime in with, "it sounds like you have OCD and you should get CBT for it and take Prozac and also look at this article I googled that will tell you about what you have." The former is potentially extremely helpful, the latter is potentially dangerous. Armchair diagnosis and treatment recommendation, for many reasons, can actually get in the way of someone getting the help they need from a professional who is actually capable of providing that help.
posted by so_gracefully at 7:12 PM on October 16, 2011 [1 favorite]


Note to Canadians: psychiatrists or mental health practitioners who are MDs should be covered, or at least, they are covered by Ontario (not elsewhere?). Psychologists are not covered, though they should be.

I think that for extended treatment of depression, one really needs to see a psychiatrist or GP with some specialty in mental health. Most GPs know only one or two treatment possibilities, and don't know what to do if you're not reponsive other than up the doseage.
posted by jb at 7:39 PM on October 16, 2011


Danila: "I never think of psychiatrists as therapists because they don't do much besides diagnose and dispense medication."

That very much depends on how much you (or your insurance) is willing to pay for therapy sessions. Clinical psychologists bill less per hour than psychiatrists, non-psychologist therapists much less. Unless you are paying out of pocket for individualised therapy, or you have an atypical insurance plan, you will be scheduled for 20-minute medication management sessions by a psychiatrist perhaps once a month, and 1-hour talk therapy sessions by a cheaper non-psychiatrist one-to-many times per week. If you engage a psychiatrist as part of your therapeutic plan (instead of just your medication management), then you may get some or all of the many different talk therapy modalities they are trained to perform, and sometimes multiple days/week. Many psychiatrists book a huge chunk of med management patients explicitly to effectively subsidize the time they spend in intensive talk therapy sessions with other patients.

so_gracefully: "'it sounds like you have OCD and you should get CBT for it and take Prozac and also look at this article I googled that will tell you about what you have' ... Armchair diagnosis and treatment recommendation, for many reasons, can actually get in the way of someone getting the help they need from a professional"

This is why most licenced clinical professionals can not (or should not) drop into something like AskMe with advice that sounds like that. As a physician, if you tell me you have a symptom cluster, and I tell you either "sounds like this" or even worse "get this kind of therapy" or "try this pill", then I have established a treating relationship with you (disclaimers to the contrary such as "I am not your doctor and this is not medical advice" create a very porous legal defence given the statutory and emergent nature of the doctor-patient relationship within most jurisdictions). The issue of payment is secondary, and non-payment does not void the relationship - how could it be otherwise, given the number of unpaid medical bills? So the irony is that open forums often feature a deficiency of advice from people often most trained in diagnosing and treating those diseases. You may be experiencing this symptom cluster, and one or two other people may also have felt something that they think sounds kind of similar. But if you are not working with that thing, and analyzing dozens of variations of it a week, hundreds of times a year, thousands of times in a decade, then your ability to recognise, discern and appreciate a normal vs abnormal lifecycle and progression are relatively constrained.
posted by meehawl at 7:56 PM on October 16, 2011


Not according to its prescribing literature (and hence clinical evidence) it doesn't.

At least two people in the thread, namely the OP and me, have told you that it does, based on personal experience.
posted by Gator at 8:13 PM on October 16, 2011


At least two people in the thread, namely the OP and me, have told you that it does, based on personal experience.


I shouldn't even have to respond to that. But I will. In scientific terms, that is called anecdotal evidence, and it proves nothing at all. There are any number of reasons any given person might feel "better" over a period of a few days, which could be completely coincidental and not correlated in any way with the drug you are taking.

There are clinical trials for this drug. There is an extensive literature on it. It is a member of a well known class of drugs that all work approximately the same way, meaning there is a huge body of science to point to that says there is virtually no likelihood you would find clinically measurable effects of any *statistical* significance within a couple of days at a normal dosage (something we don't even know in this case is what dosage that is, how the Zoloft was tapered down, etc.)

This argument is as old as medicine. But in this case, your attempt to shout down a broad scientific consensus based on a huge number of clinical trials for SSRIs by insisting that "two people in this thread say so" makes that evidence irrelevant is no different that a claim that elephants are scared of 2 car garages, which is why you never see one in a driveway.

You'd think I was insulting the OP. I'm not, although I really don't see why this thread exists in MeTa in the first place (there is a trend lately of people using a cursory "thanks MeFi" to post what is essentially chatfilter here). I'm sure the OP feels better, and that's great. I'm not doubting her improvement, self-reporting being the only basis we have for such things in the absence of a clinically significant sample to compare it to.

I'm telling you what the science says. I'm not stating an opinion.
posted by spitbull at 8:56 PM on October 16, 2011


I think part of it is the placebo effect because you are finally doing SOMETHING about your illness.
posted by Lovecraft In Brooklyn at 8:59 PM on October 16, 2011


Of course it is. And placebo effects are real and potent. It's completely understandable that the sensation of optimism that comes from "trying something new" -- a new medicine, a new therapist, a new approach to the problem -- would cause someone to feel renewed optimism, which is a great thing. But this is why it is downright dangerous (in terms of MeFi becoming a repository of searchable medical advice) to assert that anecdotal experience trumps scientific evidence. Because it is so unlikely that the patient's bloodstream concentrations of citalopram have even come close to the reaching an effective level after only 2 doses (literally, that's what we're talking about) that the risk of becoming quickly disillusioned when that initial optimism fades and the drug has not even kicked in yet is serious, and a not uncommon reason why people stop taking meds, or as the OP did with Zoloft, start adjusting their own dosages in dangerous ways trying to produce an effect for which they have become impatient, or which they think has somehow ceased. For the vast majority of patients, SSRIs as a class and Celexa in particular take several weeks to produce noticeable effects on dysthymic moods or OCD/anxiety symptoms. The average appears to be at least 3-5 weeks, and often longer.

SSRIs are not simple medicines. Their effects are difficult to measure or quantify and their mechanism of action is not fully understood. The side effects are often quite serious, up to and including increase in suicidal ideation. Being in fairly constant contact with your prescribing physician during the first few weeks taking this or any SSRI is a damn good idea rather than relying on a bunch of non-MDs on a website, none of whom know you, your case history, your symptoms, your life circumstances, how you've responded to other drugs or treatments, or what else you're taking.

Like I said, yay for luckynerd feeling better. That's freaking great news. Wonderful news. We don't need to discuss or debate why this is the case for the purposes of this thread. But the odds of it being due to 2 doses of an SSRI, Celexa or any other version, are statistically so unlikely that to blithely accept the statement and act like it must obviously be true does no one any service.
posted by spitbull at 9:10 PM on October 16, 2011 [2 favorites]


Also, let me suggest another reason we shouldn't be giving medical advice here, or taking personal experience as a substitute for scientific evidence. SSRIs can and often do trigger hypomania or increased OCD symptoms in patients with underlying bipolar or anxiety disorders. These effects can sometimes precede any significant antidepressant or anxiolytic effects. And they can easily be mistaken for the drug "working," when what you are actually experiencing are dangerous side effects that will continue to increase as the concentration of the drug increases, so that what feels like getting "better" after one week is a living nightmare a week later (and sometimes leads to suicide or other terrible outcomes).

This is a matter for the OP's physician, not a bunch of strangers, to evaluate. She is well advised, in my opinion, to be aware of the very, very low statistical likelihood that her better mood is simply the Celexa "working" for her.

I really wish we would not play doctor on Metafilter, even away from AskMe.
posted by spitbull at 9:19 PM on October 16, 2011 [2 favorites]


A meta-analysis says
Treatment with SSRIs rather than placebo was associated with clinical improvement by the end of the first week of use. A secondary analysis indicated an increased chance of achieving a 50% reduction in Hamilton Depression Rating Scale scores by 1 week (relative risk, 1.64; 95% confidence interval, 1.2-2.25) with SSRI treatment compared with placebo.
One week was the shortest time interval the authors looked at, so they potentially could have seen effects at previous time points. Another meta-analysis says the authors could detect differences for tricyclic antidepressants in only five days.

I'm telling you what the science says. I'm not stating an opinion.

There are multiple scientific papers (cited here and in my previous comment) contradicting your previous unsupported statement that SSRIs do not show significant effects for several weeks.
posted by grouse at 9:34 PM on October 16, 2011


Fair enough if you can cite science, and not personal experience, to contradict my points, grouse.

But one week, or even five days, is not two days.
posted by spitbull at 9:46 PM on October 16, 2011


Taylor et al conclude only that there "may" be measurable effects in less than a week, and by the way the literature that supports what they call "conventional wisdom" about a period of several weeks being normative is cited in their bibliography, for those who care.

So what they say is that it's possible, not that it's likely, or am I misreading the meta-analysis? This is not my field. Ironically, I am speaking from my own personal experience about the risks of assuming the early effects are benign.
posted by spitbull at 9:51 PM on October 16, 2011


the literature that supports what they call "conventional wisdom" about a period of several weeks being normative is cited in their bibliography, for those who care.

The citation for the "conventional wisdom" is the 2004 version of the National Institute for Clinical Evidence guideline on depression. This has been replaced by the current version says
It has been proposed that early non-persistent improvement in depressive symptoms may be due to a placebo response but recent evidence has emphasised that improvement starts immediately on commencing treatment and early improvement is a strong predictor of eventual response which is unlikely if no improvement is evident after 4 weeks of treatment.
(citations removed)

I don't have immediate access to the Stassen paper I linked above, but this paper summarizes it and another study:
They found that regardless of which antidepressant the patient was taking, there was a measurable early effect on day 1. By day 3, 20% of patients had shown some improvement, and by day 7 50% had improved. Furthermore, 90% of those who showed any response during the first 3 weeks went on to become full responders. Drug–placebo differences (where apparent) could be detected as early as day 5. In the third study, Parker’s group examined responders and non-responders treated by 27 Australian and New Zealand psychiatrists (Parker et al, 2000). Patients were requested to complete a self-report mood rating every third day. All patients showed a decrease in depression (and anxiety) within the first 3 days, but with little further improvement in non-responders from days 4 to 6. Again, early improvement within 1 week was a strong predictor of responder status.
So what they say is that it's possible, not that it's likely, or am I misreading the meta-analysis?

They are simply being careful scientists. Their conclusion is that treatment is associated with improvement within the first week, but this may be due to chance, just like any conclusion of statistical significance.
posted by grouse at 10:13 PM on October 16, 2011


2 days would be an almost unbelievable period in which to notice any effect.

I'm not aware of any studies on the likelyhood of early beneficial effects from SSRIs. Many of the side effects are expected immediately, however.

I know that two weeks is the point where an overwhelmingly large number of people can see effects (hence waiting that long before evaluation) but I have no idea if it's a steady climb in numbers from day one, or logarithmic or exponential. I'd be interested to know actually.
posted by Tell Me No Lies at 11:25 PM on October 16, 2011


And somehow I managed to miss the last few messages before posting.....
posted by Tell Me No Lies at 11:26 PM on October 16, 2011


Ah, metafilter. Where you can make a post saying "thank you all, you've been so helpful!" and the thread can devolve into an argument about whether or not your experience of feeling helped was valid or not.

I'm so glad metafilter helped you to go out and get the help you needed!
posted by ldthomps at 9:25 AM on October 17, 2011 [5 favorites]


Can we all bookmark this post for the next time someone complains about AskMe giving any sort of medical advice?

Only if you include all the questions where the asker got bad advice and ... oh ... they're all dead? Nevermind.
posted by banshee at 10:56 AM on October 17, 2011 [1 favorite]


The other thing that could be making her feel so much better in 2 days is not just the addition of Celexa, but the reduction/elimination of the Zoloft. Or the combo of the two.
posted by 8dot3 at 11:09 AM on October 17, 2011


Can we bring schmoopy back?

Schmoooooooooooooooooooooooooooop!!
posted by NoraReed at 12:09 PM on October 17, 2011


jb: "Note to Canadians: psychiatrists or mental health practitioners who are MDs should be covered, or at least, they are covered by Ontario (not elsewhere?). Psychologists are not covered, though they should be.

I think that for extended treatment of depression, one really needs to see a psychiatrist or GP with some specialty in mental health. Most GPs know only one or two treatment possibilities, and don't know what to do if you're not reponsive other than up the doseage.
"

I'm in BC, jb. The mister's regular healthcare provided by his job & the government doesn't cover psych visits at all, but the extended care he pays for out-of-pocket pays for two visits per year. I think that's useless and don't bother and we can't afford them out-of-pocket. My GP provides my depression meds and works with me to get types and dosages to appropriate levels. I've gone through quite a few meds and dosage adjustments to get me to where I am today. And if I need a change, he'll have good ideas for where to try next. Plus I do my own due diligence and use the internet to keep up-to-date on depression meds.
posted by deborah at 12:37 PM on October 17, 2011


My last zoloft dose (50mg) was on Thursday night. My first celexa dose (10mg) was on Friday night. My new therapist (she does psychotherapy and psychopharmacology) said it was fine to switch without tapering down.

I had absolutely no expectations about the medication working right away. In fact, I figured it would take several days for it to kick in, as has been the case when I started zoloft almost 2 years ago and prozac a decade ago. It was very surprising for me to feel the effect so quickly.

I don't have insurance and this therapist doesn't take it anyway, but my parents and husband are splitting the cost. As I told my Dad, "This is cheaper than divorce!"

And, for the record, I wasn't offended one bit at any of the comments. If someone told me that their medication change kicked in right off the bat, I'd wonder, too. :)
posted by luckynerd at 1:41 PM on October 17, 2011


Thanks to those who answered my question about therapists and medications.

luckynerd, I too made the switch from Zoloft to citalopram due to anxiety and anger exacerbated by Zoloft (took a long time to make the connection though). I wish you the best with Celexa!
posted by Danila at 5:07 PM on October 17, 2011 [1 favorite]


Reading through askme questions and their answers, I come across this advice to seek therapy a lot of the times and most of the time I didn't have any idea whether the asker followed that or how helpful it was.
It is really nice to see the other perspective and I am glad that things have been helpful.
posted by ssri at 8:25 PM on October 17, 2011


Anyone already on or switching to citalopram (or its workalike enantiomer, escitalopram) should be aware of the latest FDA black box warning concerning evidence for citalopram's ability to prolong the heart's QT interval in a dose-related fashion. This is something you should discuss with your physician to see if an EKG screening could prove beneficial for you. Lots of drugs can prolong QT intervals as a relatively common side effect of their pharmacology (for example, haloperidol, methadone, ethanol, quetiapine), but citalopram is the first SSRI to get this warning. This is why long QTs are tricky.
posted by meehawl at 8:34 PM on October 17, 2011 [1 favorite]


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