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.