On Halloween, I started taking Lexapro, an SSRI, to treat my depression. On the first day, I noticed an obvious and immediate effect as soon as it kicked in. I felt like someone had flipped a light switch in my mind. I felt good in a way that I have rarely ever felt. In the last two months, I’ve felt this way most days. I often ask myself why it took me 31 years to try an SSRI. Mostly it was due to stigma and an incorrect impression of the research. If my story resonates, I hope this post will convince you to talk to a psychiatrist.
My takeaway from scanning my memories: it’s hard to know what quality of internal experience merits help and what is a normal part of the ups and downs of everyday life. If I’d never tried various drugs, I would never have discovered that there’s a different way for Ben to exist.
When I was very young, I often threw tantrums. I would cartoonishly pump my fists and stamp my feet as I cried. My siblings only watched and laughed, which of course made me feel worse. Over time I learned to suppress these feelings. By the time I was eight I had significant emotional blunting. I’d distanced myself enough from my own emotions that I couldn’t tell if I was happy or sad. I still got excited about things, but I didn’t have internal awareness. When I recently asked my mom if she thought I might have been depressed growing up, she said, “You looked sad, but when I asked you if everything was okay, you said that was your neutral face. I believed you.” In high school, some classmates nicknamed me “android” because they saw me as an emotionless studying machine.
It wasn’t until I went to college and had my first serious relationship that I felt myself reconnecting to my emotions. My girlfriend and I would have horrible yelling fights mixed with euphoric moments of connection. In retrospect, I think I blamed her for some of my negative internal experience. After we broke up, I had occasional panic attacks with no apparent triggers. I’d be working on my homework alone in my room and suddenly flush with anger. I’d go for a run at midnight in Riverside Park and shout into the dark Hudson River. I sought therapy and it seemed to help for a while.
More recently I dated someone who’d had clinical depression her whole life. Outside her episodes, we were great together. We helped each other become better people, played, and adventured. During her episodes, though, we’d both get dragged down. Seeing the intensity of her depressive episodes, I felt sure that I wasn’t depressed. She experienced severe memory loss, crying bouts that would keep her up all night, and negative thought spirals that torpedoed her performance at work and caused her to quit working for about a year. I thought, “I can still work most days, so I must not be depressed.” Still, we suffered a lot together. At some point I couldn’t bear her blame and suffering. She couldn’t take what she saw as my constant need for control and supremacy. In our final conversation she hardly said a word as I tried to reason with her for hours. I still remember the washed out sunlight as I left her place at 7am. It was hard to appreciate that light with this new hole in my heart. The world seemed veiled by my loss.
I don’t want to give the impression that my life has been an uninterrupted nightmare. In social situations I tend to genuinely feel as happy and engaged as I look. My friends and family have always been warm and supportive with the exception of some early sibling rivalry. When I’m alone or with a long term partner I feel different. When my guard is completely down, I become aware of feelings of weight, tightness, pressure, and sadness. I thought it was normal. It pushed me to be an extrovert. This made it all the harder to recognize that I had a problem.
The road to recovery
During my last relationship, I started getting into nootropics. I read Slate Star Codex’s survey results to find interesting candidates. Tianeptine, an atypical tricyclic antidepressant, and phenibut, a GABA-agonist anxiolytic both stood out as highly rated and low risk. They are unregulated for medical use in the US, so you can buy them with a credit card on normal websites. I never admitted to being clinically depressed or anxious, but I thought taking these things could make me feel better than baseline. Both did! Tianeptine has only a few hour half life, so it doesn’t last all day. Phenibut is considered addictive, so I never did it more than once every four days. Neither were good long term solutions, but I took them occasionally. These were my first hints that a chemical intervention might work for me.
I tried a lot of other ways to feel better. I learned to meditate for 5 years. I went to a 10 day retreat. I went to therapy. I read books like Feeling Good, Nonviolent Communication, Waking Up, and Search Inside Yourself. These all helped me understand my own mind better, becoming aware of my emotions good and bad. I felt like I was making progress, but at some point I seemed to hit a wall. Sometimes I’d engage in self-destructive behavior like fasting for 3 days or eating a whole pint of ice cream in one sitting. I’d seek out romantic relationships to fill the hole inside me, only to throw them away when the hole didn’t close. Nothing seemed to work reliably.
When I started my new job in July, I noticed I had increasingly frequent depressive episodes. I’d feel viscerally bad for no particular reason. I’d feel a weight in my chest, a lump in my throat, and resistance in my mind. Some days it took me an hour just to get out of bed in the morning. In social settings my mind would spin with over-analysis, judging myself for every little thing. When I woke up with tears in my eyes one day, I suddenly felt sure that something was wrong with my mind. I asked myself what was going on and came up blank. This finally seemed like enough evidence to take action.
I’d read that the FDA had just granted ketamine breakthrough therapy status for depression. Reading the literature, it seemed to cause lasting positive changes without the need for a daily pill. I heard stories from multiple friends who tried it and saw it change their lives. I got quotes from organizations in SF that provide ketamine therapy. They all asked for referrals from either a primary care or a psychiatrist.
I don’t know why, but I was afraid to ask my primary care about it. Maybe it meant admitting I had a problem in some official way. Maybe I thought I was insulting all the people with “real” depression to call my lesser symptoms comparable. I pushed through the fear and sent him a two sentence email asking for a referral. He responded with a worried tone, explaining that ketamine therapy is a highly experimental treatment only indicated for those with the most severe, treatment resistant depression, and we should try the traditional routes first.
I was thunderstruck that I hadn’t thought of trying the traditional routes myself. My parents are doctors. The first question with any illness was always “What medicine could cure me, or at least suppress my symptoms?” Why did I draw a line in my mind around antidepressants? Why was I willing to pay $3000 for an experimental new treatment when I hadn’t tried the normal ones for $10?
That day over the phone, I told my GP about my symptoms. By the end of the call he had prescribed Lexapro. It’s been incredible. I’m finally able to fully enjoy and appreciate the privilege that is my life.
My biggest misconception around antidepressants is that they don’t work, and even when they do, people stop taking them after a while. I’d read this in books like Feeling Good written by psychiatrists. I’d never met anyone who said their life was dramatically better because of antidepressants. I’d never talked to someone about their personal experiences with the drugs. It was only after I got my prescription that I started a more serious literature review.
Luckily Slate Star Codex, written by the pseudonymous psychiatrist Scott Alexander, has an excellent overview. We have no idea why these drugs work even though we know a lot of the receptors they act on. For example, Tianeptine and SSRIs have opposite effects on the serotonin system but both are antidepressants.
Even measuring depression is hard. Some surveys map the same score to “mild” and “very severe,” so probably don’t put too much weight on the labels. Generally it’s best to measure depression by the severity of the episodes rather than how you feel on an average day.
It seems antidepressants have a bimodal effect on people. Sometimes they really work (responder), and sometimes they make things worse (non-responder). If you’re a non-responder it’s easy to stop taking the drug. In one representative study of a particular antidepressant, two thirds of the subjects were responders, one third non-responders. This leads Scott to recommend that people just keep trying if the first drug you take doesn’t work. Effect size is a measure of how much difference a drug makes when you take it. Effect sizes for SSRIs (~.3) are equivalent to a weight loss drug that makes you lose 9–14 lbs. These effect sizes are controlled for responder/non-responder. For comparison, morphine for pain has an effect size of 0.4 and is considered extremely effective.
Side effect stereotypes are overblown. Most of the side effects of SSRIs appear not to be permanent except maybe the sexual dysfunction. I’d be surprised if any of the side effects are permanent in people who start taking SSRIs as adults. Only ~20% of people experience emotional flattening. Doctors notice changes in depressive symptoms before patients: “they start smiling more and talking more and getting out of the house and are no longer thinking about suicide.”
In his update 4 years later, the message was similar. He reiterated his point about responders vs non-responders: “there are some patients for whom SSRIs work very well.” If a drug works for a small percent of people and helps those people a lot and it’s not hard to experiment, it’s worth it for lots of people to try. SSRIs are mostly thought of as anti-depressants but they work for anxiety, too, with even bigger effect sizes. SSRIs are crazy cheap (~$0.50/pill) compared to therapy ($150/hr), so they should be a first line of attack.
In 2019 Scott did a survey on particular drugs. 60% of respondents found SSRIs effective. Side effects were mild or nonexistent for most people. 80% of people were able to stop without real difficulty. Prozac and Lexapro were rated highest; Paxil sucks.
My experience on Lexapro
I feel happy, alive, confident, and ready to tackle difficult tasks. I laugh and smile more in conversations. I have more compassionate and less negative self-talk. I get out of bed quickly in the morning. I’m excited to face the day. I second guess my social interactions less. In romantic situations I find it easier to express my needs and be playful.
There’ve been few downsides. I feel a constant subtle stimulation, which makes it harder to stay asleep, but not fall asleep. It’s almost impossible for me to ejaculate. For the first two weeks I had dry mouth, but that resolved itself. I’m supposed to stop drinking alcohol, but I already quit 3 years ago. LSD, psilocybin, and other similar psychedelics have no effect.
I still occasionally have what you might call depressive episodes, but they’re far less severe.
I’m not a doctor! Please proceed with caution.
I’ve never had a bad experience on any psychoactive substance. Some people do. It’s possible that my mind is particularly fertile for these things, and in others it would have negative effects. A friend tried Lexapro and he couldn’t sleep at all. Tianeptine works well for him. Everyone is different, and the only way to know is to try.
Sometimes SSRIs suddenly stop working, or if you take a break, they don’t work after the break. In David Foster Wallace’s case this meant suicide. I have to think it’s better to have loved and lost than never to have loved at all though. And who’s to say he would’ve lived as long as he did if he hadn’t tried anything in the first place? Still, it’s best to go in with your eyes open about the risks. You only get one mind.
The silence around antidepressants was part of what kept me away from them. Since I started talking about them, I’ve met many people whose lives have been saved by these drugs. If you’ve felt sad with no apparent reason, you’ve tried the usual routes like therapy and meditation, and you’re not sure what else to do, consider antidepressants. I’m happy to chat about this kind of thing any time. Please don’t suffer alone.