The Washington area—home to the National Institute of Mental Health, the American Psychological Association, and the American Psychiatric Association—can be both a good place to find excellent help and a tough place to stare down the stigma associated with mental illness.
“In Washington, the stigma may be worse than it is elsewhere,” says Wendy Hookman, medical director of the Washington Center for Women and Children’s Wellness in Rockville. “It’s probably because a lot of people are involved in government jobs where there is concern about security and drug testing and privacy. We have a very work-focused culture.” Hookman, who completed her psychiatry residency in New York City, says that people there seem more open to talking about therapy.
Carrie Holl, a psychologist who trained in Los Angeles, has noticed a difference between West Coast patients and those she sees at her Dupont Circle practice. “I see more obsessive thinking here,” she says. “I see highly functional people who are still working and who are hiding their symptoms really well, but they are suffering a lot.”
When people do decide to seek help, they typically turn to the Internet—an okay first step as long as they use reputable sources such as the Web sites of the National Institute of Mental Health (nimh.nih.gov) and the Centers for Disease Control and Prevention (cdc.gov).
Eventually, it’s important to undergo an evaluation by a mental-health professional, such as a licensed clinical social worker, psychologist, or psychiatrist. Clinical social workers and psychologists can provide therapy in private practice or in hospitals and other settings but generally cannot prescribe medicine or order medical tests. A psychiatrist is a medical doctor specializing in the treatment of mental illness.
People who are uncomfortable seeing a mental-health specialist or who don’t have access to one should consider talking with their primary-care physician.
“Insist that they take the time to talk to you,” says Akil. Some mood and anxiety disorders can be confused with physical ailments because symptoms can include upset stomach, digestive problems, headache, and fatigue. “I tell medical students that when people are presenting with a somatic complaint you can’t get to the root of, consider a psychiatric problem.” She also notes that certain diseases, such as heart disease and cancer, can be accompanied by depression.
Blood tests can rule out things like thyroid disease, anemia, and Lyme disease and can have symptoms that mimic those of depression. Meanwhile, patients need to talk openly about everything that’s bothering them—and not just physical complaints. “Bring a list,” Akil says, “and stick to it.”
“Calling in the Troops”
Treatment often involves medication. Many antidepressants treat both depression and anxiety. The most popular are selective serotonin reuptake inhibitors, or SSRIs. This group includes Prozac, Celexa, Lexapro, Zoloft, and several others. Serotonin and norepinephrine reuptake inhibitors (SNRIs ) are similar to SSRIs and include Effexor and Cymbalta.
Both SSRIs and SNRIs work to normalize levels of naturally occurring brain chemicals called neurotransmitters. SSRIs and SNRIs are more popular than older classes of antidepressants such as monoamine oxidase inhibitors (MAOIs) and tricyclics because they tend to produce fewer side effects. However, medications affect people in different ways; for some, the older classes of antidepressants are still the best choice. In cases where an antidepressant alone is not enough, drugs such as lithium or thyroid medications can be added.
Antidepressants take two to eight weeks to build up in a person’s system, but side effects such as nausea, headache, or agitation—which are usually temporary—can occur immediately. “If someone is already anxious, this can be a tough time,” Akil says.
When Betty began taking Cymbalta, she felt sick and had trouble eating. “I had to very slowly work up to 60 milligrams,” she recalls. “It didn’t really work until I got to 60. Once it did, I became a different person. It’s the perfect drug for me.”
While waiting for medication to kick in and side effects to diminish, doctors sometimes schedule patients for frequent appointments and emphasize companion treatments such as exercise, a healthy diet, social activity, and family support. Says Akil: “I tell people this is the time to call in the troops.”
Meredith, who takes the anticonvulsants Depakote and Lamictal to regulate her mood, says her husband’s support was critical. He developed a sense for when her mood was dipping toward depression or ratcheting up toward mania.