Meet Marius Commodore, MD. He’s a psychiatrist and internal medicine doctor who has advised the Nurx medical team as they treat mild to moderate depression and anxiety through telehealth. Unless you’ve been living off the grid for the past two years you’ve been inundated with headlines about a pandemic-driven mental health crisis, and a shortage of providers available to treat it. We asked Dr. Commodore to go behind the headlines and answer our questions about the causes and treatment of anxiety and depression.
Can you explain a little bit about why some people experience depression and/or anxiety and others do not—to the extent that we know that?
I think that last part is important, “to the extent that we know that,” because we do not know that. It’s likely that there is some genetic predisposition. Most illnesses have their genesis in the genes somewhere, but what leads a genetic predisposition to become an illness is hard to determine. Some people under-produce neurotransmitters or probably have under-activity of those neurotransmitters in parts of the brain, so it’s not just about the levels of neurotransmitters but about parts of the brain and how they’re activated. The brain doesn’t operate in isolation—it’s part of a network, so how it operates could be impacted by the formation of its networks in childhood, or by illness or a head injury. It is not known why some people develop depression and others do not. We certainly know that psychology is the basis of the problem but we don’t have tools for treating it in a surgical, predictable way like we do with a medication like antibiotics.
Is there a difference between depression and anxiety when it has no apparent cause vs when it’s linked to loss or trauma?
As with everything related to mental health and health in general, it is hard to generalize about individual experience. But overall one might expect that targeted therapy would be an especially important tool to use with treatment of depression that has to do with an identifiable trauma, because talk therapy can help unpack the traumatic event and help the patient address questions about guilt and survivor-hood and other troublesome thoughts and feelings related to the loss or trauma. But from a practical standpoint with medication, the medications you would use to treat the depression or anxiety wouldn’t differ, and the goals of treatment and expectations of duration of treatment would be the same. If we’ve decided that the trauma or loss continues to affect you in your everyday life, that it impedes your ability to function, then you would be helped by treatment in the same way as somebody who experiences mental health issues with no identifiable cause or triggering event. But it’s important to remember that one can have extensive trauma and grief but if it doesn’t affect your everyday life and function, then there is no need to treat it necessarily. But if it’s affecting your life in a significant way, and preventing you from experiencing joy, you should pursue treatment.
Nurx offers prescription treatment for anxiety and depression for as little as $0 in copays or $25 per month without insurance.
So many people have lost loved ones during the pandemic. How do they know if their grief is within what’s considered normal, and when it might be clinical depression?
This subject is somewhat controversial and there was an interesting New York Times article about the diagnosis of Prolonged Grief Disorder, and the debate around whether and when grief should be considered an illness. Of course, the response depends very much on the nature of the relationship and the nature of the loss. Most people can agree that the loss of a grandparent will have less prolonged effects than the death of a spouse or child. When it comes to trauma, a house fire in which you lose everything would be acutely traumatic but you might be expected to recover more quickly than if you’re the victim of a war crime. What’s considered normal and expected depends on the profoundness of the loss or trauma, how it affected you and cultural norms around how long grief should last.
If you’ve lost a loved one and your ability to function is significantly impaired six months or a year later, treatment cannot make your grief disappear, but it may make the ground under your feet feel more solid and the days feel more light, and help you can get out of bed and face the day without it being such a burden. Of course no medication will make you stop mourning your loved one, but it may be able to restore your ability to feel joy from the things you used to enjoy, whether it’s seeing the sun rise, smelling your morning coffee, watching ESPN after work, or spending time with friends. Those joys can return even while you continue to grieve.
Why do some treatments/medications work better for some patients than others?
Unfortunately we don’t have very good tools to help us understand what will work for one person vs another. There is emerging evidence around genetic testing that might help us in terms of side effects, to show us who will be most susceptible to experiencing certain side effects. But we don’t have good info on what will work better for you, so there’s sometimes trial and error involved. If your sister and mother are on an antidepressant that works we might be more likely to reach for that for you. If you have had lots of side effects from a particular class of medication we might decide not to use that class anymore. But we don’t have good usable information yet on how a given individual will respond to a particular treatment.
This is not so specific to mental health treatment. Even for antibiotics, while we have great tools to decide if a given antibiotic is going to work for a given infection we don’t have good tools to tell me if a particular patient will get a skin reaction or diarrhea. So even with more established treatments we might know what works but not how effects will affect you.
So it’s important to remember that there are multiple treatments and if one doesn’t work you can move on to others. Don’t give up if that first treatment you try doesn’t make the difference you’d hoped for. That’s easy for me to say but it’s important for patients to know.
How long should a patient expect to wait for a treatment to take effect?
There’s a fair amount of science indicating that if you feel not improvement at all within the first 3 weeks you are unlikely to feel something later. After 3-4 weeks science indicates we should change the dose or change the drug. But also know that once you do start to feel improvement it takes 6-12 weeks for a given dose to give you all it’s going to give you. If you start feeling better at 3 or 4 you might feel even better at week 6 or 9.
How long should patient expect to stay on treatment?
Once a patient has achieved an acceptable dose for them, with a medication that’s right for them, we suggest they stay on for a year at least. After that year you can keep going or, if it’s your first or second episode of depression or anxiety, work with your medical provider to taper if you want to see how you do without the medication.
However, if you have had more than 2 episodes of mental health illness you should stay on your treatment as long as possible. Of course I always listen to patients, and some patients say “I know this is my 4th episode with depression but I want to try quitting my antidepressant,” and if thats’ their choice I will always work with them to taper.
It’s important for everyone on daily mental health medication to know you shouldn’t stop cold turkey. Work with your care provider to gradually taper off the medication, usually reducing by about 30% per month.
What else should Nurx patients should know about prescription mental health treatment?
I would say two things: First, as Wayne Gretsky said “You miss 100% of the shots you don’t take.” So if you are asking yourself “Could I live better?” you owe it to yourself to take a shot. It couldn’t actually be worse than what you are going through now.
Also, you didn’t get depressed over night and you won’t get better over night. If it feels like getting better is hard it’s because it is, but it’s completely worth it. The vast majority of patients get somewhat better, they don’t all get perfectly better, but somewhat better can be huge.
When medication helps you feel better and function better, even if just partially better, it leads to other positive changes in your life that can make you happier. Treating your depression may help you exercise more, which in turn leads you to feel better in your body or about how you look. Or it might help you perform better at work which could lead to more money or career success.
I am excited to be working with Nurx to chart a new course into an exciting and necessary area of care, and empower patients to access high-quality mental health treatment from the comfort, privacy and convenience of wherever works best for them.
Learn more about getting mental health treatment through Nurx.
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