The Knowledge Center

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Emotional Distress: Counseling or Medication

Emotional distress comes in many forms and shapes. There are no x-rays or blood tests to explain what is going on or what is wrong, just your verbal description. The two most common mental health problems are anxiety and depression. However, there are many other diagnostic conditions such as problems with anger, concentration, mood and/or thinking.

Anxiety and depression come in varying degrees with different causes. They may arise from situational problems.  These may include difficulties in a relationship such as marriage, problems with money, and performance problems in school or work that may produce anxiety, depression or both. Family difficulties are also often a source of distress. It is hard to believe 50% of marriages end in divorce, but only 40% of people get divorced. How is that difference possible? Some people get divorced, two, three or more times, so the statistics on divorce go up but the people are the same.

Some people have anxiety or depression or both and yet nothing in their life experience appears to be the cause. For some, emotional problems are genetic in origin and there is a history of the difficulty in the family. The depression or anxiety seems to hit like lightening, seemingly out of no where. In other cases a trauma is the cause of problems precipitating either or both anxiety and depression. Trauma may come from witnessing a tragedy, violence, or being hit on the head in a car crash. X-Rays, EEG, cat-scan may reveal nothing, yet emotional problems emerge.

So what do you do?  Most people initially go to their primary care doctor. Some primary care doctors will take time to talk to their patients and family. Pediatricians are often better than doctors of internal medicine at talking with their patients and parents. Whether you are depressed or anxious, the most common medicine prescribed will be an antidepressant. Most antidepressants are prescribed by primary care physicians, not psychiatrists. Unfortunately, over-burdened primary care physicians often do not follow up but leave it to their patient to set up another appointment if something is not working. Further, most patients I have seen are not aware of side effects that they may be having from their medication.

The most common prescribed antidepressant last month was Lexapro simply because it was the newest. Next month it may not be. Lexapro has three virtues. It helps both anxiety and depression. It works within five days, not the eight weeks it takes many of the older antidepressants, and one tablet a day works as well as two or three. It has only two frequent draw backs: weight gain and in both men and women, interference with sexual performance and interest.

Many physicians are reluctant to prescribe anti-anxiety pills. They worry it is addicting and I have seen patients addicted to Xanax. Unfortunately, Xanax lasts only three hours. As it leaves your system you may have a resurgence of anxiety as a result of withdrawal and take another one immediately. If you are afraid of flying that is no problem. You take one pill, perhaps Xanax, ½ hour before flight time. The plane takes off you are fine. The pill wears off but you know you are landing in one hour and there is no further anxiety. Another common anxiety medication is Klonopin. It starts in thirty minutes and lasts eight hours. It wears off slowly and you don’t have rebound anxiety and so don’t need another one immediately.  Knowing you have the pill is itself reassuring so you may not even bother to take it. Every antidepressant has to be taken every day and the doctor will tell you to stay on it for a year. I have seen patients on Paxil or Zoloft who have been on the medication for four years, gained forty pounds, but thought it was just a part of the depression. Prozac, Paxil, Zoloft have remission rates of 35%. But 70% of people have some degree of relief though not a total loss of symptoms. So it is easy to misinterpret what is going on.

You may choose to see a psychiatrist to help you with your emotional concerns. Most psychiatrists will see you for 45 minutes the first time and tell you to come back in two weeks. They will then see you for twenty minutes to follow up. The third time they may see you for 15 minutes. Follow-up visits allow the doctor to assess symptoms and side effects and titrate your medicine.  Picking an antidepressant is not obvious. They vary person to person both in effectiveness and side effects and only trial and error provides a clue.  Fifty percent of people who start an anti-depressant will switch to another.

You may have gone to see a mental health professional. Psychologists will have Dr. in front of their name. Social workers, nurses or professional counselors will be called Mr. or Ms. Some mental health professionals may discuss medication with you and others may think it is not their responsibility. You may have started with a counselor and the presenting problem lessened quickly. The average length of psychotherapy, to use a more technical term, is six sessions. Many individuals are helped to better cope through a long-term involvement. Many people see a therapist as well as take medication and all evidence is that for depression the combination of the two is more effective than either one alone.For some people an antidepressant or tranquillizer is sufficient. They may have not had that much to say and they thought the therapist was boring. In other cases they might have liked the therapist and felt it just wasn’t necessary to return. For some the experience with psychotherapy is profound.

Does therapy help? It depends who you ask. There are many different theoretical orientations to psychotherapy. Some tell you that you should have “evidence-based-therapy”. They maintain cognitive-behavioral therapy, a type of evidence-based therapy, has been shown to be the best. Cognitive therapy was radical in that it disposed of psychoanalytic therapy which involved exploring your childhood. Cognitive therapists maintain that you need to identify the ideas that are generating the distress and change your thinking. I am sure that works as well as anything else. Whatever the orientation, if your therapist has common sense and is responsive and warm, then you will feel helped. That is the only real evidence present in research as to what works. Talk helps when you are in distress and some conversations will be more constructive than others; especially the chance to discuss current problems, feelings and life experiences with a competent mental health professional.  There are individuals who despite taking multiple psychiatric medications participate in long term psychotherapy yet struggle with intermittent emotional difficulty. Without medication and psychotherapy their lives would be more profoundly compromised. The science is not yet complete and we do not all have the same emotional barometers in a challenging world.

Dr. Jeremy Kisch is a licensed clinical psychologist and has diplomate status with the Amerian Board of Professional Psychology.

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