Oct 18, 2022

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Scot: Troy, I got a question for you. Are you ready to delve into Mitch's mind today on the podcast?

Troy: I don't know. I don't know if I'm ready for this, but it sounds like I don't have a choice.

Scot: Mitch, are you ready for this?

Mitch: I guess. You guys, welcome to my mind. Let me show you around.

Scot: I hear it's kind of noisy in there. Is that true?

Mitch: It can be. Yeah, it's quite loud.

Scot: All right. Well, today we're going to talk about medications for some who might have been diagnosed with depression. They're called selective serotonin reuptake inhibitors, otherwise known as SSRIs. And for individuals that have been prescribed these, sometimes finding that right specific medication can be challenging and a frustrating process, but in the end, it can lead to a lot of different benefits. And that is what Producer Mitch has discovered, and that's what we're going to talk about today.

We're going to talk about SSRIs, what they are, how they work, how they could benefit somebody, some of the side effects, and then this medication dialing-in process, what that could be like, at least in Mitch's experience.

This is "Who Cares About Men's Health," where men talk about health and health issues. And we also provide some information, inspiration, and a different interpretation of your health. I bring the BS. My name is Scot. Countering my BS with his MD is Dr. Troy Madsen.

Troy: Hey, Scot. That's me.

Mitch: Producer Mitch is on the show again, and a lot of openness talking about his own experience so others can benefit. So thank you, Mitch, for being so open. We appreciate that.

Mitch: Happy to. Happy to share.

Scot: And also joining us today, our expert, Dr. Scott Langenecker. He's a clinical neuropsychologist from Huntsman Mental Health Institute, and he's going to help us better understand our topic today. How are you doing today, Dr. Langenecker?

Dr. Langenecker: Doing well. Thanks.

Scot: Mitch, why do you want to talk about this topic today? And by the way, no pressure.

Mitch: No, it's cool.

Scot: This is just the point where people decide if they're going to keep listening to a podcast or not.

Mitch: Oh, okay. Sure. Yeah, let me just nail it here. So one of the things that I really . . . the reason I really wanted to talk about this is that I had a lot of emotions and hesitancy and just kind of some mental barriers between me as I was dealing with some pretty severe anxiety, a little bit of depression, and where I am today because I was afraid of what meds would do, right? I had people telling me that they were going to make me a zombie. They were going to change the type of person I am.

And I want to make sure that we can talk about this plainly and say, "Hey, here is what my experience has been. Here's how much better I'm doing because of Lexapro and Wellbutrin."

And then on top of that, the thing that I could . . . When I was first starting to get on medication, there was a journey of finding the right medication, trying a couple of different things, emotional waves, weird eating habits, etc., that my doctor didn't really tell me to expect.

And when you go online, it's kind of hard to find people talking about it. So I want to make sure that we have a chance to at least voice and give someone out there, "If you are starting on medication, this might happen. And it's okay, and there's a light at the end of the tunnel."

Scot: What was your situation like, Mitch, before the medications that led you to want to go on the medication or to even consider it? What was that journey?

Mitch: So I think we've talked a little bit before, but I was experiencing what we now kind of know as a general anxiety disorder of sorts, right? Where I was so anxious about so many things. I was nervous about the future. I was nervous about contracting COVID at the time. I was constantly talking poorly about myself, and I couldn't get myself out of those types of spirals.

And I think I've mentioned before, it was . . . To kind of give how out of sorts my brain was, it was everything like . . . Scot, we've worked together for a very long time. Love you. Think you're super great. If you sent an email that was worded slightly too directly, I would be a mess. I would be a wreck. I would be afraid that I was going to lose my job. My friend doesn't like me anymore, blah, blah, blah. And there was no real basis for that. It was just all up in my head.

And that's what eventually got me into therapy. And we started working through things and doing some behavioral therapy and talk therapy and working through some old traumas and things like that. But it just wasn't quite getting there. I wasn't quite getting the peace of mind I was hoping for.

The work that I was doing in therapy was not quite getting as effective as it could be. And so I was told, "Hey, maybe a medication would be right for you." And so I got it and after a little bit of a rough spot, I can't tell you how much better things are these days.

Troy: And you mentioned, Mitch, a little bit of a rough spot. Maybe something that's worth exploring a little more, and maybe letting people know about that. What exactly do you mean by that, by the rough spot? I assume you're talking right after you went on the medication?

Mitch: Yeah. Right after I got on the medication, there were a couple of weeks where . . . I think the term is titration or titrate. You're trying to find what's the right dosage, what's the right drug, what's whatever, what works best in your brain.

And we tried a couple of different doses. We tried a couple of different medications, but that journey was a little different. I cried into a Wendy's hamburger one day for reasons I cannot explain. Just felt wrong, whatever. And so, yeah, I wanted to kind of talk about those a little.

Troy: Yeah. And I'm sure Scott will talk more about that too, but I think that's not unusual to have that when you do start the medication. It may feel like things are worse before they get better. And it sounds like that's kind of what you went through.

Mitch: Mm-hmm.

Scot: So, Dr. Langenecker, what exactly was Mitch experiencing from a medical standpoint? Can you explain that, or is it unexplainable?

Dr. Langenecker: Yeah, there's a tremendous and potentially emotionally overwhelming controversy/discussion about what these medications actually do, how they work, what's the sort of mechanism at the level of a neuron that actually helps people to process emotions differently.

So what we do know, based upon what they're called, these selective serotonin, norepinephrine, and maybe even dopamine reuptake inhibitors, what they do at a very basic level is they kind of block the vesicle where those neurotransmitters, monoamines, sort of get sucked back up into the neuron in the synapse.

And by blocking the reuptake or the reabsorption of those at the level of the synapse, that means more of it is out in the synapse potentially to play and to facilitate some of the neuronal function.

This is at the level of the synapse. And we're talking about 13 trillion synapses in the human brain. How we extrapolate that to Mitch's sensation of the Wendy's hamburger and the tears, I mean, this is a stretch way beyond my skill set.

Mitch: Sure. Right.

Scot: That's quite a juxtaposition, isn't it? Chemical reactions at the synapse level versus that hamburger in Mitch's hands.

Mitch: Yeah, crying into a Baconator in the back 40 of a Sam's Club I think I was at. Yeah, that's very different. There's a long stretch

Dr. Langenecker: But they're related. They're definitely related. So there are a couple of different schools of thought about what's going on. One school of thought is that there's sort of this lack of serotonin within the synapse and the neuron can't do the work that it needs to do, and so it kind of stumbles around. And if you've got 13 trillion neurons kind of stumbling around, things don't go the way you'd like them to go.

I think people are pretty confident that that interpretation is probably, at its core, faulty. And the easiest way to think about that is when you have a headache, what do you treat it with? You might grab a couple of ibuprofen and your headache might go away. Do we think that you have an ibuprofen deficiency? Probably not. You probably have something else going on, and the ibuprofen is helping that other process to resolve, and then your headache goes away as a result of that.

I don't know if that analogy helps, but that's kind of a way to think about it.

There's a newer line of research that is really kind of mind-blowing, which is that we, as human beings, you probably heard we're like 70% water. And our genetic code is not so much what we are, but we're like a standard upgrade 3D printer that's just changing in real-time every day, every second, every minute. And so our genetic code is kind of just telling our cells which proteins to create and where to put them and how to build, and how to fix, and how to set things up.

And if you think about this at the level of 13 trillion neurons, it really gives you that humility for how little we understand about how our brains actually do what they do. Maybe we could figure out a heart valve. We can get that down, but 13 trillion neurons, that's a tall order.

And so there's some sense that the SSRIs or variants of SSRIs are actually changing the way that the RNA accesses the genetic code, the way it accesses it, how it uses that information, how it actually gets about the business of sort of 3D printing ourselves as we move forward in space.

I know that's a lot of detail, but the basic idea, the basic concept is that there might be some sort of rigidity in the way that the genetic code is accessed. And so it doesn't allow for that dynamic re-updating of the brain that's moving forward in real-time.

Mitch: So we don't exactly know how they work, but we're pretty confident that they do work. Is that what I'm hearing?

Dr. Langenecker: We're pretty confident that for 100 people in a room with depression or generalized anxiety, if I give them an SSRI, I'm pretty confident. I'd take this to Vegas and I'd spend everything I've got that 40 of those people are going to feel a lot better.

Now, if you told me in Vegas, "I want you to pick which 40 of those people are going to feel a lot better," I would not make the bet.

Mitch: Got you. Okay.

Scot: I feel like I got a little bit of insight. I think Mitch nailed it. I feel like on one hand when medications are prescribed, the people prescribing them or the people that created them know exactly what mechanisms are being altered to create the desired outcome. But I feel that that's not necessarily the case. I feel like we've discovered that this particular compound makes people feel better when they don't feel good. Is that accurate?

Dr. Langenecker: It is. And we talked about this before. I'd say over 90% of our breakthroughs in depression in particular have been sort of serendipitous, like we tried treating patients with Parkinson's and tremors with this drug and their mood got better, or we tried slowing down people's seizures for epilepsy with this medication and this got better.

And in almost all of those instances, it didn't actually work at all for what it was intended to do, but we had the system set up where we could observe people and notice that their mood improved and that mood improvement was sustained.

Troy: So what you're telling us, Scott, is essentially SSRIs are like Tang. Like the space program produced Tang, other research produced SSRIs and we found other uses. That's kind of what I'm hearing here, but it is interesting to hear that.

Dr. Langenecker: Yeah. I mean, there's a darker side to this, and this goes back to the stigma that we've been talking about, which is we kind of had this thought in the back of our mind for a really long time that people were just built a certain way and that they were weaker and that their character was flawed. And we didn't really think about mood and anxiety as like, "Hey, that's probably a medical condition."

And so we didn't put a lot of money into understanding it, and so a lot of our breakthroughs have been just kind of random, lucky breakthroughs from people trying to fix some other problem that we invested money in.

Scot: And I feel like also . . . First of all, I've often said that the human body is just a big chemistry experiment, right? And we're just a centimeter away out of being out of balance from a chemical standpoint.

So here's how I'm interpreting what I'm hearing. When Mitch was given maybe the initial SSRI . . . Because that's a class of drugs. There are a lot of drugs that fall within that category. It did some stuff in that chemistry that was not necessarily in the direction we wanted to go. And we don't know why, but it just kind of didn't work. So we've got to try something else to see if that would be better.

Dr. Langenecker: Well, yes. I mean, the easiest way to think about it is we are . . . Let's just say for purposes of hypotheticals, there's a certain subset of 2,000 neurons of the 13 trillion we have that are just kind of out of whack when somebody is experiencing depression.

What do we do? Well, we give people a tablet. The tablet has the medicine in it, it goes into their GI tract, it gets transferred through their liver, goes through the bloodstream, maybe it goes through the blood-brain barrier in some percentage of what we sent them originally, and then maybe some of that is actually making it to those 2,000 neurons that need a little pep talk.

And along the way, there are all sorts of other cells that are like, "What the heck is this stuff? This stuff is not good for me." And so we're kind of fighting between the systems that really need the medication and the systems that are kind of like, "Well, I didn't really ask for that."

And as an example, I'm sure we've all heard, "Hey, you are what you eat." Well, it turns out that a lot of the microbiota in our lower GI create serotonin. They're involved in this whole party and we've never known that for forever.

And so we're sending these meds down into that same spot in our lower GI and sort of thinking, "Well, nothing bad will happen. It'll work out okay." And so it takes a while for the body to kind of equilibrate in all of these other areas where the meds are going, where we don't really want them to go

Troy: In terms of spinoffs, it's fascinating that so many big blockbuster drugs . . . Because SSRIs are blockbuster drugs. They're one of the most prescribed medications. Another blockbuster drug, Viagra, was also discovered by accident as well. That was discovered when they were investigating heart medication and then all these men were reporting erections.

Dr. Langenecker: Awkward.

Mitch: They found that, yeah.

Troy: They found it, yeah. So often that process of discovery kind of follows that path. But it sounds like SSRIs were similar in terms of that route.

Dr. Langenecker: Yeah. And a lot of the data we have suggesting SSRIs are effective are data from mice. When we put them into a tub of water, they'll swim longer. When we put them into an open maze, they'll go into the scary spots more often.

A lot of these sorts of analogies to what is depression and anxiety are a bit of a stretch. The real proof in the pudding is, and I hear these stories all the time, "I was on vacation, and I forgot my meds at home, and when I came back I was just in a bad space," or, "I accidentally switched the medications and I was off for a couple of weeks and things went downhill." So for those 40 out of 100 people that these medications are helpful for, they're really helpful. It's not just accidental.

Troy: Now, I have to be the skeptic in the room because that's my job here. Because I know there's someone listening who's thinking this and has heard this. There have been some studies and there's been a little bit of press attention in recent years of studies suggesting that SSRIs are no better than placebo.

What are your thoughts on those studies and have you seen those and heard others cite those, or did that ever come up when you talk to people about SSRIs?

Dr. Langenecker: Yeah, I love this question for two reasons. The first reason why I love this question is because it convinces me that human beings are in the business of recovery. So if I give you a sugar pill and you're feeling awful, the natural inclination for a lot of people is just to start feeling better.

And if you think about the analogy I was talking before about a real-time 3D printer, nobody wakes up in the morning and says, "Oh, I feel awful. And I think I want to feel awful for another three months. I think that's probably a good idea."

Everybody wants to feel better. And it turns out we're super creative, we're good problem solvers. And so some subset of people just need a little bit of . . . I use the word permission, encouragement, whatever you want to do, to sort of kick off that healing response.

Is it really a placebo? Probably not. Is it just that little nudge that people need to do what they probably wanted to do or were hoping to do anyway? Absolutely.

Now, added to that, if you follow those placebo responders long enough, you'll actually find out that that placebo continues for a good number of people. But it doesn't for other people. They actually get sick again.

And if you give people SSRIs for a long period of time and you continue to give them SSRIs for a long period of time, many more of those people will stay well over time than the people who initially responded to the placebo.

So the placebo is a good thing. We love it. Most people complain about it. I think it's awesome. I think it convinces me of the magic of being human. But it may not be enough to sustain wellness for some people.

Troy: That's interesting. So essentially what you're saying is a lot of these studies, short-term people receiving the placebo, essentially a sugar pill, it's that hope of improvement that seems to elevate their mood, maybe treat anxiety, the hope of being able to heal. But like you said, the long-term sustained effects, you really just see that with the SSRIs then.

Dr. Langenecker: Absolutely agree. And as Mitch has told us, the SSRIs are a piece of the puzzle. You want to get to the point where you're going to do some work in therapy or in life in general where you're going to make some changes.

I use the example all the time . . . It's a tired example. If you're using the same ingredients to make your chili, it's probably going to taste the same. So even though we might add a little bit of SSRI, we might need to actually change the way we make the chili, change a few other ingredients so that it actually gets us where we want to go and it tastes better.

Scot: Mitch, take us through kind of your process with it. You talked about when you first started a particular SSRI that you had some unexpected, unwelcome responses. What was that process of dialing that in like?

Mitch: It was kind of shocking. When we're talking about brain chili or whatever, the first . . .

Troy: Brain chili.

Dr. Langenecker: I love it. Brain chili.

Mitch: So when it came to my brain chili, we put a little bit of . . . I had already been trying to do the work, I'd already been trying to do one thing or another, and I was doing therapy every week to try to get better, etc., and it just wasn't quite getting where we needed to go. So tried the pill the very first day, and it was within four to five hours stuff started to feel different.

At the start, there was maybe a pretty good feeling, but I started to feel nauseous for a while. I got just dizzy for a bit. That was kind of strange. I was told it would probably pass.

The next day I took the pill, I was suddenly very irritable all day long. I was picking fights with anyone and everyone who wanted to wrong me that day in some small slight or whatever. I've never been one particularly with road rage, but that day I was very, very angry.

Third day, I'm suddenly crying again into my burger at the . . . I'm like, "Why am I eating a burger?" It was just bad.

And I reached out to my doctor and the answer I got back was basically, "It can take some time to get used to these meds. And some weird things can happen when you're trying to get on them."

But it wasn't until that first weekend, and we're talking like a week on the meds, suddenly I didn't feel anything. I didn't feel any weirdness. I didn't feel anything. And I thought maybe the drugs had stopped working or maybe I'd become used to them.

But after talking to my therapist and my doctor, that's kind of what we're hoping that it feels like, right? That you just feel normal, but maybe just a little less reactive, or maybe just a little less likely to go down the dark path, or maybe a little less likely to listen to the angry depression monster on your shoulder or whatever, right? It's a little easier to do all of these things.

But man, oh, man. And that's what I want to talk about a little bit today. That first week I'm on Reddit. I'm like, "I have an upset stomach," or, "Hey, what the hell is going on in this way?" or, "Is anyone else feeling extraordinarily like this on the first week of their pills?" And there weren't a whole lot of resources on that. A lot of people just saying, "Yeah, the first week can be rough." That's the euphemism they use, rough. And it was just like, "Wow, I was not expecting all this."

Troy: So was it just a week for you, Mitch, or did it last longer?

Mitch: A little over a week. I think I was still feeling a little irritable for a little bit afterwards, but yeah, it took me about a week to get used to everything.

Scot: Dr. Langenecker, is that experienced differently by many different people? Is that maybe why Mitch wasn't finding specifics or people don't vocalize specifics or . . .?

Dr. Langenecker: Well, there are a lot of different stories out there. Well, let's start with sort of our baseline. Our baseline is things are not going well in Mitch's brain, right? Mitch is doing all sorts of stuff to try and fix that. He's going to therapy. He's doing stuff on his own. He's making all sorts of changes, not quite there. And now we introduce a medication.

And as I alluded to before, this medication goes through the GI tract, right? It goes through the cardiovascular system. It interacts with your microbiota. It interacts with your autonomic nervous system.

And eventually, after a couple of weeks . . . And, Mitch, your response is a little on the early side. But after a couple of weeks, it actually gets the desired change in those neuronal targets pretty far away from where the liver is unpacking that stuff.

And along the way, all of these other systems are thinking, "Whoa, wait a second. Didn't ask for this. What is this stuff doing? What is this stuff doing to the system?" And so some of the side effects, some people actually feel more agitated at first, which is a little counterintuitive. Some people get that dizziness. Some people get the nausea and indigestion.

And the way we report in drug trials is, "Seventeen percent of the people experience dizziness and 13% had impotence and 2% had indigestion." It's not a user-friendly framework for somebody saying, "Hey, why is this happening to me?"

To add to that, we're introducing a change in a system that isn't working so well. And so when you introduce change in a system that's not working so well, other things can pop up.

I know that's kind of an oversimplified explanation, but as we've alluded to before, I'm not a physician. I'm a researcher studying this from a different sort of angle.

Scot: Mitch, was it just the singular medication and then you just had to kind of go through the week or 10-day process, or did you try some different medications?

Mitch: So lucked out with the first one. For my generalized anxiety, Lexapro, spot on. We did tweak the dosage a little bit after a couple of weeks. After I got used to it, they moved me up to a higher dosage so I'd have more of the effects. And that was a pretty decent . . . There wasn't a huge shift when they went from . . . Going from zero to whatever my first milligram dose was rough. Going from the second to the third was not a big deal.

However, a couple of months later when I was still having issues with depression and I talked to my PCP, he suggested I get on Wellbutrin, and it was the same thing again. It took about a week, two weeks, or so until I started feeling normal again. I was having all sorts of weird symptoms again, or side effects, and then back to normal.

Troy: Did you swap meds or did you just add the Wellbutrin?

Mitch: We added on top. There's a whole bunch of ingredients in my brain chili.

Troy: A lot of special sauce.

Mitch: A lot of special sauce.

Troy: I like it.

Scot: So how are you feeling about that, Mitch? I mean, we talk about the stigma of being on medication and how you were kind of raised that it's a moral failing or there's something wrong with you. You're not just on one pill. You're on a couple of pills now, so how are you handling that?

Mitch: It was a little weird when I had to get my mental health advent calendar thing, where I got my little pill organizer and had to fill it every week and make sure I have my dosages right. There was something that made me feel like I was a sick person, right? I was an unwell person.

But what really shifted and changed for me, and really kind of made me get over a lot of that stigma that was so deep in me, was actually the work I was doing with my therapist. And like Scott just mentioned, yeah, some stuff came up when we got my anxiety meds all figured out. We found a lot of . . . there were traumatic events in my past. There was all of this stuff that I was unable to even allow myself to think about or work through.

And suddenly, by turning down the volume just a little bit of the noise in my head, to just soften some of the more reactive parts of my brain just a little bit, I could actually work through some of those. And it allowed us to make some really great breakthroughs that have significantly helped my self-esteem, significantly helped my understanding of who I am and where I am in the world, etc.

One of the things that keeps getting talked about is that I might not have to be on these all the time. Maybe. We'll see. It's kind of a "if we remove this ingredient, is it going to change the way that your brain works?" But it has allowed for a lot of growth.

Troy: And I'm curious about that, what you just mentioned, Mitch. Scott, maybe you can speak to that. When people start an SSRI, how long should they expect to be on it? Should they say, "This is something I'm going to be on for the rest of my life," or are there a number of people who eventually transition off an SSRI? What's your experience with that?

Dr. Langenecker: Yeah, the current recommendations are if you start an SSRI and you experience benefit, you probably will be on that, or should be . . . "Should" is such a strange word to use when we're talking about depression and anxiety. But it's best practice to be on that for at least two years.

And to what Mitch described here, I think the reason why we've learned that it has to be that long is not necessarily all because of the effect of the medication. It's just this reality.

If you're going to make changes in your life that can potentially minimize or mitigate or reduce some of the emotional upheaval, some of the noise in the brain that Mitch was talking about, it's going to take a bit. It's going to take a bit for you to sort of get those changes into a habit, into a structure.

And then it's going to take a little bit longer for the people who love you and maybe the people who think they love you, but love you less than they should, to accept those changes. And during that time, you might need that little boost.

And so that's kind of the rule of thumb. It's a bit of a helper along the way, but those changes . . . Changes are hard. Changes are hard to make and they're hard to sustain. And so two years is a good number. There are some folks who go to 20 or 30. But most everybody should expect about two years.

Troy: But it seems like one of the themes that is coming up here, just in what you said and what Mitch has talked about as well, is it's not just about the SSRI. It's not just about the pill. It's about therapy and making additional changes. And then, like you said, maybe then you get to a point where those changes are enough, where eventually you might transition off the SSRI, but that's just one piece of the puzzle.

Dr. Langenecker: Yeah. One way I like to think about it is you want to get to a period of homeostasis where you feel pretty good about yourself, about the world around you, about the people you're interacting with. And that takes a bit.

And sometimes when you take the medication and you start to feel a little bit better and you start talking with a therapist about it, you sort of identify some of the relationships and some of the people that are triggers for you. And then you start to work through, "Well, do I have to be triggered by this person? Do I have to interact with this person? What part of it is that person? What part of it is me? What part of it is the relationship?"

So much of the work is really reimagining your relationship with yourself and with other people. The medication gives you a little bit of space to do that thinking without so much emotion.

Scot: Mitch, talking about your experience, you hoped that maybe you could help other people since there seems to be a lack of that information. Is there something else about your experience with the SSRIs that you wanted to make sure that you got out into the world?

Mitch: Just that it has helped a lot of people, the medication has, and it's helped people like me. And with how I'm feeling now and the progress I'm making today, I would deal with that week or two of feeling kind of crappy over and over again. I would always have made that choice.

Scot: Might have been nice to know that it could have been as bad as it was, maybe.

Mitch: Yeah. It would've been nice to . . .

Scot: Or how long it's going to last, so you know, "All right. Just a few more days." Kind of like when you quit smoking, for example.

Mitch: Yeah, absolutely. I did not know when I quit smoking that my shifts in nicotine levels were going to cause such an emotional response. But in that case, there are people out there, addiction specialists and things like that, that have talked about very openly on Reddit and places like that about, "Hey, you might have some weird feelings after you quit nicotine."

But same thing. If you're changing something with your brain, it might take some time, but if you are one of those 40 people that it could really help, if you're someone like me, it is 100% worth it to go through that rough patch.

Scot: Just night and day for you? Like, your life is noticeably better?

Mitch: Very much so. It's mostly in my ability to do the work, mostly in my ability to work with my therapist and actually try the things that I'm thinking about of speaking to myself more positively, or stopping and listening better in my communication with my relationships, and things like that.

It used to be I was so high-strung, so anxious, so whatever that I couldn't. I couldn't focus. I couldn't give myself a breath or a break. Everything was at code red all the time. And I can't make any improvement on that system if it's that sensitive.

And so by turning it down a little bit, I've been actually able to work on things and self-esteem and anger issues and hyper-fixations on things. I've been able to actually work on those and get better at them. And I wasn't able to before. I just could not. And so it's allowed me to improve my life.

Scot: I feel, Troy, like there's a parallel between some of the other topics we've talked about on the podcast. Sometimes you need to . . . We've talked about testosterone therapy. Maybe you need that because your energy is slow and you can't exercise, right? It's not the thing that's going to make you better. It's the thing that is then going to allow you to do the things that will make you feel better. Whether that's eat better or exercise or be able to do the mental work as well.

I would imagine that's pretty important, isn't it, Dr. Langenecker, for people to realize it's not just a pill? That's just the beginning point that allows you to do the things that are really going to get you to a place where maybe you've never been before.

Dr. Langenecker: Yeah. I mean, we talked about this sort of thing before. Self-improvement, if we want to use that old phrase, or building resilience, or recovery, whatever framework you want to think about it, it's a journey. And medication for many people . . . I said 40 out of 100. If I said, "Hey, you 100 people, I want 40 of you to take Prozac," or, "I want all of you to take Prozac," 40 would get better.

And then if I said, "Oh, man, 60 of you didn't get better with Prozac. I want you all to try Wellbutrin." And then 20 of those 60 are going to do better with Wellbutrin.

And then the 40 who didn't get better with Prozac and Wellbutrin, "Hey, let's try transcranial magnetic stimulation." And another 13 of those folks get better. We sort of just chip away at it here.

So the basic idea is sometimes you need just a little bit of something something to get you started, and then you're moving along the right path.

And for depression and anxiety, you're feeling good about the path. You're feeling like it's a good journey to be on.

I want to sort of put a public service announcement bit in here, sort of two basic things. One is most people, when they start taking these medications, the dose is too low. And the reason why the dose is too low is because PCPs have . . . I mean, they've learned. Maybe they don't talk about it like they didn't talk about with you, Mitch, but they've learned that people are really uncomfortable with the side effects.

And so they're pragmatists. They're like, "Okay, let's get a medication started. Let's try and keep the side effects low so that the person actually continues to take the medication." And that's kind of the default stance.

And then what happens is sometimes people don't go to that second step or the third step, and so they're really kind of under-treated.

And so anybody out there, if you've tried a medication for depression, an SSRI or SNRI, and you're like, "Oh, that really didn't work for me," most of you didn't get a high enough dose or didn't take it long enough.

That doesn't mean that it's going to work for everybody. I think I've made it clear these meds aren't going to work for everybody. But oh, for goodness's sake, give yourself enough of a shot to see whether it'll help you.

And that's a safe question to ask your doc. "Hey, I've been taking this for a couple of weeks. Is this the right dose? Do we need to go up? Is this the therapeutic dose?" I know that may be an uncomfortable question to ask, but it's a really important question.

Scot: Well, Troy, that wasn't too bad. Mitch's mind wasn't as bad as I expected it to be.

Troy: It was all right.

Scot: It's a happy place now, which is fantastic. Or happier.

Mitch: Happy. Oh, yeah, sure. Whatever.

Troy: Yeah. We took a swim in the brain chili, and we came out okay.

Dr. Langenecker: We're finding a way to fewer . . . Less chili powder.

Troy: Exactly.

Mitch: Less chili powder. A little spicy.

Scot: I hope that this was helpful to somebody listening. If you have been experiencing symptoms that perhaps an SSRI could help, or if you've been on an SSRI and you have experienced those side effects, maybe didn't get the benefits, I think Dr. Langenecker gave us some great advice to ask questions about the dosage, the time you're on it. Maybe you need to try a different type of SSRI medication to get it dialed in. And then just be ready to do the work.

Mitch, I just love hearing your story about how much better you feel and how things are going. So thank you for sharing that.

Mitch: Happy to. I hope someone out there is going through something similar and give yourself a chance, right? Give yourself a chance to be better.

Dr. Langenecker: And you deserve to feel better. We've talked about it before. It doesn't have to be this hard. If you're struggling, give it a shot. We're here to help.

Troy: Mitch, too, I think just the fact that you're willing to talk about it, it's a big part of just removing the stigma. I think that's a big barrier for a lot of people. Just knowing that there are a lot of people taking medications and you just need that extra help sometimes. And so it's great you're willing to share that.

Mitch: Yeah. No problem.

Scot: Dr. Langenecker, thank you for being on the show. Mitch, thanks for sharing, and thank you for caring about men's health.

Dr. Langenecker: Thanks, everybody.

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