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Podcast: Anxiety and What to Know Before Starting Medication

Adult psychiatrist Dr. Tal Weinberger joins the podcast to normalize anxiety and offer actionable steps when it feels overwhelming, including positive lifestyle choices and starting anti-anxiety medication.

There are the normal day-to-day fleeting anxieties that affect everyone—from meeting someone for a first date to the anticipation of giving a big presentation. Then, there’s anxiety that feels ever-present. Moments of anxiety are normal. Long-term anxiety affecting your quality of life isn’t and coping with it isn’t something anyone has to do alone. In this episode, meet adult psychiatrist Dr. Tal Weinberger, who both normalizes the anxiety we all feel from to time and explains when it might be time to start an anti-anxiety medication. Tune in for everything you need to know, from who to discuss anxiety and medication with, what lifestyle changes may happen when starting medication and how long people typically stay on these medications.

Dr. Tal Weinberger portrait taken on Jefferson campus

Dr. Tal Weinberger (©Thomas Jefferson University Photography Services)

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Complete Episode Transcription

Jessica Lopez: Muscle tension, poor sleep racing, heartbeat, ever-present butterflies in your stomach. These are ways your body is expressing anxiety and it’s something we all experience. Whether it’s anxiousness before meeting someone on a first date or an ever-present uneasiness whose origin is hard to pinpoint. Moments of anxiety are normal. Long-term anxiety affecting your quality of life isn’t and coping with it isn’t something anyone has to do alone.

Welcome to the Health Nexus podcast, powered by Jefferson Health. I’m Jessica Lopez.

Carly Williams: And I’m Carly Williams. We’re back with more help questions for Jefferson Health experts to weigh in on.

In this episode we connect with adult psychiatrist, Dr. Tal Weinberger, to discuss the signs that it might be time to start taking anti-anxiety medication. She helps break down how you’re diagnosed with anxiety disorder, considerations before taking medication, including side effects, and what to expect when and if you decide to go off these medications.

So let’s get into it.

Dr. Tal Weinberger: I’m Dr. Tal Weinberger. I’m an adult psychiatrist. I am currently division director of outpatient psychiatry at Jefferson. I have been in Philadelphia for many years. I did all my training at Penn, both medical school and residency and I have been at Jefferson for 14 years. My area of special interest is in women’s mental health, so I really feel very passionate about treating women during pregnancy and postpartum and making sure that they and their families get good care.

Lopez: Anxiety has become a bit of a buzzword lately. Can you tell us how you define anxiety and what are some of the distinctions made between normal anxiety and when it becomes disordered?

Dr. Weinberger: Part of the difficulty is in that anxiety is something that is, unlike other medical issues, something that exists on a continuum with normal. Given the fact that there are certainly times where we’ve all experienced anxiety and it’s been quite normal, it can be really hard to make distinctions and say when it becomes more problematic or pathological. The criteria that we really use for the most part to determine whether somebody’s anxiety has become a problem that we need to think about treatment for is persistence of the symptoms. How long do they last? And pervasiveness of the symptoms, right. How much of their day on a day-to-day basis is taken up with the symptoms. If somebody is anxious because something stressful has happened in their life, even really a very tremendously stressful thing that causes them great anxiety, generally we would expect that as that stressor resolves, the anxiety will abate with time.

It may not be linear, and it may take quite some time, but we do expect that at some point we’re going to be moving towards improvement or resolution. As opposed to, with an anxiety disorder, often people will come in and say, “Of course, I’m anxious. Look at all these difficult stressful things that are going on in my life. Of course, I’m anxious.” But in the case of somebody who’s really struggling with an anxiety disorder, there’s almost always something that’s causing anxiety most of the time—if it’s not one thing, it’s something else. The other thing is that we would expect people with anxiety [in] normal life circumstances generally [they are] able to take their mind off it—sometimes for a brief period of time they can’t, but in general, they’re able to enjoy other things in their life. And people with anxiety disorders can sometimes do that as well, but the anxiety does tend to take up a good deal of their mental space.

Other things that we sometimes see with anxiety disorders are difficulty with sleep, which again can be normal for a short period of time if somebody’s going through a really difficult crisis they may have trouble sleeping for you know, days or even weeks maybe. But people with anxiety disorders will often have more kind of chronic longstanding difficulty with sleep.

Lopez: In addition to sleep, are there other symptoms of anxiety that come up in your patients?

Dr. Weinberger: Sometimes people will complain of physical symptoms like tension in their body. Sometimes people will actually have real physiological symptoms like headaches, stomach aches, those sorts of things and they’ll have extensive medical workups, and nothing will come up and eventually we may attribute it to anxiety and treatment for anxiety can be helpful with those physical symptoms, as well. Sometimes it’s really more obvious that the physical symptoms are anxiety, right. People talk about like muscle tension racing, heart butterflies in their stomach. Those can all be symptoms that again when they’re short term can be signs of normal anxiety but when they’re more pervasive and persistent can be symptoms of an anxiety disorder.

Williams: When we’re talking about treatments for anxiety, what are some things people should consider before taking medication?

Dr. Weinberger: So that’s a great question. When we have established that there is an anxiety disorder that requires treatment, in other words kind of using those criteria that we talked about earlier where it’s really persistent and it’s really pervasive and there may be some associated symptoms, in a situation like that, medication should be on the menu and really can be the first option for some people. Psychotherapy is also a really great treatment for depression and anxiety, and we really see our best outcomes when psychotherapy and medication are combined. That being said, there can be reasons or personal preferences where people really prefer medication over psychotherapy or psychotherapy over medication and in a case like that, I would kind of be more inclined to make it a matter of choice and it’s obviously always a matter of choice. Patients can always say no to your to your recommendation, but I might make a stronger recommendation in the case of somebody really with more severe symptoms.

So, if somebody who’s really having very severe depression or severe anxiety, we would be more likely for a number of reasons to want to try to help them first with medication and then certainly psychotherapy can absolutely be part of that equation as well. If somebody’s having milder symptoms and they really feel very strongly against medication for whatever reason, then that might be a situation where we might be more inclined to say, okay, let’s try psychotherapy, let’s try some other things first and then if those things don’t work we can revisit the idea of medication.

Williams: Who can you have this conversation with? Do you have to go to a psychiatrist or a licensed therapist?

Dr. Weinberger: There are lots of different types of mental health providers that can do psychotherapy. Some psychiatrists can do psychotherapy—I think others are less comfortable with it and more comfortable with medication—but certainly, there are many psychiatrists that are very comfortable doing psychotherapy. There are sometimes insurance obstacles to psychiatrists doing psychotherapy and so that can be an issue. Psychologists, social workers can be excellent psychotherapy providers and often are psychotherapy providers. In terms of prescribing medications, honestly, most of the psychiatric medications prescribed in this country are prescribed by primary care doctors and that’s a function of a lot of different things.

Williams: Carly here. Want to clarify that by ‘psychiatric medications,’ Dr. Weinberger is speaking specifically to medications prescribed for depression and anxiety. Okay, back to the episode.

Dr. Weinberger: The reality is that access to psychiatrists is really very limited. Unfortunately, there’s much, much more need than there are us to meet that need. And having primary care doctors or OB-GYNs prescribe medications for depression or anxiety, especially from the earlier stages if it’s less complex, can be a really great solution. When the system works, what we’ll have is a primary care doctor starting somebody on a medication and then if it works then great, but if they run into obstacles then that would be a point at which they would come in see us.

Lopez: What about once you start these medications, are you allowed to consume alcohol while starting a new anti-anxiety medication?

Dr. Weinberger: It really depends on what we’re talking about with anti-anxiety medications. There’s sort of two broad categories of medications that we use to treat anxiety. There are immediate acting anti-anxiety medications that for most people tend to be more short-term treatments, for some people they can be longer term treatments, but in general those are medications that are used temporarily to treat acute anxiety and as a bridge to more definitive treatment. So that’s one category of medications. So these are medications that work immediately and to help reduce anxiety. The medications that we tend to use longer term and we’re more definitive treatment are medications that are the same medications that we use to treat depression for the most part, most of them, and those are medications that take some time to work. They’re medications that you need to take over the course of weeks to months and we really need at least four to six weeks to really see whether the medication is helping or not.

That first category of medications probably should not be consumed with alcohol. So those are, these are the benzodiazepines that class of medication. In general, they work similarly in the brain, although obviously the benzodiazepines are safer for many reasons and more helpful for anxiety, but, generally speaking, those medications should not be combined with alcohol.

The second category of medication, so longer term treatment for depression or anxiety though what we call serotonin reuptake inhibitors or serotonin norepinephrine uptake inhibitors and there are other medications that are more novel that are similar to those classes. This is what the caveat that obviously combining any medication with alcohol is never like a great idea and certainly with heavy alcohol is really not a good idea. But those are medications that certainly in somebody who otherwise is safe to drink alcohol, they’re not somebody who has a problem with alcohol, and somebody who is drinking alcohol casually having a drink or two every now and then while on those medications, that’s not something we would discourage.

Williams: And what are some common side effects people should be aware of when taking anti-anxiety medications?

Dr. Weinberger: I’m going to address the longer-term anti-anxiety medications. Unfortunately, there’s a lot of inaccurate and distorted information on the internet about side effects of these medications. That’s really scary for people understandably when they see it. And I think it’s really very unfortunate because it really adds to fear and stigma about taking these medications when they’re needed. Even really kind of individual horror stories, which I’ve heard a lot of people say, “Oh, I read on the internet about this person who took this medication and this horrendous thing happened to them,” but—those are situations that are obviously real that whatever happened really happened to that person and if that person were my patient we would work hard to understand what happened and how to avoid that in the future—but those individual horror stories are really not a reason not to take those medications when they’re recommended to you.

Most people tolerate these medications fine either with none or minimal side effects. When people have side effects, they’re often things that we can work with them to either mitigate or avoid or, worst case scenario, potentially change them to a different medication. So, I think unfortunately people sometimes do Google searches and then get scared and then say, “I’ll never take a medication in this class at all,” and that’s just unfortunate because that’s not good advice or an accurate assessment of how most people tolerate these medications. So that being said, okay, talking about actual side effects.

This is what I tell my patients when we start one of these medications, short term, sometimes in the first week or so, sometimes people can have a little bit of headache, a little bit of nausea, sometimes people with anxiety in the first couple days of taking one of these medications can actually feel a bit more anxious. What I will generally tell people is that these side effects should abate within several days to a week. If they are tolerable, try to wait them out. If they’re awful then call me and we’ll work with you to try to mitigate those side effects and there are things that we can do to mitigate those side effects and bridge people to effective treatment eventually. Those are the shorter-term side effects.

The longer-term side effects that we hear about most frequently are—and I always talk about these with my patients—number one is sexual side effects. A lot of people are aware of those. There’s a lot of information out there on them and those are real. People do sometimes have sexual side effects from these medications. Many people don’t have sexual side effects but some do. What I hear most commonly is that the medication is helping and the person’s having some sort of sexual side effects but they’re mild and not really interfering with their life and so often the decision will be made that it’s worth it.

Sometimes sexual side effects will be really problematic and really will interfere with somebody’s life and that is something that really needs to be taken seriously. And again, these are situations that if this happens, which it can, discuss it with your doctor. Often I think in those situations people will just stop their medications but if there are things that we can do, there are things we can do in terms of adjusting the medication or doing other things to mitigate those side effects or make them make them go away or better. What I found is that it is really important though, when we start a medication like this, is to discuss the possibility of side effects, sexual side effects from the outset, because that really does increase the likelihood that if a patient experiences one of those side effects, they will bring it up with me. And they’ll be feel comfortable talking about it with me because I’ve told them that it’s something that could happen. As opposed to if I haven’t then they might not feel comfortable bringing it up on their own but when these side effects do happen and when they are significant, there are definitely things that we can do to address them.

The other side effect that I talk about with my patients with these medications are that sometimes, again, not in everybody, but in some people can notice some increased appetite with these medications, which if it’s something you’re not aware of or not necessarily paying attention to can lead to some weight gain over time. So there’s no magical weight gain with these medications. It’s not like you put the pill in your body and you gain weight. It doesn’t work that way. When people gain weight on these medications, it’s because they’re hungrier, they’re not full as readily and so they eat more. And so generally speaking, when people are aware of that and monitoring it, they are able to manage that with behavioral interventions—watching what they eat, exercising more, those sorts of things. Sometimes— again less usual—sometimes people really do have problems with appetite and weight gain that can’t be managed with sort of behavioral changes alone. And that certainly can happen and can be an issue for some people, in which case again, there are things that we can do. So take home, don’t stop your medication, discuss it with your doctor, side effects can be addressed.

Lopez: If you are taking a long-term medication, is that something you will be on for the rest of your life?  Or is there an average length of time people stay on them?

Dr. Tal Weinberger: It really depends a lot on circumstances. That is a question I get often is if I start this medication, do I need to stay on it for the rest of my life? And the answer is no. But there are some individual considerations that would guide how long I would recommend that you would stay on a medication. If somebody has had really multiple episodes of depression over the course of their life that may have been triggered by stress or may not have been triggered by stress, that’s really very different situation than somebody who’s had one episode in the context of a very significant stressor. So somebody who’s had one episode in the context of a very significant stressor, that might be a situation where, especially if the stressor has improved or resolved, and again the other really important mitigating factor is therapy.

What we see in our data is that when we compare effects of medication and psychotherapy, medication tends to work faster, but psychotherapy tends to be longer lasting. So, in other words, people who have a good response to psychotherapy and stop psychotherapy stay well longer, than people who have a good response to medication and stop medication. So in a case of somebody who’s, if you had one episode under sort of very specific circumstances and their life is changed and maybe they’ve had a really successful course of psychotherapy, that might be somebody who really could be a candidate to stop their medication, they may choose not to. I’ve definitely had people in that situation say, “I’m feeling so much better. I’m feeling better than I ever have. I don’t want to rock the boat. I want to stay on this medication,” and that’s a reasonable decision. I’ve had other people say, “I feel like I’m really in a very different place now. I want to see how I do without this medication,” and that’s a very reasonable decision as well.

Caveat here is that what we do see is that the highest period of risk of relapse is the first year. Generally, we want to wait a year if possible before we even consider that conversation. I like to see somebody well for a year and then we can start that conversation. Somebody else who’s really had recurrent episodes of depression throughout their life might not be as good a candidate to stop their medication. And somebody who’s had three or more episodes of depression really is somebody who should probably consider staying on medication and definitely because their risk of relapse is quite high. Those would be some of the factors we would think about in terms of advising somebody how long to stay on a medication.

The other important factor that we take into consideration is the strength of a person’s support system and the severity of their past episodes. In other words, if somebody has had an episode that was really very severe where they’re really very depressed and impaired and may have even been suicidal, we might want to think longer and harder about when to stop medication in that person as opposed to somebody who really had a more mild episode, and somebody who has people in their life who might notice if they’re starting to do poorly off medication, might notice and say, “Hey, you really should call your doctor before things get really bad.” That can be another kind of indicator of how safe it is to stop a medication because sometimes when people start to have mild subtle symptoms, they may not notice right away and other people in their life may notice first.

Willliams: That’s a great point. And if someone is ready to go off their medications, how would they go about doing that? I wouldn’t think they would stop cold turkey.

Dr. Weinberger: That is something to be done with your doctor. These are medications that again, there’s a lot of misunderstanding around what it means to stop these medications and have a problem. I’ve had a lot of people come to me and say, “I wanted to stop my medication so I stopped my medication than I felt horrible.” And then that was more proof to them like how damaging and toxic this medication was to them. So these medications, like most medications, if your body gets used to them, you can’t withdraw them abruptly. We need to withdraw them slowly and carefully and your doctor could do that with you. If somebody’s on kind of a more moderate dose of a medication, what we would do is taper it slowly and then generally we can achieve getting the person off the medication successfully without problems. Sometimes we need to back up and do things even more slowly for some people who are especially sensitive, but generally we can get people off medications comfortably when it’s appropriate to get them off medications.

Lopez: Besides medication, what are some other ways people can help manage their anxiety? When we’re talking about self-care, we’ve already talked about how beneficial psychotherapy is, but are there other self-care tools that you encourage patients to use?

Dr. Weinberger: A lot of those things are really crucial first steps. Again, sleep is huge. I think we all know intuitively that if we get a bad night’s sleep, we handle everything poorly the next day and everything is all distorted and difficult and so just think about somebody who’s really struggling with depression and anxiety and then on top of that isn’t able to sleep and then like everything is accentuated. My trainees will tell you that I really ask a lot of detailed questions about people’s sleep and their length of sleep and their quality of sleep because it’s just so, so, so very important. Both as a predictor of depressive symptoms and anxiety symptoms and also as a symptom of depression and anxiety. Helping with sleep can be super, super important. Exercise can be really important. Also, there’s a lot of data out there on exercise really being, having a very, very effective treatment for depression and anxiety.

Beyond that there’s certainly some data for yoga. There’s some data about [the] Mediterranean diet being associated with lower rates of depression. But I think the important thing to get across is that, if those things work for you, that’s great. If you’re exercising and feeling well, if you’re sleeping regularly and feeling well, if you’re doing yoga or whatever it is you’re doing, eating healthfully, and you’re feeling well, that’s awesome. You don’t need me. You never need to be in my office. That’s fabulous. I think unfortunately where we sometimes run into trouble is with people who really are genuinely struggling with depression and anxiety and who are trying those things and who are really trying those things really hard and they’re not working. And then there’s somebody in their life telling them, “Well, if only you would just exercise,” or “if only you would take this supplements” or “if only you would do some sort of meditation, you wouldn’t feel this way.”

And they’ve tried those things—they genuinely have—and they’re not feeling better. And then it’s [a] double edged sword because they’re depressed and they’re feeling bad about themselves because they’re depressed or they’re anxious and they’re feeling bad about themselves because they’re anxious. And now on top of that, they can’t fix it, and they feel like they should be able to because there are all these well-meaning people in their life telling them that if only they did this they would feel better and they’re doing it and they don’t feel better. And so that’s more evidence that they’re defective or flawed or there’s something wrong with them or they’re not doing it well enough. And it adds. At some point in those situations, I would absolutely encourage people to try positive lifestyle changes to feel better and often those things can be really quite helpful. But at some point, if they’re not helpful, or they’re not as helpful as we like, we have to call it and move on to other things.

Williams: I say this loosely because, can we really say we’re out of COVID? But at this stage in the pandemic, can you speak to how it has affected people’s anxiety and any personal reflections?

Dr. Weinberger: There’s been a lot of literature out there and a lot in the popular press about COVID and its impact on mental health and depression and anxiety and other mental health outcomes. And I think it’s intuitive. We don’t necessarily need somebody to do a study. It’s intuitive that like social isolation is not good for people’s mental health. And I think we could all probably predict that and that was true. The silver lining there is that it really has brought a much greater degree of awareness to these problems. People who are struggling are really taken more seriously now, that sort of COVID has really drawn more attention to the seriousness of these problems and the legitimacy of these problems. And people are more willing to talk about it. People are more willing to seek help. People are more open about it. And now what needs to happen next is we need a lot more resources because before COVID, there were more people needing help than there were of us. And now it’s really true. But again, I think there’s more knowledge of how desperately we need those resources and hopefully we’ll be able to respond to that by having more resources.

I think the other really gift that Covid gave us, and obviously many horrible things happened as a result of covid, but I think the other silver lining here is the access to telehealth. So before COVID, being able to do psychiatric care, psychological care over telehealth was really very limited. Insurance companies didn’t authorize it. It wasn’t really an accepted sort of form of treatment. And now it’s become something that we offer and insurance companies have embraced it and providers have embraced it, patients have embraced it and it’s really increased access to care. We watched our numbers in the first couple months of COVID and it really increased our access to care in our clinic tremendously. So many more people were able to make their appointments and now had access to care because of telehealth. Having people have the option of telehealth really provides options for people who don’t have transportation or who don’t have child care or who have other obligations during the day at the time of their appointment, those are opportunities they wouldn’t have had otherwise.

Williams: What a reassuring conversation, normalizing anxiety and getting help if and when you need help, especially now.

Lopez: Agreed. And in this episode we focused on anxiety, but if you head on over to TheHealthNexus.org, you’ll find a full Q&A with Dr. Weinberger where she also talks about depression, how that is diagnosed and treated. Plus, additional content like what to expect during your first therapy session and how to recognize signs of hopelessness in family and friends.

Williams: Check the show notes for that link. If you enjoy our podcast, we truly appreciate a rating on Apple, Spotify or wherever you listen to podcast. We love your feedback!

Lopez: Production support for today’s episode provided by Dan Bernstein and Brittany Rafalak. This podcast is edited with support by Barbara Henderson. We’re your hosts, Jess Lopez…

Williams: …and Carly Williams. Thank you for listening!

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