Episode Title Here
Off The Charts Podcast
Hosted by Dr. Bobby Parmar
[Dr. Bobby Parmar, ND] (0:03 - 0:36)
Hey everybody, welcome back to Off the Charts. Today we are talking about antidepressants. You may wonder why.
I think it's a really important topic for us to cover for so many different reasons. I think my perspective is a little bit different than what most people have heard, even from their healthcare providers. So I'd love to share my patient experience over the last 18 years about how I use antidepressants, how I think about them, and how useful they can be in a lot of people's lives.
So let's dive right in.
[Paige] (0:37 - 0:47)
Great, I have a lot of questions. As a naturopathic physician, a lot of people would assume antidepressants wouldn't be part of your approach. Why do they have a place in your practice?
[Dr. Bobby Parmar, ND] (0:48 - 5:06)
I get this question all the time, which is why you're even asking. And people expect when they come to see me that they're not going to be offered a prescription medication to help with their mental health. They'll expect that I'm going to give them a prescription for a walk in nature.
And yes, that's amazing. Or that I want to give them a natural agent that might help them with their mood. And yes, that's a thing.
Like we'll talk about that too. But a lot of the time, so many people are coming in because they're in a place where they're really unable to dig themselves out of it. And there's too many things happening with their lives.
There's too much going on. And I say this to a lot of people all the time, that we kind of like to live in this world where we just have so much happening. There's like 500 year events happening every two years.
There's like existential things that we're constantly having to process. There are climate change and wars and new battles that we have to pay attention to and political threats and housing crisis and economic recessions and pandemics. Like we're constantly dealing with all kinds of things that are beyond our own personal lives that affect our personal lives.
And then we have to deal with our personal lives too. And we have to deal with things like the things that happen with our children and our parents and sickness in our own lives and the stress of work. And all of that we're supposed to be able to somehow withstand.
We're supposed to somehow become resilient in spite of, despite, in the face of all of these things. And I think it's a lot to ask of any person. And some people are really good and like to be able to deal and cope until maybe they're not able to.
But there's a lot of people who are just finding themselves in situations where they have enough and too much going on that they just need support. And sometimes a lot of those things affect our nervous system, our precious, delicate nervous systems that over time get traumatized and have repetitive stresses that influence the way they even function chemically. Some people are born with things like this that set them up to have issues like this.
And then society and living in this world then take advantage of that. And we're supposed to like just, you know, like, bitch, just get stronger. Like we're supposed to just sort of buckle up and be able to be okay with all of this.
And I don't think that that's the way it works for the vast majority of people. And so there's help. And one of those tools that comes into play in my practice, even as a holistic practitioner, are prescription antidepressants.
And they come in so usefully. They're so helpful in so many different conditions, aspects, and then specifics in a person's life that I hope we're going to be able to talk about. I mean, we will.
But that's why I think they are transformative. I think they can really make or break it for a lot of people when we use them appropriately, effectively, and we match the right one to the right person. I think that's where a lot of people get stuck in that they speak to people who prescribe them, they're given to them after like a five minute conversation.
And I think that there's like an issue there where we're not necessarily getting to know the person well enough to understand what version of a person is coming up and showing up in front of us for us to be able to effectively decide what does this person actually need, both lifestyle wise, personally, through like therapy, setting them up with the right counselor, because even that is very important. Setting somebody up with the right counselor is also really unique.
And like there's not going to be an assurance that you meet with the right counselor and then that person is going to be the right person for you right away. And like a lot of this process involves time. And in order for us to speak to a person and get to know them, we need time to make the right decision for what they're going to take.
So that's also involved. And I think a lot of people are turned off because they're just thrown pills because it's like, hey, you feel like that here. Like it's not, it's not necessarily the right way to do it.
And I think nobody's better than a psychiatrist who spends time or a holistic physician who spends time getting to know the person to decide the right agent to use with them. And I think that's where we shine.
[Paige] (5:08 - 5:20)
Amazing. But how do you decide when lifestyle changes alone are realistic versus when someone needs medication to even get to a place where those changes are possible?
[Dr. Bobby Parmar, ND] (5:20 - 9:00)
We have this conversation and I say, listen, you're coming to see me. Are you in a place where you feel like you could use some help to get you to a place to do the lifestyle things that might help? If I meet, because this is one of the problems with depression and is one of the problems with anxiety.
Depression itself makes you not want to take the thing that helps with your depression because you're depressed. Anxiety makes you not want to take the thing that helps with your anxiety because you're anxious. So you get afraid of things.
You're nervous. You're worried. You're worried about side effects that you read about.
You're worried about that person, you know, that had a negative experience on that thing. And you don't want to be that person. And you have the problem that is most likely to prevent you from taking the solution to that problem, or at least a helping agent.
So I set that up like that with a lot of people. I'm like, listen, you're coming to see me, you suffer from depression, or we figure that out together. You suffer from anxiety, we figure that out together.
And then I say, one of the things that's going to happen here is that your condition is going to want you to not take the thing to help your condition. Know that that's part of this. So once we discuss that, and try to massage away those fears, a lot of people kind of like, not surrender, but feel safe now, knowing that maybe the fears that they have, or the pessimism they have, is their condition talking.
And that if we are able to identify that, that liberates them to be able to then feel, oh, okay, yeah, actually, you're right. Why would I let this condition be in the driver's seat of my decisions? Why would I let that make the choice for me?
I want to make the choice. I don't want this disease to make the choice. You know, we're not supposed to go to bed angry with our partner.
Same thing here. We're not supposed to make decisions when we're upset. We're not supposed to make these kinds of decisions that affect the rest of our lives when we're super sad.
We're not supposed to make these decisions that affect every aspect of our lives daily, and then 10 years from now, when we are really fearful. Why are we making decisions in those kinds of states? So we need somebody to help us understand.
Put that aside for a second, and let's see a little clearer. Without that, at least you're aware of that, so that you can make a better decision to then decide, “I actually do want to take something now, because maybe that is then going to help me make better decisions of my eating habits. Maybe it'll help me make better decisions for me going and getting activity or moving.”
Maybe it'll help me make better decisions so that I'm not showing up negatively in my loved one's lives, and that maybe that translates into my community wanting to be with me more, because I'm not this sort of anxious person that makes them not want to like be around my energy, or maybe a depressed person that makes them not want to be around my energy. I'm not as isolated. Maybe this is a method to try to get those life things better, so that all of them are working together, rather than, let me go try to figure this out with my food first, and then focus on that, and maybe not have that turn out the way I'm hoping it will, and that it dives me deeper into this ditch that I find myself in in the first place.
[Paige] (9:01 - 9:08)
So helpful. Can you talk about what antidepressants actually do in the brain?
[Dr. Bobby Parmar, ND] (9:09 - 11:57)
Yeah, there are all kinds of antidepressants. One of the things I really like to make sure people know is antidepressants, it's a label. They're medications, they're drugs, they're natural substances as well, that work on chemistry.
So when a person is taking a specific medication, let's say a medication called duloxetine, otherwise known as Cymbalta, we can use it for depression, we can use it for anxiety, we can use it maybe for sleep, we can use it for pain, we can use it for all kinds of things that are implicated with the way that chemistry maybe went off in that person. Dysfunctional nerves that fire inappropriately, that send signals that make us feel nervous, or dysfunctional nerves that have been so stressed for so long and are born out of a body that already had a problem, maybe generationally, even generational trauma has carried over, and all of that sets up this body to have this error in how it communicates with itself and how it communicates with us, like who we are, and then therefore how we communicate with the world around us. Those chemicals, neurotransmitters, serotonin, dopamine, norepinephrine, just names, fancy names for chemicals that influence the way we feel. And we can influence those chemicals with agents, like the ones I just mentioned.
You can influence them with this pathway, and this pathway, and this pathway, and each one of these can show up differently. So a person can feel anxious, and so we use this medication because they're over-firing, they're an anxiety more prominent person. This person is more likely to have crying spells or nightmares, and so we use this agent because it's more likely that that chemical is probably more off in that person.
This person experiences fatigue, and so we're not going to necessarily use an agent that doubles down on the fatigue in that person, we're going to use an agent that gives them energy, but also helps with their depression. But each chemical operates, do we have it down to an exact science? No, because if that was the case, then we'd be able to literally be like, that person gets exactly this, this person gets exactly this, this person gets exactly this, and then everybody would be cured, and nobody would have any issue with going from one to the other.
It's really a soup, it is really a complicated soup, and we are just trying to figure out if you can influence some of the ingredients with that soup. I feel like Salt Bae. Antidepressant Bae.
If we could do that with medications to actually make it so that it's just, the soup is a little bit clearer, less murky.
[Paige] (11:58 - 12:05)
A lot of people worry about weight gain. How does what antidepressants do in the brain connect to changes in appetite, metabolism, or weight?
[Dr. Bobby Parmar, ND] (12:05 - 15:37)
That is easily one of the most common questions I get asked. When a person comes in, they go, great Bobby, like you really explained these medications well, I'm liberated like you said, and I want to take them, but I'm really actually afraid, not because of my anxiety, but because of the real likelihood of me gaining weight. This is a very important thing for us to talk about, because a lot of people who are depressed, and a lot of people who are anxious, already have gained a lot of weight, and they don't want to add to that.
We don't want to like, or create another physical problem, or a self-esteem issue, or an issue with like, now I'm going to give them an agent that makes them gain even more weight, that puts more pressure on their knees, and then they can't do the activity they need to to feel better in all of these ways, both mentally and physically. We're not going to sabotage this person. A lot of people are unaware when they come to see me, that one, that antidepressants, certain ones cause weight gain.
A lot of people are unaware that the one they're on causes weight gain. They're like, what? Nobody told me that.
What are you talking about? And that a lot of people will find that within the first six months-ish, there's a slow and steady five, ten pounds, and they're like, how did I get here? How am I ten pounds heavier by the six month, or maybe a year mark?
It's because antidepressants work, specifically SSRI, serotonin specific antidepressants, work in a way that makes you want to eat more. It makes you want to crave things more. It actually encourages you to feed, but then it also sometimes, because it's like flattening you, because it's trying to make you feel more neutral rather than super high or super low, that neutrality of serotonin can sometimes make it so that a person actually feels neutral enough in a way that their metabolism also neutralizes.
So it's not just making you eat more, it's also making your metabolic rate go slower. And a lot of people don't respect that enough, that there's a lot of evidence to suggest that this is, a person could be like, I am definitely not eating more. I am definitely exercising still, and yet I'm still gaining weight on this thing.
How is that possible? It could blunt your metabolism. If a person has a really significant concern around, I don't want to gain weight, that's going to be really disastrous for me, then we choose an agent that doesn't do that.
And there are some that don't do that. Or if we have no other option, because it's the only thing that works for them, and they're like, I really, really remember that it worked well for me, like Cipralex worked well for me, or Paxil worked well for me, I want to do that again, but it made me gain weight. Then we'll say, well, why don't we give you another agent to help you not gain the weight at the same time that you're taking this antidepressant, so that you at least don't have to worry about that.
And then we use GLPs, or we use other medications to help blunt that in these people. But that obviously involves a good conversation about what that means to be taking both of those things, one for your mental health, and one for preventing the side effects, and then not making a person feel like they're just taking an entire kitchen worth of medications. But that also is possible, but it is absolutely one of the most crucial conversations, because people will not want to go on antidepressants because of the weight gain.
And we don't speak about it enough that it does do that. They absolutely do, especially the SSRI class.
[Paige] (15:38 - 15:46)
And do different antidepressants tend to be tolerated differently, especially in those first few weeks when people are most nervous about side effects?
[Dr. Bobby Parmar, ND] (15:48 - 18:15)
Tolerated is an interesting word, because a lot of antidepressants, when you first take them, and this is the other thing that a lot of people get really nervous about, that they'll be like, I don't want to have, like, I don't want to have a lot of the side effects show up where I'm dizzy, or nauseous, or lightheaded, or I feel like emotionally unstable, or I feel more anxious, or I'm suffering from sleep issues as a result of it, because they do do that too. SSRI medications can disrupt your sleep.
They can make your sleep quality, the architecture of your sleep, not be as good. And so a lot of people will be like, but I already have that as a problem, and I don't want to make that worse. A lot of the times it's an adjustment period.
So you become tolerant to most of them, in the sense that once it's in your body, it has to enmesh in your brain, it has to enmesh in your nervous system, it has to get sort of adapted. And sometimes that means you take a week, two weeks, maybe a month, in order for, like, the disease, the, like, nausea to go away, and you do then become tolerant to the side effects, because you gave it some time to, like, become woven into the fabric of your being. These are complicated things, right?
A lot of these things are complicated that way, and that you have to allow for that time. And if a person has a lot going on, and they're like, I don't want to feel sick that way, like, well, a lot going on is probably going to make you feel worse, because the lot going on is going to take advantage of your depression, it's going to take advantage of your anxiety, it's going to take advantage of your stress. I always tell people, there's no better time to take them than when you have a lot going on, because you're not about to take them when you go on vacation, because, like, you need to take them when you're in need of them, and allow yourself some of that grace to feel a little bit of the disturbance that can happen when you first start taking them.
There are things that you can do to manage that, for sure. You can absolutely get on a plan where you're experiencing nausea, take some ginger. So maybe some ginger will help you with the nausea on the first few days.
You're feeling a little dizzy, make sure you're hydrated so that your blood pressure isn't dropping, and that you're taking extra solutes or electrolytes to manage some of that. So you can absolutely minimize the impact of that, but at the same time, we shouldn't be afraid that there's going to be this, like, adjustment period, because most people do have that, whether it's mild or moderate or sometimes severe. And in those cases, we move away from that agent, because we don't want to really disturb somebody's life.
[Paige] (18:16 - 18:22)
How do you actually match a specific antidepressant to the way someone experiences depression or anxiety?
[Dr. Bobby Parmar, ND] (18:22 - 21:59)
There are people who experience, and this is the beauty of antidepressants, I love this part of them, that if you came in to see me and you were feeling low mood, and you were sort of hopeless as part of your depression, that's how it sort of you experienced depression, and you're tired. Some people don't experience it as fatigue. Some people do.
Actually, that's the way we sometimes diagnose depression, or at least start the conversation. They'll be like, why am I so tired? And like, your thyroid's fine, your iron's fine, nothing else is going on in your life, all of things are totally okay, medically, and yet you're still really tired.
And then we'll go through a depression questionnaire, and it'll reveal, actually, this person is really tired because they're depressed. That's why they are. So in that instance, we would use energizing, we call them activating antidepressants.
My preferred one in those instances is called bupropion, otherwise known as Wellbutrin, a lot of people know it by that name. It is a very effective agent. It works on dopamine, and it encourages energy in the body, because dopamine is this thing that like, when we have it, we feel like motivated.
When we don't have it, we feel unmotivated. When we have it, we feel like that get up and go kind of feeling. When we have it, we feel like we want to go do things.
And that, for that kind of person, can be altering of their life so that they feel so much energy during the day, or at least more than they used to, that it ends up making them do more. And they're able to be active, they're able to do the kinds of things they weren't doing before, socializing, because they weren't able to do that before. And then, all of a sudden, their sleep is amazing, because they were actually exerting a lot of energy through the day, both mentally and physically, that their sleep, if they had sleep issues before, they were maybe a night owl or an insomniac.
Maybe they just didn't, they woke up a couple times in the middle of night, but maybe they sleep better. That's another thing, too. A lot of people think that just because antidepressants are activating means that it's going to interfere with their sleep.
That can happen, for sure, but we shouldn't be afraid of that in a person who suffers from sleeplessness, because what if just giving them energy in the day actually is the solution for them being tired enough at night that they sleep well? We shouldn't be afraid of that with these groups of medications, either. So Wellbutrin or Bupropion, that is a very helpful medication for energy.
Then there's other medications like one called duloxetine, I already mentioned. Really helpful for pain. It gets into like norepinephrine pathways that are pain mediator pathways.
If a person is depressed and they also have chronic back pain from an injury, or maybe they just feel pain as a result of them being depressed, that is a really good one because it works both on the depression part of their neurochemistry, their serotonin, but it also really helps with pain pathways. And so imagine liberating a person from their pain so that they're able to like now function better in life. And using this medication absolutely does it over and over and over again.
A lot of people are like that pain I used to have, that is so much better. I'm able to go ice skating again for the first time in years. I'm able to actually do things like play with my kids and I haven't done that in so long.
I can tell you more often than not that that is what happens. And so we should be looking at this person in that lens so that we're able to see like this person has this constellation of things, let's use this agent for that. And then everybody else gets treated the same way.
[Paige] (22:00 - 22:11)
Let's talk about pain between the sexes. Do you see meaningful differences between how men and women experience depression and how they respond to antidepressants?
[Dr. Bobby Parmar, ND] (22:12 - 24:09)
Differences between the sexes is interesting here because... So men experience depression usually singularly, like it's not influenced by hormones unless they have like low testosterone, right? And that's an easy-ish thing to measure.
Like we measure your testosterone, we're like oh look that's low and then hopefully you feel better and if you don't feel better then let's use an antidepressant as well on top of that. The difference with women is we have PMS, we have something called PMDD which is an essentially a severe form of PMS. So disruptive and disturbing PMS symptoms for a few days, maybe a couple weeks every single month. We have postpartum, so after pregnancy.
We have pregnancy, we have perimenopause and menopause. We have all of these other influences on this body, not mine but like a woman's body, that influence the way they experience chemicals and how their chemicals are received, their levels of that chemistry, what goes into the hormonal input to those chemicals. All of that is so different in a female body.
That there are different times in a woman's life that she is more susceptible to those hormones dysregulating and then having a negative impact on her nervous system and the chemicals that I'm speaking about. So it's more often that we see times where women need antidepressants for all kinds of reasons. You could, I'll give you an example, but PMDD is one of them.
You know what PMDD is?
[Paige] (24:10 - 24:10)
No, I doubt.
[Dr. Bobby Parmar, ND] (24:12 - 28:26)
Premenstrual dysphoric disorder. It's like PMS on steroids. It's like PMS but suicidal.
It's like PMS but rage. It's a PMS and serious depression. It's PMS with anxiety through the roof.
It's PMS with extra psychological and physical symptoms. It's horrible in so many women's lives. And one of, we know that it is both a psychiatric issue in that psychiatric medications like antidepressants work and can work very well.
And it's a physical gynecologic issue in that hormones play a role with it. It's not one or the other. It's both combining.
But one of the downstream effects is women will experience depression-like symptoms or anxiety-like symptoms because of these hormone changes or their sensitivity to these hormones. And one of the ways that we can absolutely make really significant benefits is using things like an antidepressant called Sertraline, some Zoloft, or Fluoxetine (Prozac), citalopram (Celexa), or escitalopram (Cipralex / Lexapro). This group of SSRIs is so helpful.
And we know that there's a serotonin effect with PMDD because when we use the dopamine medications or the norepinephrine medications in this group, they don't work as well. You know that serotonin ones specifically work uniquely and effectively in this group for these terrible symptoms before their period. And you know these women, they'll be like, the last two weeks were horrible, and then they get their period and they're just like, oh my god, miraculously that was so much better.
Like, I can't believe it, I can't wait for my period to come. Ad flo, can't come sooner. But the two weeks leading up to it, if you give that woman an antidepressant like this, or you identify that this is a problem, and then you say like, oh my god, it can really help you, and you don't have to give it to her every day, it could just be literally the seven days before if that's when she gets symptoms, 14 days before if that's when he gets, and that it doesn't have to lead up into the system, doesn't have to build up over months like it does for clinical depression, it's not the same. It has a direct effect within days of somebody taking it, even that day when they have PMS or PMDD, to re-pattern and reshape the neurochemistry in the brain, because it's totally different.
It's like a different way that it happens. Like, neurosteroids are involved that affect all of these other downstream chemicals that an antidepressant, like a SSRI specifically, completely block and help serotonin float into the pool between nerves and feed those nerves so they don't have to suffer and be like, I need something, but it's not there to feed them. It can be miraculous for these people.
And the number of women who come in to see me who are like, my PMS is terrible and I want to eat my husband's face off, and that they're just like, my relationship is coming to an end because of this. I've been given ultimatums about this. I've been told like this can't happen anymore, and I also don't want it to happen.
What is an option for me? Antidepressants. We can call them something else.
We can call them PMDD medications. We can relabel them PMS medications, if it makes people more comfortable, if it makes people more likely to take them. Because antidepressants, the label has such a bad, it's such a bad thing.
Like, we think like, I don't want to go on antidepressants. Like, why do you want to put me on antidepressants? Like, that's off the table.
And it's like, well, it's only because like, it's like that because we've attached these really negative connotations to them. Like, big pharma wants us to all be taking it. We're, only reason we're taking so many every year and prescriptions keep rising is because big pharma is influencing.
It's like, maybe life is stressful. Maybe a lot of people are just really stressed and it's gotten to them. Maybe that's true as well.
[Paige] (28:27 - 28:42)
Zooming out a bit, how do antidepressants fit into hormonal transitions like PMS, postpartum, or perimenopause, even though they're not hormone treatments? How can antidepressants help with hormones in general?
[Dr. Bobby Parmar, ND] (28:43 - 31:20)
Antidepressants, they don't help with hormones per se. They help with the way hormones can fuck shit up. So like, if you, if you are going through a symptom as a result of your hormones changing, well, let's say you have a baby.
After you have a baby, you find yourself feeling alone and you're like, I am taking care of this child and the sense of overwhelm is just too much. I just had a baby. I had surgery because I had a C-section and now I'm recovering from that.
And I'm not getting parental leave that long. And my partner, if you have one, isn't offered it also that long. So all of these stresses, on top of the fact that your hormones just took a nosedive out of a plane and have completely crashed after your pregnancy.
You had tons and tons and tons and tons and then you have a baby and now they're all gone because you're, you're like, not supposed to be ovulating so that you're able to breastfeed if that's your choice. So your body is allowing for that to happen. But all the hormones have completely shifted.
You know, there are cultures in the world that are like, lady, take a month off, take a hundred days off. You're doing nothing. We're our world here that is completely unrealistic and I think it's become less of a norm.
So a lot of women find themselves in this hormonally affected time and they feel depressed, not themselves, and they think thoughts they don't want to think about their babies, about their situation, about themselves. And those women, when we screen for them in their pregnancy, did you have depression before? Are you depressed during your pregnancy?
Are you going to be alone afterwards? Are you going to feel like you're alone? That's why we should check in with pregnant women and then new moms within weeks of them having this baby.
Because who knows what their situation is and how it's ever changing. Antidepressants in this population for postpartum depression can save their lives. It can literally make them no longer think the thoughts that they're thinking that they didn't want to in the first place.
So hormones don't essentially, we're not treating the hormones, we're treating the thing that the hormones allowed to happen on top of life circumstances that took actual advantage of it.
[Paige] (31:20 - 31:28)
Clinically, how do you distinguish between hormone-driven mood symptoms and depression? And does that distinction always matter when choosing treatment?
[Dr. Bobby Parmar, ND] (31:30 - 33:48)
When we ask patients whether or not there are specific things that they're experiencing that qualify, usually their questionnaires we use, for depression like hopelessness, lack of joy, lack of energy, changes with your sleep, changes with your eating habits, your relationships, have people started to make comments about the way you're interacting with them, like it's long questionnaires and some are short, to try to understand how is this impacting your life.
It doesn't matter if it is a hormone. All that matters is that you feel the way you feel and that you can use these medications to help the feelings that the hormones allowed to create. You know, we use antidepressants for things like endometriosis.
We use, it's a, it's predominantly a, like a, believed to be a gynecological issue and yet one of the main things is pain. So we'll use antidepressants, major air quotes, call them something else, call them pain medications. You, why don't you call antidepressants Tylenol, for God's sake, call them analgesics, because if you change the label, more people would probably take them.
So let's call this an analgesic. We'll call it duloxetine analgesic instead of an antidepressant. We'll call it, um, like a pain reliever that we use in endometriosis.
So hormones are affected, um, you take hormone medication to block your hormones, to help with the signs and symptoms of this disease, but you can also take duloxetine to help with the pain. You can take something called Elavil, amitriptyline, and nortriptyline to help with the pain. We do that with IBS, irritable bowel syndrome.
The pain can be so bad that some people will say, would you consider taking an antidepressant to help with your pain of your irritable bowel syndrome? Not because I want you to feel happier, not because you're clinically depressed, but because we're using it in a way that it works chemically in the body to help with pain. So the point is you can have lots of reasons why you feel the way you do, but you can still use the agent for both your mental health and also a physical symptom that's resulting from that problem in the first place.
[Paige] (33:50 - 33:59)
When pain is chronic, especially in women, where do antidepressants fit into treatment and when are they appropriate versus not?
[Dr. Bobby Parmar, ND] (34:01 - 35:10)
It depends on the reason for their pain, it depends on what their goals are, and it depends on if it's chronic pain versus acute pain. If somebody experiences pain and it's just, it's, just how dare I, it's period pain, we wouldn't necessarily use an antidepressant because that's like, that's a, that's inappropriate for acute use that way, right? It's not like it's PMDD, it's pain.
We use pain medication for that person, but if it's chronic pain, like endometriosis pain that a person is debilitated by or just affects the quality of life long term, yeah, use it then. Because when you have something constantly telling the nerves all the time, stop behaving that way, like stop sending pain signals. If you have a chronic pain condition, you can use antidepressants for their pain.
You can absolutely use them because the depression itself isn't necessarily mutually exclusive with their pain in order to qualify for using a medication that way. If they also have depression on top of that, great. Kill two birds with one pill.
[Paige] (35:11 - 35:18)
How often do you see emotional or psychological stress manifest as physical pain, particularly in women?
[Dr. Bobby Parmar, ND] (35:19 - 39:22)
My gosh, like we are just at the beginning of understanding the connections between our mental health and the somatization of pain or of those symptoms where like a person can have so much influence and power over our body. Like I use these examples all the time. You can look into all kinds of circumstances in your life where you felt pain.
Actually, I'm going to use an example that I thought was so interesting. A number of years ago, there was this case report of this guy who was like a construction worker and then he ended up in a hospital. I think it was in the UK.
He ends up in the hospital because a nail went through his boot. A giant construction nail went through his boot. So he ends up going to the ER and then they have to give him all kinds of fentanyl, like opiates, to make his pain subdued in order for him to even have the boot taken off so they can x-ray it properly.
So this man is writhing in pain and he's just like, no, you can't take the boot off, it's off. So they cut the boot off and they see that the nail went between his toes. It didn't go through his foot.
It didn't go through his toes. They went between his toes. So there was no damage.
There was no injury. But he didn't know that. He thought the nail went through his foot.
So he was writhing in pain to the point that he needed fentanyl to help with his pain. That's a case report that was written up and I love it because we see examples like that and we're like, oh, I can't make myself feel that it's in your head. And it's like, yes, it's in your head, but that doesn't mean that you can always think yourself out of it.
Because what if the way it's in your head has now manifested in your body and now your body through your nerves has learned this is how I operate or this is my belief or this is how I fire or this is how chemistry is shaped. This is how I get inflamed. This is how everything gets tense, like migraines.
Migraine is pain. Migraine is pain. You can get migraines from stress, from tension, from looking at a computer screen too long.
We can influence our bodies in all kinds of ways. And my point is we have so many reasons to be influenced because we live such busy, full, stressful, full lives where so much is happening to us. Of course, it's easier for us to have a threshold that's lower for what's going to affect us.
Like we're all meant to sort of be building our threshold to block all of this stuff. But there's so much to block. It's hard for that threshold to rise, right?
We're filling our cup all the time. Maybe there's not enough to fill because maybe finances are an issue. Maybe you're not able to see a counselor weekly for 12 straight weeks to get CBT, cognitive behavioral therapy, to help you.
Maybe you can afford it. Or maybe a pill for you can help you in that time because for you it matches where you're at. For pain, for your mental health, for the way your mental health affects your body.
All the time. But we shouldn't get it twisted that just because there is an effect of our mind, our psychology's ability to affect the way we feel, that the answer is in the mind. The answer is also in the body because that's where it's showing up.
[Paige] (39:22 - 39:26)
Can people become dependent on antidepressants?
[Dr. Bobby Parmar, ND] (39:28 - 45:47)
Dependent is an interesting word because like we use the word dependent to kind of suggest that somebody is going to not be able to come off of that thing without suffering and going through withdrawal. And that is usually not true for antidepressants. They don't like become so addictive in the brain that you need it to survive.
Or at least your nervous system's belief is, I need that to survive. Like opiates. It doesn't work that way.
Antidepressants can cause what's called discontinuation. Meaning you can stop one cold turkey or two fast. And there's a lot of people asking me like, I don't want to be on it because I'm gonna be on it forever.
And I'm not gonna be able to get off because like my aunt can't come off of hers. And it's like, yeah that happens. If we use an antidepressant that comes out of the blood really fast, like it's half life.
The amount of time it takes for half of it to be gone is really short, like half a day. Then by the next dose, it's almost gone already. So if you miss that dose, you're gonna start getting symptoms of that.
We call that discontinuation. Not dependence. Discontinuation.
And we use the word finish. Like fluish, insomnia, nausea, irritability, and agitation. Sensory disturbances.
We call them the zaps. Like you get lightning bolts in your brain, in your body. And hyperarousal.
Like lights bother you. And like noises bother you. And you're just like, ah this is the worst.
That's real. That's not dependence. That's just coming off of something or having something come out of your system too fast.
And your body is going through a temporary like loss of that thing. It's like, oh I'm it was so enmeshed and now it's being ripped away from me. That's very different.
So we should really coach these people. When you're ready to come off, I have a couple rules. If when you're ready to come off, let's say your season of stress that affected you situationally, that you want to see whether or not you don't need your antidepressant anymore, you want to come off.
I have a couple rules. Rule number one, if you live in a place that's kind of gloomy and dark and rainy, like I live in Vancouver, rule number one is can you wait to come off until it's sunnier? And can you wait to come off until maybe it's spring or summer?
Because if you start to come off of it in a gloomy season, how are we going to know the difference between you in gloomy season versus you feeling your best self in spring and summer? Like encourage people, like unless you're in some kind of urgent situation where you need to come off of it because you have a side effect that you just really don't like, then can we wait to just see? Because I don't want to set you up for failure in this, right?
Because a lot of people get seasonal affective disorder, they feel sad, there's a sad, and I don't want to conflate the two. The second is if we chose an antidepressant that has a very short half-life, you better believe that when you are ready, like Paxil is one of them, Effexor (venlafaxine) is another one. These ones come out of your blood so fast that if you miss your next dose, you are fucked. And you need to be on top of it.
And that bothers a lot of people. But if it's one of those, then we need to make sure your weaning is long. So we have a couple rules that way.
The longer you've been taking an antidepressant, so it's usually more than a year, that's a lot, that's considered long. The lower the half-life or the short of the half-life, the quicker it comes out of your body. And the higher your dose in the range of the therapeutic dose of that drug, the longer it's going to take for you to come off.
And we have rules like you're going to take 25% every one to two weeks, less than you did before, but some people are so sensitive they can't do that. So we'll be like, okay, get the pharmacist to make you a smaller version of that or give you smaller versions of that so you can come off 10% at a time. So it's like 90% this week and then 10% less the following week and 10% less the following week, or even every two weeks, to make it so it's easier for you to not get this like discontinuation effect.
So all of that matters. And some people will choose at the very beginning of the conversation, they'll be like, I don't want to be on any of those. I don't even want a chance to be on a medication that's going to give me any of that risk of not being able to come off of it.
I'm going to feel like I'm in a trap. I'm going to be on this forever. I don't want to be on it forever.
I just want to be on it for the next year to help me through this time of my life. Divorce, death, something. Then you'll say like, well then let's not pick one of the ones that is going to be hard for you to come off of.
Let’s pick one of the ones that’s easier for you to come off of—bupropion (Wellbutrin), citalopram, or Prozac, which is also known as fluoxetine. Let’s pick those.
Because really, there's no huge difference between the efficacy of all of these different antidepressants. They're all roughly equal in their efficacy. And we don't have this one outperforms this one.
It's, is this one going to be right for you the way you experience anxiety and the way you experience depression? So if a person is on wanting to take something, they want energy and they want to be able to come off easier and they have anxiety. Wellbutrin, let's use Wellbutrin for you.
That's going to be easier for you to come off of this thing. In fact, there's very little discontinuation of that. Or if you went on vacation, you forgot your prescription, you're gonna be like, I'm really forgetful.
And at least you won't suffer so much from this discontinuation effect. So it's, yes, these things are true. Like discontinuation and like having side effects, but they don't have to be true for you.
If you have somebody working with you to make sure that we respect your values and what you want to have, and get out of it, and for how long you want to do that for. That makes it so much better. It makes it so much more palatable for people.
Like, don't worry, I'll take care of you. Like I will walk you through this both onboarding, a right one, and offboarding at some point in the right, gentle, safest way.
[Paige] (45:48 - 45:55)
So when someone is doing well, how do you think about whether or when it might be time to taper off antidepressants?
[Dr. Bobby Parmar, ND] (45:55 - 47:55)
I don't know. And I've had conversations with my colleagues about, should we be checking in yearly and asking them, time to come off? I leave it open ended.
I don't want to constantly be checking in on somebody and saying, of course, I want to check in. Have you gained weight? How do you feel on this?
Do you feel good? Do you feel like there's leftover symptoms? Should we change the dosage?
Should we add another agent in? Should we use something different because this was not working for you? Should we try different things?
Should we use natural agents on top of it? I'll check in on those. But checking in, I'll be like, it's time for you to stop.
No, I don't want to be the person to decide what's happening in your mind, your brain, your nervous system, and your life. I'll leave that to you. Am I going to check in with you every six months if things aren't going really well?
Even if they're going really well and be like, no, I need to check in with you just because I want to monitor you properly. Yes, that'll be your opportunity to tell me how things are going and whether or not you feel like I'm getting pregnant. I don't want to be on anything when I'm getting pregnant because I've read things that it's not great for the pregnancy or the baby.
Then we'll have a full conversation. Is that true for you? What if your pregnancy is not kind to you and you need something to help you through it?
What if you experience pregnancy depression? We need to be really careful in those instances too because depression in pregnancy is also a risk for problems with the baby and with postpartum depression. So a lot of people will say that to me.
It's time to come off. I'm like, whoa, let's have the conversation. And then I'll give you all the information and say, do you still want to come off?
And if you do still support you through it all, but I'm not going to be the one to be like, it's time for you to come off. You've been on it for a year. That's long enough.
No. But should we just leave people on things indefinitely and not check in with them and just write scripts and be like, here you go. See you next year.
Absolutely not. No. People's lives change.
[Paige] (47:56 - 48:05)
Yeah, absolutely. But do you see cases where antidepressants don't work and what options exist when someone is treatment resistant?
[Dr. Bobby Parmar, ND] (48:06 - 51:01)
Yes. People will say, um, for genetic reasons, there's fancy genetic tests now that can tell you whether or not a specific kind of expensive are like five, $600, at least where I am, but they can tell you whether or not your genetics have coded for something like an antidepressant to work for you or not work for you because of the way it's metabolized in your body. So it'd be like, this one's not metabolized very well.
You shouldn't use it. A lot of people will be like, I did that test or I want to do that test to pick the right agent for me. Are there people who don't have that as an option and they still have gone through a bunch of antidepressants?
They've gone from one class, SSRIs, they tried two of them, then they moved on to a different class and then that didn't work for them. They moved on to another class. They didn't like the side effects.
Does that happen? Absolutely. Does that mean it's not worth trying even one, two, three because they can be life-changing?
No. Keep trying under the safety of the rules I've just described and under the safety of the conversation. Keep having the conversation because what if you just needed the fourth one to be the one that worked for you?
And a lot of people say that too. Are there people who are treatment resistant? That's a thing where we need different agents, not antidepressants.
We need antipsychotic medications that we use for these people because for them, that's maybe what they needed. Do we need natural agents? Sometimes like people, I also underestimate natural agents, what they can do.
Saffron is one of my favorite things. Saffron, the spice, the actual spice that we put in things is kind of expensive. It's not very expensive for supplements, depending on what you consider expensive.
Saffron acts like an SSRI. It actually acts like Prozac in the brain and it works really good for reducing inflammation in the body, inflammation in the brain, and it works really well at helping increase serotonin. So we can use that too.
What if you were resistant to these other drugs but you were resistant to the natural agent? Or you can combine them. There's very little harm in doing that too.
There's all kinds of creative ways to use agents to help both with benefit, the side effects coming off of it. I love saffron for helping people come off of antidepressants when they're having a hard time coming off. Just use a little bit of this medicinal spice, but as a medicine, as a supplement, to help yourself not experience too much of the withdrawal effect or the discontinuation effect too.
We can get really creative with helping people. It doesn't have to be like this rigid box that we have to work with. So yes, there's treatment resistance and we use all kinds of interesting things with these unfortunate patients that didn't just get it right on the first or second try, but that shouldn't mean we should not try them in the first place.
We should absolutely try.
[Paige] (51:01 - 51:05)
What can someone do to make antidepressants work better for them?
[Dr. Bobby Parmar, ND] (51:07 - 52:23)
When we're talking about using these medications, for some people they are the be all and end all. You fixed everything. You literally fixed everything with this one pill.
I am totally fine and that is what a wonderful outcome to be like. A pill made me totally better. Is that true for everybody?
No. Do people still need you to hold their hand and understand what they're going through in their life and the stresses that they go through and they need counseling for that? Referring them to a good counselor?
Helping them with actual therapies that are available to them? EMDR or CBT or just talk therapy? Are there things that we can encourage them to do like group sessions?
Encourage them to speak to other people because nothing is worse than isolating in your depression and that's what depression wants to do. It wants us to not tell other people about our depression. It wants us to hide and it wants us to build that monster that doesn't want to speak to anybody because it feels like we're not deserving of that or deserving of care from other people.
So we should always be trying to have these conversations to fill in the whole picture so that it's not just about this one pill. But let me tell you, are there people who literally just like that one pill fix everything? Yep.
[Paige] (52:24 - 52:37)
All right, so before we wrap up and honestly this has been such an amazing conversation, there's just one last thing I want to ask you. If there's one misconception you wish we could dismantle about antidepressants, what would it be?
[Dr. Bobby Parmar, ND] (52:38 - 54:18)
I just wish we didn't like put a scarlet letter on them as much as we do. You all the time in articles and on Instagram posts and there's just a shame around them and it's so bad that we think of this internal. Well, we already have shame around depression.
We already have shame around anxiety. We already have like buckle up buttercup. That's what you should be doing.
Like get stronger bitch. And it's like wait, what if that's not the answer? What if that's not the answer?
So we have shame about the problem. We have shame to even discuss it and then we add shame on top of doing something about it. Then we have shame on top of doing something about it with a simple medication that might make or break the difference.
That's my problem. I want to dismantle. I want to break.
I want to completely collapse the shame around it and openly have conversations with people around this so that we don't leave them hanging and feel like they're on their own. It doesn't have to be that way and that's what I do with my practice all day long. Listen, there's something here that might make a big difference.
You want to talk about it? We'll do another epi on this or another couple epis on this and talk all about it now. Thanks for joining.
Thank you so much for joining me today. I really had a great time and I hope you did too. Please share this with a friend or a lot of people and leave me a review.
It really helps promote this podcast. Thanks so much.
Disclaimer: This transcript may contain errors, omissions, or inaccuracies. It should not be considered a verbatim record of the conversation. For context or clarification, please refer to the original audio or video recording.
