Depression and Anxiety are widely recognised as major public health problems around the world and, not surprisingly, they practically constitute the majority of my practice in Dubai as well. As a Psychiatrist working in an Integrative clinic (The Free Spirit Collective, Integrative Wellbeing and Psychology), I often get questions about the treatment of these conditions, whether medications are needed, or I recommend therapy instead.
My approach to the use of psychotropic medications is very simple. I don’t recommend medications to all my patients, but typically enjoy discussing with them the options available and how to use at the best of their possibilities what treatment is available, accessible and convenient to them.
I consider therapy the treatment of choice or first line (alternative to antidepressants) in forms of depression that are milder or have just been diagnosed; in those cases, Cognitive Behavioural Therapy (CBT), physical exercise and holistic techniques, while actively monitoring the patients, are my recommended solutions.
Therapy is also the treatment of choice for Anxiety Disorders, specifically CBT, but I will never stress enough how those disorders are particularly complex as Anxiety can occur in isolation or be co-morbid with other psychiatric disorders, including Depression. Anxiety tends furthermore to be chronic and difficult to treat as can be induced or exacerbated by medical conditions, drugs (even caffeine) and life events, like grief, traumas, interpersonal relationship issues. People with Anxiety tend to respond less to medications and to be prone to side effects.
In the circumstance of moderate to severe depression or dysthymia (as carefully assessed with psychometric scales), I will discuss with the patient the drug of choice as research shows clearly and all the guidelines recommend (see an example the NICE Guidelines recommended in UK practice) to start a combined medication and CBT treatment. It is crucial to make sure that the patient gets a satisfactory level of understanding of the mechanism of action of the medication, of potential side effects and also of the results expected within the following weeks. I think it’s important to draw a timeline of the treatment, measured against the symptoms reported and the signs observed during the psychiatric assessment, as knowing that the drug will support this stage of treatment and then will be perhaps discontinued helps gaining perspective and modulating the expectations, while empowering the patient towards their own treatment. I noticed many of my patients are afraid of the “quantity” of medication they are prescribed and often ask for a “low” dose or “a single pill”.
Whether I always start with a low dose, as mostly recommended to do with many medications in order to minimize side effects, it is crucial to explain the concept of effective dose, which is a dose (or a concentration in the blood stream) of a drug that is able to produce a biological response. I also make sure they understand that the nature of depression is surely not a single disease with a single biochemistry deficit but rather a complex and heterogeneous condition with biopsychosocial implications.
We are all understandably concerned about possible side effects and even more so, of becoming “addicted” to medications. I try to be very clear with my patients about the side effects that psychotropic medications can display, including GI, cardiovascular and sexual side effects. I have to say that my choice of the medication is mostly based on the side effects profile, obviously within the guidelines of medications recommended for the condition. I also discuss thoroughly the possibility to experience withdrawal, better described as discontinuation syndrome, from certain medications when stopping the treatment and encourage them to reach out for guidance and support at any point of treatment. If the condition clinically allows it, we choose together a medication that is “easier” to discontinue.
Generally, if a careful review is conducted, within the first couple of weeks, the patient experiences an objective relief from the symptoms, which then tend to improve further in the following weeks. Combining access to therapy or coaching or holistic techniques, while eating healthily and exercising in my experience produces the best outcomes. It’s also extremely important to continue educating themselves while addressing underlying psychosocial issues.
Dr Valentina Faia, Medical Director and Psychiatrist at The Free Spirit Collective Polyclinic, Dubai - https://thefreespiritcollective.earth/about-the-fsc/