In the final instalment of our Q&A, registered counsellor Lauren Spangenberg explains what an SSRI actually is, how anti-anxiety meds are different to antidepressants, and the danger of going it alone.
When you say anti-anxiety medication is a little different to antidepressants, how come? Is it because of the way they affect your body?
Yes, neurologically they work very differently. They work on different neurotransmitters and an antidepressant takes a couple of weeks to work. An antidepressant isn’t putting anything new into your system that you don’t already have.
(She draws a diagram, which I forgot to photograph. It looks a little something like the one below. If you want a laymen's explanation of what we're talking about, you can watch this two-minute video and this one too. Keep going it's worth it.)
You have a synapse, which looks like this. That’s a neuron, which are like wires in our brains. We have billions of them. (This is our grey matter.) The little electrical signals come along the neurons and there are gaps, between the neurons, that’s the white matter. The messages get transmitted through our brains and they come through the gaps as chemical transmissions. Those are your neurotransmitters. It’s an electrical message, then a chemical message and it hops over the gap and then it continues as an electrical message.
What happens is we have our neurotransmitters. Serotonin is one of them. It’s the happy one. And it has a relationship with a whole lot of other neurotransmitters. A lot of our emotional information gets transmitted like this. An electrical message comes to a synapse, it’s looking for serotonin to take it across to the other side. But what happens, when you're depressed, is you don’t have enough of it. It is quickly reabsorbed, out of this gap, back into the sending neuron. There isn’t a lot of it going around.
What an antidepressant does, is it helps block this reabsorption. And it takes a while to develop that. It makes it seem like there is more of it but there isn’t actually. It’s just keeping it in the right place. That's why it’s not addictive at all. It’s just improving your brain's ability to work with what’s there.
Amazing. Thank you so much for this diagram. I always read about the SSRI … or what is it called?
Selective Serotonin Reuptake Inhibitor. It inhibits the escape of serotonin from the synapse. Firstly, it’s not putting anything into your brain that you don’t already have. Secondly, it takes a long time to get to those improvements. Anti-anxiety medication is really different. It depends on the anxiety medication and exactly what neurotransmitter it activates. But it usually decreases your stress hormones and decreases a lot of those chemicals in your brain. Like the cortisol and the adrenaline. And it has an instant effect. And we’re not fools...
Like we want the hit?
You'll know, if I take this, even if it's on a subconscious level, in half an hour I will feel better. There’s an instant reward connection in your brain. If I take this, I feel better. With the antidepressant, it takes a long time to work and its mechanism is completely different, there isn’t that association that if taking it, I’ll feel immediately better.
I don’t want to make the anti-anxiety medication the bad character in the story…
Because it’s not. But people don’t understand that they are completely different and you might develop a reliance on a medication, which is different to an addiction.
How does someone go about starting talk therapy and antidepressants? That can be a barrier. You think, omg, I’m screwed. I’m in the dark pit. Where do they begin? Who do they call, what is the process?
It is really hard. It’s not easy. It also depends on your budget. For a lot of people, the reason they are so stressed is for financial reasons. The easiest way is to go to your doctor. That’s where I like to send people. They know their doctors quite well. It’s an easier conversation to have. Go to your GP, and explain how you’re feeling. Say I need help. Your GP can guide you medication-wise. Your GP probably has a lot of referrals for counsellors in your area. That’s the easiest way. But not everybody can afford that. And not everybody can afford counselling.
There are great NGOs out there. It’s not ideal because it’s normally limited and you have to wait a bit of time. At Lifeline, you can get up to four free in-person sessions. You can find an NGO like that where you can get a couple of free sessions, or sessions that are hugely discounted. Hope House offers that.
The other great tool that I’d recommend, and people are very reluctant around this but it’s great, is group therapy. A lot of group therapy is free. Studies show that group therapy can be as effective as individual therapy. It’s different but it has distinct benefits. You don’t necessarily go as deep as you would go in personal therapy. But you get to see that you’re not alone, which is a huge thing. I think everybody feels there’s something wrong with them, I’m the only person that feels this way. And it’s so hard. Depression is lonely. Group therapy is great for that. To be in a space where people understand how you feel.
Also, just to work through things together. To be able to say, 'I’ve tried this, who else has tried this, has it worked?' And so it’s really helpful. The other great thing you get from group therapy is a lot of the time your self-talk and all the cognitive things we were talking about earlier, impact your interpersonal relationships. And in group therapy, you have to manage your interpersonal relationships, it’s a safe space to practice. Things come up and people get upset. But it’s a safe space to get upset in. It’s a chance to ask: Why am I feeling this way? Do I often react like this? Could I have chosen something different? You don’t get that opportunity in solo therapy. You don’t get the chance to see how people manage themselves.
In the moment?
In the moment. You get a self-report, but you don’t get the actual work.
Where is group therapy happening in South Africa?
In South Africa, you need to call an organisation called SADAG, the South African Depression and Anxiety Group. They are fabulous. They are huge and very professionally run. They have a wealth of resources. If you phone them, there are counsellors on the phone all the time. And they can refer you to a group near you. There are groups all over the country that deal with different things. Like the group I run, is for depression and anxiety. But there are groups for grief and there are groups for substance abuse, there are groups for transgender people and there are groups for women who have survived sexual abuse.
The hospital group work, is that only for people who are in the hospital at the time?
No, outsiders can come. Absolutely. That’s at the False Bay Hospital. It’s during the day. I run my group on a Monday morning, which doesn’t suit everyone, but when people phone and tell me it doesn’t suit them, I just refer them back to SADAG. Because there is always somebody who is running a group that will work for you.
And this group therapy, does it have a cost?
No, it’s free.
I just want to go back to the original idea of using intense breathwork/ yoga/ meditation/ excessive exercise etc to deal with depression, instead of seeking professional help. Why are we just “coping”?
I think that part of the hesitation, for some people, around facing their problems head on, and saying I need to be on an antidepressant, is around that feeling of if I do this, it means there is something wrong with me. And how do you come back from that?
People are afraid to almost label themselves. And what I was talking about earlier, this inability to tell the difference between normal distress and depression. People are like, I’ll be ok, I’ll get through this. But, when you are depressed, to try and find that motivation to get up and do these things that you’ve been using as a coping mechanism is pretty hard. People run the definite risk of trying to rely on something until it’s way too late.
"In South Africa, there are 23 suicides a day and 230 serious attempts."
When you ask what the dangers are of clinging on to exercise and wellness practices … The danger of trying to do it yourself, suicide is the danger.
The other thing is, I come from a trauma-informed approach. The question around mental wellness has shifted from what’s wrong with you, which can be a typical … let's see what boxes you tick and we’ll figure out which diagnosis to give you, and we’ll officially know what’s wrong with you. It’s shifted from what’s wrong with you to what’s happened to you. It’s much more powerful. It’s much more insightful. But yes, some of these health problems are structural.
What does structural mean?
Something in your brain that is unavoidable. You know, some of it is. But actually, the more work I do and the more often I see most of it is the result of what’s happened to you. And when you start working with that, you come up with solutions. And you stop judging yourself as damaged. Something has happened to you, that’s hurt you. We can all recover from an injury.
Where can people find you?
I do in-room counselling at an NGO and I do group therapy at a hospital. I also run a private practice. The best way to get hold of me is to go to my website.
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