goes up must come down. The natural process of stress triggering surging estrogen levels has a built-in stop mechanism, which then normalizes our serotonin levels.
SSRIs are the most common treatment for depression and anxiety, but if you’re on SSRIs, with steady serotonin levels, you miss out on this natural ebb and flow of serotonin in response to estrogen. You stay more rational and less emotional. Estrogen fluctuations help to keep us sensitive. SSRIs deaden our sensitivities.
More women than men get depressed, and estrogen may have a lot to do with this. Estrogen affects how serotonin functions in the brain. Women are more vulnerable to changes in serotonin levels and more responsive to drugs and medicines that affect serotonin. This is one reason that women may be more affected by sexual side effects of SSRIs than men. So where you are in your menstrual cycle or your perimenopausal staging will have effects on your mood, like how irritable, sensitive, or impulsive you are, as these behaviors are affected by serotonin. As you’ll see in the next chapter, it’s normal to have times in your cycle when your estrogen is lower, which means your serotonin will follow suit and you’ll feel lousy. It’s temporary and it’s natural. You don’t necessarily need daily antidepressants to mask these moods.
SSRIs can do many wonderful things for people with serious depression, and I have to admit that my patients love the way they make them feel, at least at first, but they can also take many sensations away. SSRIs tend to blunt negative feelings more than they boost the positive ones. On SSRIs, you probably won’t be skipping around gaily with a grin plastered on your face; it’s just that you’re less likely to feel tearful, irritable, and hopeless. People on SSRIs report less of many other human traits: an ability to cry, irritation, care about others’ feelings, sadness, erotic dreaming, creativity, surprise, anger, expression of their feelings, and worry.
One of my best friends from college told me a story of when she was first prescribed fluoxetine. “It really scaled back my empathy. Since I was a young girl, I’ve always felt bad if someone else felt bad. It’s a big part of who I am. I would let the other kids find the Easter eggs during the hunt, because they seemed to want them more than I did. When I first went on fluoxetine, I remember seeing another woman crying and thinking, Looks like you have a personal problem. Sucks to be you. This is what it must feel like to be a dude.” SSRIs affect emotional processing and turn down the empathy response. This can have devastating effects on the ability to parent or to maintain relationships.
It’s All Right to Cry and Get Angry
Antidepressants can be utilized as a starting point for benefiting from psychotherapy or creating lifestyle changes, but once those behaviors are firmly in place, the medications often can and should be tapered off. If you break your leg, you don’t keep the cast and crutches forever. Before you commit to a lifelong SSRI prescription, consider the dynamic emotional range you might be giving up.
My patients on SSRIs will report, “I knew the situation was upsetting. I was supposed to be feeling sad, but I couldn’t cry.” Crying isn’t just about sadness. When we are frustrated, when we are angry, when we see injustice, when we are deeply touched by the poignancy of humanity, we cry. And some women cry more easily than others. It’s normal. It’s how we’re designed, and it doesn’t mean we’re weak or out of control.
Crying allows us to deeply feel what we’re feeling and then move on. It is a crescendo that naturally leads to a denouement of intensity. For most women, this depth of feeling is a birthright, but if you really can’t stand crying, or get frustrated because you can’t speak when your throat tightens, here are two tricks that work well instead of meds. Simply think up lists of rhyming words, or subtract sevens from one hundred. Shunting blood away from the emotional centers and over to the rational verbal or calculating areas will mollify most people. (You just have to remember to do it, which means relying on your hippocampus to tamp down your amygdala.)
There are times when it’s inconvenient, to say the least, to cry, but there are other times when it’s to your advantage. Letting yourself cry can be important in communicating with your partner. A clear, visible sign that we’re upset may be just what men need. Women pick up subtle signs of sadness in others 90 percent of the time. Men are better able to discern anger and aggression; when trying to decide whether their female partner is sad, men are right only 40 percent of the time. That’s less than if they flipped a coin to help them answer. This is also a reason to express your feelings verbally and not expect your male partner to know how you’re feeling by how you look or act. They’re simply not constructed for intuiting emotion the way we are. As for families, sometimes it’s a good idea to let your kids see you cry, especially if they’ve scared you with reckless behavior or frustrated you with thoughtlessness. Tears can underscore lessons in how their behavior affects others.
But we clearly have issues around our tears. Have you ever noticed how often women apologize for crying? In part it’s because men are uncomfortable with expressed emotion, and so they, and we, have been socialized to shut it down. Another part is that emotion interferes with the forward-momentum agenda so prevalent in our society. The problem with shutting it down is that we’re stifling a piece that we need, that our partners and families need, and that the world needs.
Being sad can help us make clear-eyed assessments of our lives. Depressed people are no longer in denial about unpleasant or hurtful truths. SSRIs can create complacency in times when action is needed, perhaps to leave an abusive spouse or a dead-end job. Medication can make a bad situation tolerable and mask the need for change. In one study of medicated women, “these patients continued to lead dysfunctional lives, and their motivation for major lifestyle changes seemed to decrease as depressive symptoms improved.” In such situations, the symptoms of depression, unpleasant though they may be, can be the clarion call to action.
Another issue to consider: stuffing down your feelings is going to make you miserable. The suppression of anger in particular is a crucial factor in depression. People who’ve experienced depression are more likely to hold in their anger and fear expressing it, believing they must hide their feelings to preserve their relationships. Depressed patients have higher levels of anger than control subjects; the more anger, the more severe the depression.
In my office, I see evidence of this link frequently. Many of my female patients have no idea how to express their anger in healthy ways, and their suppressed anger contributes to their depression and, I believe, other medical symptoms as well. They weren’t taught as young girls that it was okay to be angry, and they weren’t schooled in how to handle this kind of emotion. Sugar and spice don’t make space for anything that’s not nice. When we don’t even know we’re angry, we can’t converse with the person responsible or otherwise tackle the problem. We cry; we eat; we soothe ourselves a thousand different ways. Instead, we need to fully feel our feelings of anger, figure out where they are coming from, pull ourselves together, and then head out the door for a face-to-face conversation. I had a patient who called me from her office in tears, saying she needed to go up on her SSRI because she couldn’t be seen crying at work. After dissecting why she was upset (her boss had humiliated and betrayed her in front of her staff), we decided that what was needed was calm confrontation, not more medication.
In an examination of women’s employment reviews, certain words show up repeatedly, like
