Dr. B’s Professional Spotlight: Dr. Josephine McNary, M.D., Answers Questions about Medication to Treat Depression and Anxiety
Struggling with a mental health condition, such as depression or anxiety, can come with feelings of uncertainty of how to seek help that feels right to you. Research suggests that the best outcomes for decreasing symptoms of a mental health condition involves pairing therapy with medication (Baruch & Annunziato, 2017; Lambert et al., 2001). Treatment factors, such as taking effective medications, building trust with a therapist, or having a positive social support, are experiences individuals may describe as contributing to positive outcomes treating their mental illness (Hom et al., 2020). But not everyone feels comfortable taking medication to treat psychological symptoms. Family beliefs, personal expectations, and societal norms may stigmatize seeking help to treat mental illness through medication and/or therapy (Cole & Ingram, 2019; Hack et al., 2020). Dr. Josephine McNary, M.D., was interviewed in this professional spotlight in efforts to demystify treatment of mental illness through medication.
Dr. Josephine McNary is a board-certified general psychiatrist specializing in medication management. She earned her bachelor’s and master’s degrees from Stanford University and attended Tulane University in New Orleans for medical school. From there, she completed her psychiatry residency at the UCLA Neuropsychiatric Institute. Dr. McNary has since obtained specialty fellowship training in both psycho-oncology and treatment-resistant mood disorders, and this training was put to use when she served as the staff psychiatrist at the UCLA Simms-Mann Center for Integrative Oncology from 2011-2015. Currently, she holds a position as attending staff at the UCLA Department of Psychiatry, where she provides both inpatient psychiatry and consultation services.
Dr. McNary began her private practice, CalPsychiatry, in 2011, and it has blossomed to include five psychiatrists across seven locations (Santa Monica, Downtown LA, Little Tokyo, Echo Park, Hermosa Beach, Marina del Rey and Santa Barbara). The practice specializes in the treatment of mood disorders (depression, bipolar disorder), anxiety disorders (including OCD), ADHD, addiction and women’s mental health. While medication management is a large part of the practice, cultivating a relationship with psychologists and therapists is foundational to the mission of CalPsychiatry.
Dr. Ballardo: Can you discuss your philosophy on medication to treat mental health conditions? How might it be beneficial in treating symptoms of depression or anxiety, for example?
Dr. McNary: We have come a long way in the development of medications to help treat a wide array of mental illnesses. While medication may not be for everyone, it is always an important consideration when a patient is coming to speak with us for the first time. For example, if someone is presenting with new-onset depression that is mild, we would first want to do a thorough history and rule out any medical causes (i.e.-a thyroid that is not functioning properly). After that, if symptoms are not debilitating and the patient is more hesitant to start a medication, we may start with therapy and some lifestyle modifications. If they fail this or decide they would like to try medication, an antidepressant trial is certainly warranted. However, for severe depression where patients may be suicidal or extremely impaired in their lives, medication is indicated and should be offered. Starting a medication is always a conversation with our patients, but I think if we help to educate them and explain how the medications can be used safely, we can make them a lot more comfortable.
Dr. B: What recommendations would you give someone who is considering starting medication to treat depression or anxiety but is nervous about side effects?
Dr. McNary: I would encourage people to speak with their doctors and get all their questions answered. Starting any new medication for any condition can be daunting, but this is what our doctors are here for! We have extensive training in walking you through the possible side effects and are well-versed in any drug-drug interactions if you are taking other medications. Most of our medications on the whole are quite safe, and I would definitely encourage people not to let the fear of side effects prevent them from seeking treatment. Even the medications with more serious side effects, when properly used and monitored, can do wonders for patients.
Dr. B: Are there reasons why someone should not start taking an antidepressant or antianxiety medication?
Dr. McNary: So there are several classes of antidepressants and antianxiety but for simplicity, I will focus on the SSRIs (selective serotonin reuptake inhibitors), which we use widely and are first line for both anxiety and depressive disorders. These medications are very safe and I would say the only serious contraindications are 1) a history of bipolar disorder or manic episodes or 2) if the person is on another class of antidepressants called MAOI’s (monoamine oxidase inhibitors). Using these two classes of medications together can result in a life-threatening reaction called “serotonin syndrome,” so if we are switching from one class to another, we typically do this slowly over two weeks to let the first drug “wash out” of the patient’s system. Other than these two contraindications, I would be careful in patients with seizure disorders, cardiac/bleeding risks, or liver impairment but I would not say these are contraindications—more things to keep note of.
Dr. B: What do you recommend clients do to promote mental health wellness in addition to taking psychotropic medication?
Dr. McNary: Great question! Medication is only part of the puzzle. I encourage my patients to engage in some kind of physical activity (preferably ones that are outside if they are struggling with depression because there is a lot of good evidence for sunlight as improving mood and sleep). I also encourage them to try to eat healthy, drink plenty of water, and keep alcohol to the suggested weekly use. Staying away from illicit substances is critical as well. Therapy can be an important treatment piece for some people, and some people find daily meditation very helpful as well. Finally, I encourage people to engage with some kind of social support system. Whether it’s a church Bible study or friend group that gets together for weekly hikes, knowing we are not alone is so important in combating mental illness. During this COVID time, virtual hangouts and FaceTime can be great substitutes for in-person gatherings to continue to feel connected with others.
Dr. B: Do any of your clients discontinue medication because you both agree that they no longer need them? If so, how long does it typically take for them to experience relief from depression and/or anxiety?
Dr. McNary: I would say that stopping a medication, just like starting one, is a conversation that should always happen between patient and physician. I discourage my patients from just stopping a medication cold-turkey, even when they are feeling better. We can definitely discuss a safe taper if indicated, but I think the biggest thing would be to try to avoid having a patient relapse. Typically, our medications for depression and anxiety can take anywhere from 4-6 weeks, but some people won’t see maximum effects for up to 12 weeks! So it’s important we give the medication enough time. If a patient is in remission (minimally affected by their symptoms) and this is their first depressive episode, I would like to see them doing well on the medication for at least 9-12 months before we start the conversation about a medication taper. Obviously someone who had severe depression or this is their third depressive episode would be a different story, and we would usually recommend these people continue medication indefinitely.
To schedule a medication consultation, please contact Dr. McNary:
310-935-0754
2444 Wilshire, Ste 414
Santa Monica, CA 90403
References:
Backman, J., & Firestone, P. (1979). A review of psychopharmacological and behavioral approaches to the treatment of hyperactive children. American Journal of Orthopsychiatry, 49(3), 500–504. https://doi-org.chaffey.idm.oclc.org/10.1111/j.1939-0025.1979.tb02633.x
Baruch, R. L., & Annunziato, R. A. (2017). Outcomes of combined treatment: Evaluating split versus integrated treatment for depression. Professional Psychology: Research and Practice, 48(5), 361–368. https://doi-org.chaffey.idm.oclc.org/10.1037/pro0000144
Cole, B. P., & Ingram, P. B. (2019). Where do I turn for help? Gender role conflict, self-stigma, and college men’s help-seeking for depression. Psychology of Men & Masculinities. https://doi-org.chaffey.idm.oclc.org/10.1037/men0000245.supp (Supplemental)
Gaddis, S. M., Ramirez, D., & Hernandez, E. L. (2019). Variations in endorsed and perceived mental health treatment stigma across US higher education institutions. Stigma and Health. https://doi-org.chaffey.idm.oclc.org/10.1037/sah0000202
Hack, S. M., Muralidharan, A., Brown, C. H., Drapalski, A. L., & Lucksted, A. A. (2020). Stigma and discrimination as correlates of mental health treatment engagement among adults with serious mental illness. Psychiatric Rehabilitation Journal, 43(2), 106–110. https://doi-org.chaffey.idm.oclc.org/10.1037/prj0000385
Hom, M. A., Albury, E. A., Gomez, M. M., Christensen, K., Stanley, I. H., Stage, D. L., & Joiner, T. E. (2020). Suicide attempt survivors’ experiences with mental health care services: A mixed methods study. Professional Psychology: Research and Practice, 51(2), 172–183. https://doi-org.chaffey.idm.oclc.org/10.1037/pro0000265