Why it can take time and effort to find the right meds to help mental health

By Jen Christensen, CNN

(CNN) — At the Lindsay Clancy murder trial, mental health professionals who treated her testified that she repeatedly sought changes to dozens of medications prescribed for depression, anxiety and other mental health conditions.

The day before she strangled her three children, slashed her wrists and throat, and jumped from a second-story window, the 36-year-old labor and delivery nurse wrote in a note on her phone that “medication stole my motherhood and my life.” During the trial, prosecutors briefly showed the note to the jury.

In closing arguments Thursday, Clancy’s attorney said she was overmedicated and not criminally responsible for murdering her children in 2023 because she was in a state of psychosis. He said she had a rare condition called postpartum psychosis, which, when left untreated, carries a higher risk of infanticide and suicide, studies show.

“She was reaching out for help, and she was not getting it,” attorney Kevin Riddington said as Clancy nodded.

But prosecutor Jennifer Sprague also brought up Clancy’s medication in her closing arguments. She said that the way Clancy killed her children showed that the act was premeditated and that Clancy knew right from wrong, misled her mental health providers and did not take medication as directed.

“She knows, as a nurse, the importance of following the instructions of your medications,” Sprague said.

Clancy has since sued her doctors, claiming that they failed to properly diagnose her and instead “subjected her to a disorganized, uncoordinated course of polypharmacy that exacerbated her condition and precipitated a severe psychotic break,” according to the lawsuit. All the providers previously declined to speak with CNN about ongoing litigation.

Dr. Joseph Goldberg, a psychiatrist and psychopharmacologist who is not connected with the case, said the Clancy trial has been “an opportunity to remind us all about the complexities of severe mental illness and the complexities of treating mental illness.”

Medication remains the most common treatment for mental health conditions in the US. Nearly 20% of adults take medication for their mental health, according to the US Centers for Disease Control and Prevention.

But it can be hard to find the right medication to treat any kind of complex brain disorder, and some take weeks to work. Knowing when to switch medicines can be a challenge, and it must be done in careful consultation with a doctor.

How mental health medications work

Mental health medications generally fall into four or five major categories.

Antidepressants, including selective serotonin reuptake inhibitors or SSRIs such as Celexa, Prozac and Zoloft, target a range of depressive and anxiety disorders. SSRIs are considered highly effective and can have mild side effects, such as upset stomach, low sex drive and headaches, which often fade over time.

SSRIs can typically take four to eight weeks to work because they alter how the brain handles serotonin, a neurotransmitter that helps regulate mood, sleep and appetite. However, they may kick in more quickly when used to treat menstrual-related mood disorders by way of the hormonal effects on the brain.

With many depressive disorders, SSRIs work by preventing cells from quickly reabsorbing the hormone serotonin. As serotonin remains active longer, the brain adjusts by desensitizing some receptors. That process spurs the release of brain-derived neurotrophic factor, a protein that acts somewhat like fertilizer, stimulating the growth of new neurons and synapses and lifting mood over time.

Other antidepressants include norepinephrine-dopamine reuptake inhibitors or NDRIs such as bupropion, which prevent the reabsorption of norepinephrine and dopamine, neurotransmitters involved in stress response, pleasure, reward, alertness and attention. Serotonin-norepinephrine reuptake inhibitors or SNRIs such as Cymbalta, Fetzima and Effexor XR prevent the reabsorption of serotonin and norepinephrine, which help shape the body’s fight-or-flight response.

Anti-anxiety medications, including benzodiazepines such as Ativan, Librium, Xanax and Valium, can work quickly to ease extreme worry, fear, social anxiety or panic attacks. They work quickly but are typically prescribed for only a short time because people can become dependent on them, and the drugs can have dangerous side effects when the nervous system’s activity drops too low.

These medicines target GABA, a chemical messenger that slows activity in the central nervous system, reducing physical and mental anxiety.

AntiMood stabilizers support people who have mood swings because of conditions such as bipolar disorder, personality disorder and schizophrenia. Drugs such as Lamictal and lithium, along with anticonvulsants and antipsychotics, can help control manic and depressive episodes, quiet racing thoughts and sleep problems, and curb risky behavior. Mood stabilizers influence brain receptors that release and maintain neurotransmitters, calm overactive circuits and strengthen cellular connections over time.

As with SSRIs, patients may need to take mood stabilizers for several weeks before noticing any improvement.

Stimulants such as Adderall, Ritalin and Dexedrine help normalize the thoughts of people who have unorganized or disoriented thought patterns and treat conditions such as ADHD, narcolepsy and binge eating.

These prescription stimulants can sharpen focus by prompting the brain to release more neurotransmitters such as dopamine and norepinephrine, which play an important role in the body’s fight-or-flight response. Common side effects include dizziness, fast heart rate, high blood pressure, anxiety, headache, insomnia and loss of appetite. Unlike SSRIs and mood stabilizers, these drugs can act quickly.

Why finding the right meds can take time

To determine which medicine may help a patient, a psychiatrist first conducts a comprehensive evaluation that reviews the person’s medical history, symptoms, substance use, delusions, hallucinations and risk of violence or suicide. The doctor then chooses an appropriate category of medicine.

As with physical conditions, not every psychiatric medicine suits every patient. Sometimes, for example, someone with acid reflux would do well on a proton pump inhibitor, but sometimes they would need an H1 blocker instead. A doctor wouldn’t necessarily know until they tried them, Goldberg said.

“A lot of psychiatry ends up managing chronic conditions to the best of our ability and also avoiding ineffective treatments,” said Goldberg, a professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York. “Human beings are fragile, and our problems are very seldom one and done.”

Unlike with other fields of medicine, though, there aren’t many options for imaging or lab tests that can give solid answers on a diagnosis, said psychiatrist Dr. Ripal Shah. “There’s a lot of subjectivity to it on both sides, on the patient and provider side.

“We do understand brain changes and are able to do imaging testing and lab testing once that illness has been found,” said Shah, a clinical associate professor of psychiatry and behavioral sciences who practices at Stanford Health Care and specializes in women’s reproductive psychiatry.

Psychiatrists need to be good detectives during the entire process, even after a patient is on a medicine. To determine whether it’s working relies on the person’s subjective experience.

“If someone has cloudy perception due to depression or disorganized thoughts, it can be difficult for a patient to come forward with an organized understanding of how they are doing on the medication,” Shah said.

Some patients are also reluctant to try medication or stay on it. And if that’s the case, Goldberg said, he often reminds them that the brain is like any other organ in the body.

“When those organs get sick, their functions go awry, we treat them with medicine. When the brain gets sick, it’s the same. What does the brain do? It thinks. It processes information, sensation, motivation, emotion, urges, and those functions can go awry,” Goldberg said.

Medicine can help.

Individualized treatment

Goldberg said he thinks finding the right medicine is less trial and error than “successive efforts to home in on the target.”

As with the game Battleship, a player does not guess blindly, he said; they narrow in on where the ships are.

“Based on my assessment of what the adversary looks like – the adversary being the depression or the psychosis or the panic attacks or the anorexia, or whatever we pick from the 250-some-odd diagnoses that we have – then I try to conform my arsenal to your unique presentation,” Goldberg said.

“Every person has their own individual presentation. Just like my flu is not the same as your flu, my depression is not the same as hers.”

If a patient tells Goldberg that they have memory problems, he has to tease out whether the problem is actually with memory or if they simply can’t focus and encode the information. “There’s a hierarchy of what needs to be treated,” he said.

Two people with major depressive disorders may have completely different psychological, biological or genetic causes. Symptoms can also shift over time, so doctors may use several medicines or dosages.

“This is how life goes. We try to come up with the best fit that will conform,” Goldberg said.

Nearly a third of adults with major depressive disorder fail to respond to at least two antidepressants, and half of people treated for generalized anxiety disorder do not respond to first-line treatments, studies show.

Deciding when to switch medicine varies, Shah said.

“If someone has a truly atrocious side effect or adverse event, they are taken off it immediately. Sometimes we tell people to give it a few weeks, especially if there’s no side effects,” Shah said. “It really depends on what class of drugs we’re talking about.”

A growing number of psychiatrists are trying an even more individualized approach. They may also use brain imaging or pharmacogenetic testing to better match patients to medications.

Pharmacogenetic testing is an emerging field that analyzes how someone’s genes affect their body’s response to certain medicines, including how quickly it absorbs the drug or whether they may have serious side effects.

Done with a cheek swab, blood draw or saliva sample, this testing mainly looks at liver enzymes that affect how the body metabolizes medicines. The test does not tell a doctor whether one medicine or another will be the perfect fit, but it can help with treatment choices if, for example, two medications that might be otherwise considered “equal.” People with certain genetic variants, for example, may struggle to break down some antidepressants, helping doctors choose a better match.

“The idea of bespoke medicine and personalized medicine is great,” Goldberg said. “And we’re getting closer.”

Editor’s note: Help is available if you or someone you know is struggling with suicidal thoughts or mental health matters. In the US, call or text 988 for help. The International Association for Suicide Prevention and Befrienders Worldwide have contact information for crisis centers around the world.

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