“This is Us” has never shied away from talking about challenging topics, and has a particular slant towards showcasing the stories of characters struggling with their mental health. As viewers, we have witnessed Jack’s and then Kevin’s struggles of alcoholism. We learned about Binge Eating Disorder and group therapy through Toby and Kate. And we saw just how scary panic disorder can truly be for someone through Randall.
This season is no different. We are beginning to see the effects of war on the psyche by watching Jack’s experiences in Vietnam. And we are seeing the consequences of Toby’s decision to come off of antidepressants to help with his fertility.
As a psychiatrist, I watched each of these storylines intently, always thinking to myself, “What will my patients learn from this”? Toby’s case made me particularly nervous, as I worried patients would get the wrong idea about medication, the decision to come off medication, and the aftermath of doing so. To help people understand these ideas — and depression and mental health in general – more clearly, I’ve clarified them here.
Don’t make medication decisions without your doctor.
On the show, Toby goes off of his antidepressants because he’s worried they’re affecting his sperm count. This is possible, but the evidence is mixed and you should talk with your doctor about your case before making any decisions. We know that many fathers are on SSRIs (selective serotonin reuptake inhibitors, or one type of antidepressant), and one study found that 13.6 per 1000 fathers took SSRIs in the 6 months before conception, but we also know that most do not experience fertility difficulties. We also know from a few animal studies and a couple case reports that SSRIs can lead to decreased sperm concentration and motility. Yet this evidence is by no means “strong” or what we would call “good evidence” (a placebo-controlled study, for example).
It really comes down to weighing the risks and benefits of coming off the medication and knowing the likelihood that it is your sperm count or motility leading to your fertility difficulties. In other words, if you are having trouble producing sperm, or getting your wife pregnant (and she has no known abnormalities, for example), going off of your medication for a few months may be worthwhile if the benefits (getting her pregnant) would outweigh potential risks (mainly, you becoming depressed again). The good news is, in the case reports, sperm counts returned to normal after the patients stopped the medications for as little as one month. This decision could be worth discussing with your prescribing doctor and should not be done without guidance.
For other people, however, going off medication is not an option. This might be because you have had serious depression or suicidality and cannot go through either again for your health and safety. Remember, conception could still take months or even years, so it is not necessarily a quick time off of medication and then back on again. For people in these situations, where the risks to you are too high to go off of your medication, you might consider switching medications if you can or even trying to decrease your dose (all in concert with your physician). If neither is an option, again, the likelihood that your SSRI is the problem is a small one. You just have to decide what makes sense for you.
Though Toby does not discuss stopping his medication with Kate or his psychiatrist ahead of time, the after-effects of his decision show that he realized the error of his ways. All dose changes should be done with the help of your provider, as they know the medications and can help you accurately weigh the risks and benefits of a dose change. They can also tell you more about what to expect coming off of a medication – or restarting a medication – and what some of the warning signs to look out for symptomatically would be. Dose increases, decreases, and concerns about side effects are all things that are part of our role as psychiatrists. We much prefer being partners in decision-making, instead of learning about (and helping fix/treat!) problems after the fact.
Going off of medication is possible – as long as you do so safely.
On “This Is Us,” we see Toby reading the list of symptoms of antidepressant withdrawal online and then, quickly after he has flushed away his medication, we see him becoming more irritable and more depressed. Watching this, you might think that once you start medication, you can never get off. You might also think trying to come off is not only dangerous, but it will lead to immediate relapse in symptoms.
This assumption is untrue and misses a key point of Toby’s history: that he has had depression for a long time (one scene implies he’s had it since childhood). For someone like Toby, with recurrent episodes of depression, as a provider I would probably not recommend he come off medication. This is due to his high likelihood of relapse. For someone like Toby, medication is life-saving and becomes preventative. It functions to “prevent recurrence” and stabilize his symptoms. For someone with a different history than Toby, who may have never been depressed before and is experiencing their first episode of depression, or perhaps has never had suicidality or severe depression before, that person may very well be able to (with the help of a doctor) come off medication and never need it again.
Experiencing symptoms of withdrawal coming off of medication, however, is actually quite common. Patients titrating off SSRIs can experience something called serotonin discontinuation syndrome – flu-like symptoms, insomnia, nausea, sensory disturbances, and hyperarousal. It is more common the longer you are on a medication, and the higher the dose — likely making Toby a high-risk patient for it. Studies suggest that the numbers of people experiencing this “syndrome” is much higher than previously recorded. Though it might be uncomfortable for a patient, it is often mild, always treatable, and usually preventable with the help of a provider to come off your medication slowly.
As a provider, antidepressant withdrawal as a central storyline of a popular TV show makes me nervous. This is not because withdrawal symptoms don’t exist, or shouldn’t be discussed, but is instead due to my worry that by focusing on the “dangers” of medication, patients could be scared away from medications entirely. A viewer might be so focused on Toby’s withdrawal that they could miss the entire storyline about how he relies on antidepressants to function in his day-to-day life. Fear tends to take over. By showcasing Toby’s inability to stop them, “This Is Us” might also make patients concerned they can become “dependent” on antidepressants.
If this is a concern of yours, please don’t let it stop you from at least having a conversation with a doctor about medication. You never know if it could be the thing that saves your life.
Depression can be a very serious health concern.
In the show, as Toby restarts his medication, he slips back into a depressive episode. He is not getting out of bed, not showering, and not helping Kate with the dog. At one point he even tries to get dressed and shave and still feels (and tells Kate that he feels) he isn’t ready to be doing anything. Kate, however, asks him to go on a walk with her and the dog, and he agrees.
These symptoms are typical of someone experiencing depression. We look for someone who has depressed mood (check!) with or without anhedonia, which is a loss of interest in activities they once enjoyed (in Toby’s case walking the dog! Check!). That person can then have some combination of other symptoms including change in sleep (increase or decreased, it was increased for Toby), guilt (which Toby experiences for not helping Kate), low energy (also check!), poor concentration, appetite change (increased or decreased), slowing of your muscles, and/or suicidality. These symptoms have to last at least two weeks to be considered a depressive episode and even though time moves in different paces in “This is Us,” we can assume his symptoms lasted at least two weeks. Although I have never examined Toby and obviously can’t officially diagnose him, he is exhibiting most classic signs of a major depressive episode.
If you notice these themes in one of your friends, you might see that they are isolating or becoming unmotivated to do things. This behavior is congruent with their disease. Though sometimes going on a walk may be a good suggestion for someone with depression, just like with Toby and Kate, it may take time for them to agree. I often suggest what clinicians call “behavioral activation” to help treat depression — walking, showering, or going to see a friend would all fit into this kind of treatment.
Depression can directly affect your relationship.
In the show, we see Toby yell at Rebecca when he is more irritable in defense of Kate. We also see Kate struggling to know what to do to support and care for Toby. All of these scenarios, and more, are possible, as depression is a disease that is affected by social systems and affects them in return.
Often people are not themselves when they are depressed. I tell patients that they view the world through depression glasses and filter everything out that does not confirm their depression. Or, they can distort events that occur to better fit their depressive view (e.g. becoming convinced that “you didn’t invite me to hang out because you hate me, not because you are busy”). As a family member or partner, it can feel hard to know what to do or say.
You are by no means alone in those feelings. It can be very hard to be a family member of someone with mental illness, and that should never be discounted. If you are ever struggling to know what to do or say to a person with depression, you can always look for resources on the NAMI website or go to a local chapter event. You might also consider going to your own therapist, a family therapist, and/or a couple’s therapist. Any and all of these options are often necessary steps for healing and change, and are a sign of strength, not weakness or failure.
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