Treating depression/anxiety or gender dysphoria first?

[Bacon]

Hey again.

I'm really confused about whether I should be trying to treat my depression/anxiety first or my gender dysphoria first. I talk to my therapist about them both, of course, but what I'm referring to is the medication side of things.

Soon I will see a psychiatrist and they will probably prescribe me meds, whether it is antidepressant, mood stabilizer, or anti-anxiety, I'm not sure. But then I wonder, if I started T first, maybe I would no longer have need for those meds? Firstly because I may feel so much happier once I start my transition but also the chemical side of things, T is often referred to as something of an antidepressant itself.

I guess it's hard to determine if my dysphoria is the SOURCE of my other mental problems, or if my other mental problems should be treated first to see if I still have gender dysphoria afterward.

Thoughts? Anyone else have a mental disorder AND gender dysphoria?

[JLT1]

Hi,

There have been a number of individuals here on Susan's who, once they started their transition, no longer needed antidepressants or antipsychotic meds.  You should consult your doctor but I  would do the T first and see where things go.

Jennifer

[WomanLikeAStar]

You should first treat your anxiety .
It is very important that you know where your anxiety comes from.

You can not begin a new life before having cleaned up the mess of your  old life .

Maybe the anxiety wants to tell you something about your intentions to transition ...
Have this treated together with your psychiatrist first .
You both can always decide to delay your transition with a few years if it happens to be a mental matter ...

[sparrow]

I wouldn't think to opine on what order these things should come in.  But, you can do a trial run -- get a single injection of T to see what that does to your mood.  Maybe the D&A evaporate, maybe they stay there.

[Venom]

Hi there Bacon,

I have major depressive disorder and generalised anxiety disorder in addition to gender dysphoria. The mental health professionals I've spoken to all believe that my gender dysphoria is unrelated to my other disorders in terms of one existing as a direct result of the other. However, it is evident even to myself that my depression and anxiety do interact with my gender dysphoria and can make it worse.

I personally began treating my depression first as the therapist I saw for gender dysphoria had a much longer waiting list. Through cognitive behavioural therapy I was diagnosed with generalised anxiety disorder, something I didn't know I had and would blame symptoms of on my depression. I'm not sure how well CBT is working, however I have experienced an improvement with my thought patterns and behaviours. Prior to therapy I would dwell on issues and eventually they would boil over in bouts of anger and irritability.

In the WPATH Standards of Care, it is a recommendation that things like depression and anxiety are being managed prior to, or concurrently with transition. More information on this can be read on Page 24 under point 3. of the Standards of Care version 7, available on their website.

I can't suggest which option will be best for you, however I can share my experience of seeking help with depression (and subsequently anxiety) first as being a positive step for my health overall. I personally do not think I would have gotten as far as I have with transition without having sought assistance for depression prior to pursuing HRT. My prescribing doctor has impressed upon me the importance of staying in therapy for the foreseeable future while I undergo the changes brought on by HRT, this is something I am okay with doing, as therapy is helping me.

Whatever course of action you choose, I wish you the best!

[AnonyMs]

I'd been on low dose HRT for years. it was great for a while but last year I so so depressed I saw a psych about it. He offered me antidepressants multiple times, and I refused them. I didn't want to confuse my gender issues with antidepressant medications - its hard enough without that.

I ended up changing to full transitioning HRT and made a few plans about my life and my depression evaporated. Imagine if I'd started on anti-depressants and the depression went away; what would I have learned from that? Sure I wouldn't be depressed, at least while taking medication, but long term I'd know nothing and have little idea what to do next. That certainty was absolutely critical to me.

Personally unless you're suicidal I'd stay away from any kind of meds part from HRT. If you're trying to stay away from HRT as well and fix it with therapy, I don't think that works long term if you are transgender. I wish it did (I didn't even try).

[SonadoraXVX]

I treated my depression first for about a year with a lgbt friendly therapist intern, he was great. It alleviated my depression for awhile, then sunk in again into my depression, got treated with anti depressants second time around, and also addressed the tg stuff, haven't gone into a spiral again. It helped me graduate with my graduate degree, now pursuing my 2nd graduate degree. Remember, there is always a cause effect, the tricky part is finding the cause, which can be a number of causes, environment and biological. You just have to figure them out, since in my case, nobody figured them, out, it was by trial and error. Your case may be totally different than mine.

YMMV.

[Kylo]

As someone with lifelong (possibly clinical) anxiety and depression who has always wanted rid of it, it makes sense to do two things.

a) Attack the source of the depression and not just try to treat the symptoms. If it's a bad environment or situation, deal with that first. If there's something you could be doing to make the situation causing your issues better, concentrate on that and not stuffing yourself with drugs. In my experience ADs and antipsychotics do nothing other than prevent me sleeping. Previously my bad environment was my ->-bleeped-<-ty home life living with a violent alcoholic parent I could not get a break from. The moment I was free of that and dictating my own life, a portion of anxiety and depression fell away. If you can identify where your depression and anxiety comes from, then take steps and make goals to eliminate it. It will probably involve some significant changes. If you are undergoing transition anyway, a part of your depression will alter if that is indeed where your problems stem from. But it's likely your depression is a many splintered issue, as more than one thing causes me depression and my depression has roots in many causes and effects. Try to identify them.

b) Start working on your own attitude. A lot of depression I see in others and in my younger self was due to a sense of entitlement or this idea that they ought to be 100% happy all of the time (I seriously doubt a 100% happiness is even possible all of the time). I thought everything should be perfect and when it wasn't I got depressed. Down the years I've come to modify my perceptions and behaviors to understand that some things cannot be changed but that I have full agency over some things in my life. And that perfection does not exist. Those things that cannot be changed need to be accepted or compartmentalized, and those things that you can change deserve your full attention and energy. Do not carry the weight of the entire world on your own shoulders. Understand that you are just a single person like billions of others trying to find their way and that sometimes you will be sad and sometimes you will be happier, but that as long as you do what you can to change this situation and better yourself, then you are doing all that can be humanly expected of a person.   

And as a final piece of advice:

c) Start some kind of creative project for yourself. Whether that project is bettering yourself to be the kind of person you want to be, writing a book, learning a skill, becoming an artist.... whatever, find something that can occupy that part of yourself that strives for more. Since I did this nearly ten years ago I fundamentally changed as a person. I stopped feeling like everything was acting upon me and that I was helpless and I started realized how little time human life offers to achieve all the things I want to try, and I started to try them. I started seeing life as a challenge rather than a prison sentence, and needless to say I am not happy all of the time - not at all - but I definitely do not dwell in pits of hopelessness like I once did. I am now pro-active, and logically that has a far greater chance of alleviating your depression through elimination than remaining passive and hoping drugs will take it away.

Don't hope too much that T will solve all your problems - I am sure depression is chemical in part, yes, but also the result of habits and ingrained behaviors and ways of thinking.

[FTMax]

I think it depends what is causing you to be depressed and have anxiety. If they are directly or indirectly being caused by gender dysphoria, then it would make sense to give T a shot first for a few months to see how or if it improves things for you. If they're being caused by things that aren't related to your gender, then other options may be a better fit.

I had terrible social anxiety and depression pre-everything. But they were all related to being seen as female, not feeling at home in my body, and not living the life I knew I could be living if I was brave enough to transition. So it made the most sense for me to get on T and see if that improved my mental state, and it did.

My anxiety is completely gone, though building up the confidence to interact socially is hard. My depression went away entirely for about 8ish months, and is now back. It's kind of related to my gender still but only by association. I've realized that my life now is vastly improved from what it was before, but it doesn't feel like it's mine because it's so similar to the life I had pre-transition. So I'm struggling with overcoming that mental hurdle, and it's incredibly depressing being stuck indefinitely in an in-between state where the end (moving and going to law school) is in sight but currently unattainable (can't start until fall 2017).

Have you gotten to the point of figuring out what is giving you anxiety? What triggers it? That would be a good starting point to assess which direction to go in.

[HeyTrace19]

I lived with moderate to severe bouts of major depression for most (ages 10-40) of my life... untreated, treated with therapy, treated with medication... but it never seemed to leave me alone.  I quit taking meds (and would really only suggest starting psych meds if you absolutely have no other choice) and started Testosterone about 5 years ago.  I no longer have that deep, hopeless, empty pit of depression nagging at me.  Perhaps it will return one day, but for me to be FIVE years depression free is pretty amazing!!!  Good luck with whatever path you choose...

[Aazhie]

TKGW's response is a lot of how I dealt with my own anxiety.  Most of it was related to transitioning, mainly other people's reactions.  I have always been anxious about just about everything but this amped things up more and I had a lot of depression before I saw my therapist.


She said she thought I could handle it with behavioral change rather than medication! Some people are okay not on meds, and some need more stability that medication can provide.  If it is very severe anxiety you may need medication. But if it is moderate you may be able to do stuff like I did.

Here's What I was assigned by my doctor and what I still do when I notice myself spazzing out:

Nap time/quiet time.  If you are insomniac like me, taking fifteen or thirty minutes to chill out and just not focus on anything stressful works a lot of good.  Relax your whole body one piece at a time, breathe deep and hold it, let it out as long as you can.  Another helpful thing is relaxing your tongue.  Between the breathing pattern and tension in your tongue, your body will produce stress hormones in response to tension in your mouth as short, stressed out breaths.  There are nerve patterns that actually let you reduce general anxiety if you do these things frequently.

My first big homework from her was to write down a tally mark on a sheet of paper everytime I start to freak out over something.  This makes you pay attention to the behavior and what might trigger it.  Do this for at least a week or two.  If I am getting more anxious at times, I will do this to remind myself not to get anxious. 

These are also things you can do while on medication, but I found a LOT of my stress levels went way down very quickly after T

[cathyrains]

Depression fundamentally alters your perception.

You need to address depression before you can make important decisions about your health and life. Medication is not always the answer. IMO, based on personal experience, behavioral therapy is the most powerful and effective tool in handling emotional dysregulation.

[veniamviam]

As a depressed and very anxious guy, I'd say to treat the dysphoria first. That being said, I'm fairly confident that my depression and anxiety stem from things other than being trans. (Not that being trans doesn't lend something to my D/A, just that it doesn't stem from there.) If I were treated for my D/A first, I still wouldn't be on T (and I've been on T for close to eight months). Depending on what kind of things are affecting your D/A, it can take a lot longer to treat (especially since mental health medications are a bit of a crapshoot and take a while to be effective). Even with D/A meds, therapy is pretty key, and some things you just aren't ready to talk about for a while. That being said, you can work on both at once, and managing the dysphoria can definitely ease your D/A somewhat. Do what you think is right for you.

[November Fox]

I have no depression (anymore), but I do still have massive anxiety from traumatic experiences in the past, and dysphoria to go with it.

My advice is to treat side-by-side. My anxiety has definitely improved a bit from treating the dysphoria (meaning that I now dress differently, wear a binder, wear a packer). At the same time you might not be able to see things clearly or treat your dysphoria in an efficient way if you're still battling with depression and anxiety.

There's no reason you can't deal with both. I have a "regular" therapist for the traumatic experiences and am scheduled to have gender therapy aside of that.

PD. I asked this same exact question to my therapist, so I think it might be important for you to discuss it with your therapist and psychiatrist as well, discuss your options in this and discuss what might be best for you in terms of medication and hormones.

[DarkWolf_7]

The way I see it is if treating dysphoria could potentially help with both dysphoria and depression/anxiety but it might only help with dysphoria still seems it might be a better option to do first because obviously treating depression/anxiety isn't going to treat dysphoria. But that is just my opinion.

I personally know depression and anxiety tends to run in my family so I know it probably isn't just dysphoria related but I don't know about your situation. But just like being on T, depression/anxiety meds aren't guaranteed to relieve depression/anxiety for everyone, so I would take that in account too.