I have been writing in this blog about how anti-depressant drugs—among the most commonly used drugs in the world—are prescribed in general, and how in particular I use them. No psychiatrist has communicated to me a different view, either by commenting directly on the blog or in person —although I know psychiatrists have somewhat different ways of employing these drugs. On the other hand a number of lay persons have disagreed with my opinions. They divide evenly, more or less, between those who think these drugs should be used more generally, even in mild cases of depression, and others who feel these drugs should not be used at all, or only as “a last resort.”

I have been writing this blog now for over a year; and many times readers have disagreed with what I have had to say—about ethical questions, politics, medical treatments, the course of certain illnesses, and so on. I have learned not to argue with them. They hold to their ideas strongly; and it is evident that we talk past each other. Sometimes readers become angry at me. One person said memorably in response to “The Cyclops Child,” that she hoped I went straight to hell, but only after someone smothered me and cut off all my fingers. I think, though, that in the matter of the use of anti-depressant drugs, the importance of understanding them properly demands that I make a further attempt to explain them.

The anti-depressant drugs came into use about the same time the first major tranquilizers were used—in the mid-1950s. Prior to that time mental illness was very destructive to the social fabric of the country. One out of every two hospital beds was occupied by a psychiatric patient. And hospital care was generally awful. (See my blog post “The Way Things Used to Be before Psychoactive Drugs.”) Not uncommonly mid-life depressions led to permanent institutionalization.

When I interned in 1959, the effects of these new drugs were being felt. Electric shock therapy, which had been the only successful treatment for a serious depression, was used somewhat less. In those days, before the use of paralyzing drugs, ECT caused overt convulsions which were likely to cause broken bones. The drugs seemed to work less reliably, but well enough.

I started my psychiatric residency the following year at Albert Einstein College of Medicine, which was considered at the time to have one of the best departments of psychiatry. The senior professors were all psychoanalysts and were still strongly influenced by that tradition. An analytically oriented therapy was tried for all the neurotic conditions, but also for depression and even for schizophrenia. These physicians would have felt embarrassed by using drugs, about which they admitted that they knew little. There were some among them that felt that the anti-depressant  drugs, even though they could be seen to be effective, got in the way of a true understanding of the patient. So, we had to learn about drugs from the more senior residents.

Four or five years later, a friend, Sandy Glassman, who was doing research on these drugs commented to me that it was difficult to establish their effectiveness in controlled studies—even though he believed, as did the majority of psychiatrists, that these drugs worked. Consequently, with this justification, there was an old guard that continued to treat patients in very prestigious institutions without medication. This practice came to an end abruptly still a few years later when a highly-regarded institution was sued successfully for not using drugs.

These medications have been used now for decades. Every clinician, world-round, believes in them. They are not a treatment of “last resort.” There is a price to be paid for putting off effective treatment, in the case of depression, suicide, among other things. I am reminded by this hesitancy to use drugs of a similar practice by German physicians when I served there in the army in 1962. They had to pay out of pocket for the patients’ drugs; so when their patients contracted a strep throat, they waited to see if they would get better without penicillin. And they usually did. Except that a certain number suffered predictably from rheumatic fever and kidney disease as the result of not treating this condition promptly! If an effective treatment is available for any condition, it should be used—barring the possibility of severe side-effects, which are, luckily few, in the case of the anti-depressants.

There are individuals who are afraid of drugs—just as there are some who are afraid of vaccination. They know people personally who have had terrible, it seems, reactions to these agents. This is called “anecdotal evidence” and is notoriously unreliable—although often convincing. A few among these frightened people believe in some sort of conspiracy between doctors and drug companies to make money at the expense of patients. But they too can get depressed and find themselves forced into treatment.

 Others have heard of the effectiveness of these drugs from the experience of friends and come to treatment with the expectation of having them prescribed. Commonly, a psychologist has referred them for this treatment, sometimes having a non-medical opinion about which drugs should be used. Nevertheless, sometimes the patient does not have the kind of depression where treatment with drugs is indicated. More rarely, a psychologist refrains from making a referral to a psychiatrist because he/she feels that intensive psychotherapy can achieve the same result. This is not true. The consequences are sometimes awful. Psychotherapy and drugs do different things. They cannot substitute for each other.

Most patients who come to treatment are inclined to accept the clinician’s advice, but for the reasons mentioned above, some have made up their minds ahead of time whether or not they will take drugs. Let me consider these various possibilities for disagreement:

A patient comes to my office suffering from what I consider to be a major depression. He/she has the “vegetative symptoms” that I have described in other posts, and that are an indication for the anti-depressant drugs. The patient says he/she wants to get better without drugs.  I explain my thinking. Even so, the patient continues to feel the same way. I am inclined, then, to wait a few weeks for that person to see that no improvement is possible—unless I think that patient is suicidal. On the very rare occasions I have not been able to persuade the patient to undertake proper treatment I will either commit the patient to a hospital—when the threat of suicide is overt and immediate—or, if it is more subtle, I will refuse to continue treating the patient. One such patient went back to the referring psychologist and killed himself two weeks later.

It is quite unusual for me to fail to convince a patient that drugs are necessary—in those cases where they are, in fact, necessary.

Often I see a patient who has been on anti-depressants for years without a trial of coming off them. Sometimes I cannot understand why the drugs were started in the first place. Not every depressed person has the sort of condition (an illness) that will respond to drugs. They are often prescribed, anyway, because it is so easy to do. If such a patient wishes to continue on these drugs, even though I think they are unnecessary, I am inclined to go along with him/her—at least for a while. Similarly, if someone is determined to start taking anti-depressants, even though I do not think they are indicated, I am inclined to go along. I explain about the two important side-effects caused by the serotinergic anti-depressants—some individuals gain weight and some suffer difficulty reaching an orgasm. Otherwise, the drugs are usually safe.  If then, they insist, I will give them a trial of the drug—placebo effects are common—and wait until that person can be persuaded instead to undertake psychotherapy.

Rarely,(but it happened this week) if the patient is a pregnant woman, I will not humor her by giving her unneeded drugs that she may have come to treatment expecting to take. There is a small, but real risk to the child. This very young woman is very upset (not clinically depressed). She is upset first by the fact of the pregnancy and then by being torn between me and her obstetrician, whom she has known over a lifetime and who is insisting now that she needs anti-depressants, despite knowing that I think otherwise. He has told her that if she does not take these drugs, she will be more likely to get a post-partum depression. He compounds this falsehood by wanting to give her a sub-clinical dose of a particular drug which would not be enough to help her even if she were depressed. In this singular case, I have told the patient that if she determines to take these drugs, she will have to find another psychiatrist.

In short, if I see a patient who is very afraid of drugs—or very afraid of not taking drugs-- I try not to appear to them as an autocratic and unsympathetic person. If I am right, the truth will become apparent to the patient over a short period of time. (c) Fredric Neuman 2013 Follow Dr. Neuman;s blog at fredricneumanmd.com/blog

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