In November of 2009, I posted an article in the Huffington Post titled, "Psychiatry's Dirty Little Secret." If you read that article you will clearly see that I do not see antidepressant medications as an easy cure all for Major Depression. I noted that antidepressants give good results in only a minority of depressed patients, and that many patients are hardly helped at all by these medications. However, in an article posted in the Huffington Post on January 29th, psychologist and researcher, Irving Kirsch, Ph.D., describes antidepressants as, "The Emperor's New Drugs". He states that, "Depression is not a brain disease, and chemicals don't cure it." He included his belief that "the chemical cure of depression is a myth." Although he did not state it, he clearly implied that antidepressants are a hoax, they don't work, and they shouldn't be prescribed at all.
To his credit, Dr. Kirsch noted that the process by which the FDA approves medications, including antidepressants, is often insufficient if not suspect. He correctly stated the benefits of standard antidepressant medications are often negligible and difficult to separate from mere placebo, and that in many cases treatments other than drugs are effective and spare patients the side effects of these medications. However, what he should have said, and what I believe he was negligent in leaving out, is that severe depression is an extraordinarily complicated condition that is biological, psychological and social in nature, and in some cases medical treatment is necessary and life saving. Indeed, I believe that the misunderstanding that needs to be clarified is not simply that standard antidepressant treatment is often ineffective, but that the psychiatric evaluation and treatment of severe depression should extend far beyond the mere prescription of an antidepressant.
The most important first step in evaluating depressed mood is to determine its severity and if it makes sense in this person's life. Sometimes a patient will come to me with complaints of anxiety and depression, and then reveal that they have just lost their job, had their house foreclosed, and received divorce papers from their spouse. I explain that it is normal to feel despondent under such circumstances! A sympathetic ear and, perhaps, something to ensure a good night's sleep for the next few days may be all this individual needs. Other people are chronically unhappy with their lot in life due to errors in the way they have learned to see themselves and their place in the world. I tend to refer these patients to a Cognitive Behavioral Psychotherapist. Sometimes, there is no obvious "cause" of the emotional discomfort, but if mild or moderate in nature, improvements in diet, reduction of stress, getting some extra exercise, better sleep, and opening up a bit more with a spouse, family and friends can slowly, but surely reverse the unhappiness.
However, as a psychiatrist, I often see patients who have been referred to me because they have not responded to simple measures. Some have already tried fish oil, herbs, exercise, and yoga without significant relief. Some are referred by psychotherapists because they are not getting better. Others have already been prescribed antidepressants that have not worked or may have even been made worse by those medications. These individuals are not merely, "blue". They are tearful and tell me they have no joy in life. They often are unable to sleep, feel tired, but are unable to rest due to anxiety. They have no appetite, or, in some cases, they spend the day shoving food into their mouth to stifle the unbearable sense of emptiness. They feel hopeless, helpless, and terribly guilty. Often they confess that they wish they were dead. Among patients I see in the psychiatric ward of the hospital are some who have already tried to end their lives. Some even hear voices telling them to kill themselves. Severe depression is not a trivial condition.
The first imperative in treating severe depression is a proper diagnosis. Not everyone with depression suffers Major Depressive Disorder (MDD). Some, for example, suffer a form of Bipolar Affective Disorder (BPAD). It is people with BPAD that are most likely to be made worse by antidepressants. These patients need a medicine known as a mood stabilizer, either alone or in addition to an antidepressant. Another imperative is a thorough review and re-evaluation of medication. Although antidepressants do not help everyone, they are repeatedly shown to be of significant value in severe depression. In some cases a different type of antidepressant can turn a non-responder into a responder. Other people with MDD can become responders by augmentation of the antidepressant with a second type of medication.
A third but equally important imperative is to rule out contributing medical factors, such as thyroid disease; hormone imbalances; and deficiencies in folic acid, vitamin B12, or vitamin D. Anemia, inflammatory disorders, autoimmune diseases, gastrointestinal disorders, and other medical conditions can also contribute to severe depression. Finally, it is still necessary to evaluate all the other lifestyle factors, such as the diet, stress reduction, substance abuse, relationship problems, self-destructive and self-sabotaging behaviors that can contribute to and in some cases be the initial trigger of a severe episode of depression. All of the above measures are part of the Bio-psycho-social approach to psychiatric illness that is taught in medical schools.
I agree completely that simply "throwing pills" at patients with depression is deplorable and often useless treatment. I also agree that many people with depression can get better without medication. However, to suggest that antidepressants are worthless, and then go on to suggest that all psychiatry has to offer is an antidepressant is more than false. It deprives a significant number of severely ill people the chance to live without depression. In some cases, it deprives them of life itself.
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