Patients want a quick fix. Society wants patients to have a quick fix, so that they can quickly return to their usual performance at work and home.
Patients still have shame about seeking help from a psychiatrist or other mental health professional. So they ask help for their depression from their primary care physician. The PCP feels an emotional pressure to provide the quick fix in that 15-minute appointment – the same pressure that he responds to when prescribing antibiotics to a adequately squeaky wheel of a patient with a common cold. If he does talk to the patient about therapy, the patient balks at the cost (in time and effort, if not in price). Even if the patient doesn’t balk, there may be a wait to get the patient in. In the meantime, to help the patient feel some relief, an antidepressant is prescribed. It helps the PCP and the patient that as a group, SSRIs and the antidepressants that followed them are a lot safer than tricyclics.
This is how PCPs as a group came to write the vast majority of prescriptions for antidepressants, and this class of medications ended up in top 4 by U.S. sales. Revelations that negative studies about these medications in the past were not reported or that they may not work a lot better than placebo for those with mild-to-moderate depression, don’t seem to have much impact on sales.
I wish this were not so, that there was less stigma about mental illness, that our society did not demand quick fixes, that PCPs did not find themselves in the position of writing so many scripts for antidepressants, that when they did write such scripts they always did so after ruling out adjustment disorder, bipolar disorder, and mood disorders secondary to medical conditions, medications or substances of abuse, and other differential diagnoses.
Until this comes to pass, PCPs must watch for at least the following clues to determine, post hoc, which patients might be hurt by antidepressants:
- Patient has a dramatic response (my rule of thumb: be very concerned if the patient is 50% better in less than 4 weeks or almost 100% in less than 2 months).
- Patient has either new-onset anxiety, irritability or anger or worsening of existing anxiety, irritability or anger at any time after starting the antidepressant.
- Patient starts to sleep a lot less than what would be expected and does not mind it because he’s not feeling too much tired.
All of the above could be clues of the worst harm (short of the rare actual suicide solely due to an antidepressant) that can come to patients prescribed antidepressants – a hypomanic or manic episode triggered by an antidepressant. Every antidepressant script should be written initially for month at a time and only after the patient has understood the importance of promptly reporting any of the above signs and symptoms.
Patients do this if they are calmly counseled that while some jitteriness is expected early on with antidepressants and we want them to get better quickly, the above picture could be an early sign of worse side-effects to come. A patient with such a response may potentially be prescribed antidepressants again, but only after he has been evaluated thoroughly for bipolar disorder, and only with a lot closer monitoring than the usual patient with depression.
Admittedly, these clues don’t help determine which patients don’t need antidepressants in the first place. That determination requires spending time with the patient and collateral sources to adequately consider a broad enough differential diagnosis. Unfortunately, no short cuts there.
Dheeraj Raina is a psychiatrist who practices at the Depression Clinic of Chicago.
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