Quality of life matters.
This straightforward assertion gets complicated when we discuss the treatment of depression. Depression is common, part of a family doctor’s daily schedule; it can affect anyone, although certain groups are at higher risk. There have been many hypotheses as to why we as a species are susceptible to depression (and its frequent companion, anxiety), but in the day to day practice of medicine, those proposed etiologies end up being less important than the nuts and bolts of management.
Mental illness is often a chronic condition that needs to be managed, rather than a brief episode that can be cured. There is no equivalent of a course of antibiotics for mental illness — the vagaries of the human brain that leave it prone to depression and anxiety are currently best understood as a multi-factorial model, where genetic predisposition interacts with environmental conditions in an endlessly recursive loop to produce symptoms. The most feared and obvious outcome of depression is suicide. Suicide is relatively rare, but treatment for depression is often thought of in terms of suicide prevention, particularly in popular culture.
Treatment for depression should be multi-pronged, with the option to try antidepressants for stabilization and some variation on talk therapy. In practice, patients often lack insurance coverage that would let them try either or both. Whatever type of talk therapy is used, developing a therapeutic relationship with a professional counselor provides strong support for mood. The cognitive distortions and emotional dysregulation of depression are predictable; helping patients recognize these and develop coping skills can give patients tools not only to prevent suicide, but to make their daily life more than just surviving.
Surviving is important, but it isn’t enough. The dirty little secret of antidepressant treatment is that it does not prevent suicide. If all we look at is likelihood of survival, then antidepressants aren’t effective. So why use them?
Because enjoying life is important. Quality of life matters. And with antidepressants, patients are more likely to be able to enjoy life.
Starting patients on antidepressants can be frustrating, both for patients and for doctors. There is no guarantee that a particular drug will work. There is never any guarantee that any drug choice will work. It is not uncommon for patients to try medications, one after another, without any symptom relief. The world remains gray, flat, colorless and pointless; anhedonia strips away the essential elements of a fulfilling and rewarding life. Joy becomes impossible. And when a patient is living through this, starting a new medication that brings side effects (nausea, vomiting, diarrhea, sexual dysfunction) without any relief from depression seems like a cruel joke — you’re depressed, so let’s have you suffer more.
Patients often stop taking a new antidepressant early on, when we expect side effects to be at their worst, with no symptom improvement on the horizon for weeks or months. Remaining on a once-a-day medication that makes you sick, dizzy, and unable to orgasm for six weeks or two months with the hope that it will eventually reduce your symptoms of depression is a lot to ask.
Doctors need to be careful in explaining this timescale to patients, because patients are the ones making their own health decisions. Without the patient’s full and committed participation, these trials will end up as footnotes buried in the medical record, ruling out future trials of a medication that might have worked if given more time.
It’s also important for patients to understand that, while many patients get some relief, more severely depressed patients tend to see more improvement. After all, there’s more room to see the difference there. A patient who is mildly depressed may not find the side effect to benefit ratio worthwhile. Side effects to antidepressants are real, and minimizing patient experiences of them to try to promote their use results in patients who don’t trust their doctors to be honest with them — and who are therefore less likely to give medications full trials in the future.
The social stigma surrounding the use of antidepressants is also a very real force in patients’ lives. A patient who has come to terms with that stigma enough to try one antidepressant may have a different reaction to an augmentation or a change. A patient who staked all their hopes on the first trial, only to have no relief, may be so overwhelmed with disappointment that they don’t want to try a second drug. Physicians can work with patients on these issues, rather than against them, by normalizing their experiences and validating them. It is not necessary to validate a fact in order to validate a feeling. A doctor can say, “I can see that experiencing that symptom was upsetting,” while remaining aware that the symptom described is likely unrelated to the new medication.
Media discussion cyclically invokes the idea that depression is related to life circumstances and society — external factors, in addition to innate, biochemical factors. It is certainly true that we exist in a social context. We live in a world where fear and uncertainty are a part of our everyday lives, where many of us remember where we were on 9/11, where marginalized groups continue to be targets for harassment and violence. The mind is the product of the brain, and the brain changes depending on what we experience and what our genetics allow.
What that means for us is that, unless we plan on founding the first successful utopia in human history, we need tools to help us live meaningful lives in the world we have now. And antidepressants, particularly in conjunction with therapy and with societal change, can help — as long as we treat them and our patients with the appropriate respect, and don’t promise what we can’t deliver. Antidepressants may not keep patients alive, but they can help patients have a higher quality of life, and that’s a worthwhile goal.
Kristin Puhl is a medical student and can be reached on Twitter @kristinpuhl.
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