Today I saw a female patient who has problems with use of multiple recreational drugs and alcohol. I was the first psychiatrist that she has ever seen, she has however for the past two years been taking mirtazapine – an antidepressant – and this is prescribed by her hospital physician. I almost never prescribe medications outside a psychiatric remit, however antidepressants are regularly prescribed by doctors whose area of expertise is not psychiatry. GPs, ITUs and stroke wards often start their patients on these medications, and hospital physicians can also be very fond of them.
The notion that there is a very common disease called ‘depression’ that can be addressed with the use of antidepressants is very prevalent in our society and although psychiatrists are ‘experts’ in it, the general abandon doctors show with antidepressant prescribing would suggest that its treatment is something on which all doctors have purchase and is not just the preserve of shrinks. Yet can this be a good idea? Many doctors’ insight into this area may be no more nuanced than that gleaned from their teaching at medical school, which from my recollection was simplistic and dogmatic. Is low mood such a problem that we cannot but afford to have all doctors tackling the problem, or has the diagnosis gone feral and now needs to be tamed by expert tamers with chairs and whips?
In truth ‘depression’ is a very difficult thing to define and any doctor who says that they can reliably differentiate it from sadness is deluding themselves. Our current best shots at a definition, or at least the one that most people agree on, are the vague aggregation of symptoms offered by DSM-IV and ICD-10. These definitions are so broad however that they stand accused of pathologizing everyday sadness and have in part lead to the ridiculous notion, useful to some, that one in four of our population suffers from a disorder of their mental health.
Standing aside whether widely used criteria are worthy, most doctors – including psychiatrists – pay little heed to operational criteria, and instead simply going to a doctor once or twice and stating that you’re ‘not quite yourself’ is most often sufficient for a prescription of antidepressants, which is a de facto diagnosis of depression. It’s illuminating often to ask people who say that they are ‘depressed’ what meaning they attach to this; the selection of responses I have had range from those equating to mild dysphoria to those expressing unremitting misery. It is also not unusual for a question about someone’s supposed mental distress to be framed in more concrete terms: ‘I’ve got a lot of trouble with my housing’ being an unfortunate favourite. If the first doctor won’t provide you with antidepressants, the second surely will. Doctors we feel they must help and antidepressants allow them to avoid admitting the boundaries of their efficacy.
Thus a patient who entered a consulting room simply sad, and often unfortunate, leaves anointed as ‘depressed’ having now a stigmatizing mental health disorder, and as this is a disease that sits independent from a life narrative, other avenues of relief which might have otherwise been explored are tacitly discouraged. Now take the patient we started with. Anyone standing next to you at a bus stop would tell you that if someone was already taking four psychoactive substances on a daily basis, then addressing these might be the first place to start. This is what I’d have said to them, but in this rights-based society if I think this and a patient thinks differently, who’s right?
You might think then that this is a call for psychiatrists to act as gatekeepers to the prescribing of antidepressants. Actually no, depression and antidepressants are one of the stories of our age, which means that they effect everybody and everyone has a part to play in their sensible use. I’m not going to go so far as to say that there is no such thing as ‘mood disorder’ but in recently years we have all reimagined humans as intensely vulnerable beings, which inevitably means that people will view themselves in this light. As the prominence of religion in European communities fades and market capitalism continues to propagate the excluded, medicine has become the place to turn for suffering of all kinds, social, physical and mental but this is no substitute for a supportive community. They don’t teach us at medical school how to know the limits of our business, so we’ve been simply blundering on. If all doctors can prescribe antidepressants, then all doctors should be part of the conversation about when we’ve gone too far and we should tell people that they’re a lot tougher than they think.
Also published on bmj.com blogs