in Thinking about psychiatry

Antidepressants prescribed by psychiatrists only?

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.

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  1. Antidepressants are definitely seriously over-prescribed. If you’re feeling depressed because of something crap going on in your life, you need talking therapy, not antidepressants. They are supposed to be prescribed only for Major Depressive Disorder. Which, from my own experience, means feeling so low that you’ve been lying in bed for two weeks, constantly thinking about suicide, you can’t concentrate on anything and your life is really severely being interrupted.

    In my opinion, that’s roughly how depressed you need to be, every day, for weeks at a time, for NO good reason, to consider taking antidepressants. If your symptoms are mild to moderate, you probably only need cognitive therapy; preferably combined with a support group, a healthy diet, regular exercise (especially something like Yoga), avoiding alcohol and too much caffiene, perhaps some supplements and vitamins.

    I don’t know if the public view ALL people as incredibly vulnerable. Rather, people mostly expect others to ‘soldier on’ and get on with their normal lives despite personal problems. Our society has become so superficial that personal loss or depression are seen merely as inevtiable sources of hopelessly awkward social situations and those who suffer should be left well alone until they ‘snap out of it’.

    Whether you suffer from a mood disorder or not, it’s important to know that they are genuine medical conditions. Not something you can cure by pretending it’s not there and “soldiering on”.

  2. Unfortunately it is a symptom of the way that hospital medicine is practised that antidepressants are often just added in to the mix of medications after the consultant realises the patient has some poorly defined or investigated emotional issues. Although mirtazapine is an unusual choice – anything other than bog standard SSRIs or tricyclics is usually queried by pharmacy.

  3. the author may or may not be one of the enlightened few, but my psychiatric care is dismissive, invisible and lacklustre, my GP is the only trustable body.

    i’m also on mirtazapine. for dual use, anti-anxiety and as an anti-depressant.

    i’ve never had my issues taken seriously, and have only ever been written off as “emotional” in a hurried manner, treated like crap, told to just go for a walk. the “get up and get on with it” approach fails, i call up because everything is not working, and it’s back to the first sentence…

    the only difficulty, is that my GP is only a gateway back into the same cycle.

    and Sarah, you are utterly wrong… there are people that carry this problem with them with the smiliest of faces, i can assure you! if you don’t look the type to be depressed, you are *forced* to carry on, even when it leads to further breakdown and further depression, which leads to a breakdown in trust between yourself and the CMHT. this happens to a great many people it seems. it should be noted that the “survivor” movement isn’t called the “survivor” movement because of mental health problems alone. quite often it’s called the “survivor” movement because of getting through the psychiatric system itself…

    it’s frustrating that everyone is after a simple concept. and it’s frustrating that the psychiatric system seems to be cherry-picking who it wants to treat and who it doesn’t…. of course, if they understood what the realtime experience was like then none of this would be of issue.

  4. I think you misunderstood what I said. I’m not suggesting that people can’t or don’t carry on with their lives despite suffering from depression. In fact that’s sort of my point. People do it – soldiering on pretending nothing is wrong – because they are expected to.

    But like I said, that doesn’t cure the depression, rather, as you pointed out, it only makes things worse. Prescribing antidepressants can be part of that pattern – too often the doctor writes the prescription, sends you to a ‘counsellor’ who you wait six months to see, and who tells you ‘you need some exercise’ and doesn’t understand the nature of true mood disorders. I’ve been there.

    It’s even worse if you have an eating disorder. The resources are so limited that people are routinely told – “sorry, you’re not sick enough to get any treatment, come back when you’ve lost some more weight.” It’s like telling somebody with cancer “sorry, that tumour’s not big enough yet. we’ll treat it when it’s grown a bit more…”

  5. “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?”

    Both of you but alongside rights is responsibility. If the patient isn’t aware of the impact of multiple recreational drug and alcohol use she possibly needs to be made aware and ’empowered’ to make some choices about dealing with her problems. After two years on mirtazepine and possibly several visits to her GP she must have some awareness of alcohol and drugs upon her mood? She may be using these to alleviate her misery or to blot out the pain but an honest appraisal of her current situation and a commitment to tackle it means having to accept responsibility for reducing and possibly stopping her use of drugs and alcohol. Ideally this would be with appropriate support but that opens up a whole can of worms regarding accessible and appropriate services.
    I do agree that some doctors are only too ready to prescribe antidepressants inappropriately. It’s incredibly frustrating when someone is referred and they have been through a variety of short term antidepressant prescriptions “none of which worked for me”. There is a general tendency to pathologise the human condition and the lack of social and community support, 24/7 media & entertainment, diminution of established religions and a desire for quick fixes often leads to this result. A GP has several minutes and the quickest solution appears to be medication. It will be interesting to see how the use of CBT via the Improving Access to Psychological Therapies (IAPT) pans out and whether this will provide the desired outcomes.

  6. 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.

    This is an important point, and I think it’s the main argument against the over-prescription of antidepressants. Unfortunately it’s a rather subtle one. You often here people claiming that antidepressants shouldn’t be widely prescribed because of “side effects”, but this misses the point because it implies that if an antidepressant with no side effects were invented, it would be appropriate to hand it out like candy! And since SSRIs are, contrary to popular belief, very well tolerated, this is what actually happens.

    The best reason to not prescribe antidepressants is that the patient isn’t depressed. But this is also a reason not to prescribe talking therapies (at least not ones that target depression)…

  7. Over a period of 16 years I walked into a doctors many, many of times ‘feeling “not myself’ or “sad” and left without antidepressants unfortunately for me each time within a few days I would be in the bottom of that mental pit in the darkness warding off suicidal thoughts and going through the day to day motions in a zombie like blur to keep my family and home running. Again, I would start to feel better, decide I’ OK now, and merrily go on my way. Several months later there I would be starting to feel “sad” and “not myself” and knowing I was descending into that deep dark mental pit, make the appointment to see the doctor at which point the cycle would begin where I undervalued the horror of my depressive episodes (combined with thought of drugs with their side effects and the stigma of needing drugs to be normal)and walk o
    Finally I did manage to get to the doctor and slid into the pit as I sat down in the waiting room. through blubbering tears I was finally prescribed the anti-depressants. It was extremely hard for me to keep going with them. It was a good 6 months before I felt like a normal human being, I realized then that even my “good” days were very poor. 12 months later I was weaned off and 9 months after that not a single depressive episode. I’m happy, i mean really happy now, something I’ve not experienced during the growth of my teenage children, since it was Post natal depression that I never managed to shake off (I think).I only wished I had a doctor that prescribed me them earlier when I sought help during my “sad’ and not “myself” stage instead of going through years of floundering in and out of that mental hellish pit.