Stephen Ginn on antidepressants: psychiatrists only?
24 Jun, 09 | by BMJ Group
Recently I saw a patient who has problems with use of multiple recreational drugs and alcohol. The patient had never seen a psychiatrist before, but has been taking an antidepressant for the past few years. This is prescribed by a hospital physician. I almost never prescribe medications outside a psychiatric remit, but 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.
Stephen Ginn is a psychiatrist in training working in London. He writes the blog Frontier Psychiatrist.
First of all, thanks for raising this issue. Like most conditions - pneumonia, eczema, tension headaches, epistaxis, there are no straightforward treatment guidelines. There is no universal global consensus of most conditions. That is partly the beauty of medicine that we empirically learn how to treat our fellow humans. I am a avid follower of evidence medicine, but after many years I ”know” that the reality of day-to-day life does not always fit in with the guidelines.
Back to your blog. Although you initially suggest that ”we” -GPs, ITUs and stroke wards and hospital physicians - are somehow like cowboys describing these ”anti-depressants”. Not sure were your evidence is for it. We do a HAD score, as do many hospital doctors. and a limited psychiatric evaluation. True, with increasing pressures of day-to-day life in the 21st century and the decreased social, family and community sense - not to mention decrease of religious involvement, we GP’s are becoming more and more the new priests and pastors for the community. And we don’t give absolution or communion but counseling, relaxation tapes and indeed sometimes anti-depressants.
I suggest you spend some time in my surgery and trying to solve societies problems by saying no to them and then see how tough they - and perhaps you as well are…
Gerard 't Hart
June 28th, 2009 at 6:48 pm
family physicians can treat psychiatric problems in their clinics
Dr.N.P.iswanathan
June 29th, 2009 at 1:21 pm
The anti-psychiatrist claim that there is no such thing as mental illness is a bankrupt and also dangerous one. Syndromes for depression or schizophrenia are (unfortunately) real. Entering a psychiatric ward suddenly throws those deadly syndromes out of the text- book and into frightening actuality. I was sectioned and if I had not met other mentally ill people I might have been more sceptical about the truth of these syndromes and symptoms.
The condition of ‘melancholia’ is an ancient thing, alas across all cultures.
The problem is the drugs that are given for mental illness. Anti- depressants can actually mimic illicit drugs, such as speed or so- called ‘ecstasy’. Prozac was an example of a SSRI that transformed itself from a medical treatment into some sort of unsafe ‘lifestyle’ monster.
Mental illness is probably a spectrum, ranging from the average to the extreme. The difficulty for a GP or consultant is judging where depression has become something that is beyond everyday sadness and turned into a sinister thing.
Zekria Ibrahimi
June 29th, 2009 at 3:59 pm
[...] One guy puts it this way: 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. [...]
The sadness « Nelly And I
July 2nd, 2009 at 12:59 am
As a fellow psychiatrist, I’m disappointed by your article and I would be troubled by it had my expectations of better not been crushed so much by working as a psychiatrist in recent years.
Contrary to what you write, “depression” may been seen as a term with some utility in society to describe symptoms nad signs which can aggregate in greater or lesser number in human beings. Yes a largely phenomenological description without a molecular or pathological basis may be flawed but who ever expected psychiatry to be any different (4 thousand years of philosophy hasn’t gotten any closer to being able to provide an analysis of how qualia result form certain neusological processes). Many of us who have lived with phenomena which can be described in “mental illness” terms (persistent low mood engendering suicidal ideation, anhedonia, psychomotor retardation, ruminative or circular thought patterns), who have such phenomena aggregating in our family history, who have recovered from these phenomena and who can recognise such phenomena in historical accounts going back at least two millenia, find it trajic that qualified psychiatrics haven’t come to terms with the difciculties of false positives in diagnosis. Of course some people will state they’re persistently low in mood when they are not, they may say they feel suicidal just to provoke a response or for another reason but that can’t undermine the fact that for some people these phenomena are part of problem that can respond to medication. As a psychiatrist who has experienced bouts of “depression”, I find it a considerable divergence from the facts that some of the symptoms can be treated without medication. In my mst serious episodes, the healthiest diet, abstaining from work, daily 3-mile joggs, comedy therapy, sunshine, great films, favourite books and the company of beautiful women will not pull me out of my state. It is hugely physilogical for me. My sense of taste changes, my balance, I slow down, I have circular-repeating thoughts of only a few words. Do not be able to distinguish this from what you call regular sadness is bordering on negligent.
For symptoms which by their very nature can be faked I humbly suggest the following rules:
1) What would the person gain by faking illness? Not as easy as it sounds, some fears are only floating on the borders of our consciousness.
2) Does the person look unwell; look for palor, tiredness, anxious face, unkeptness; and are these normal for this person.
3) Does the account “hang together”. “I’m really depressed Doctor, my wife’s annoying em and I can’t sleep”, might be more anger-related difficulties than anything depressive, poor example but the meaning of words and what they point to is crucial.
4) Get a collateral history, what is this person’s best functioning level and when were they last there. Do they enjoy life when well (I certainly do!)
5) Family history, especially any family members spent time in psychiatric institutions and suicides and suicide attempts.
6) Look at the response to antidepessants or ECT, it can be quite dramtic in people with genuine symptoms.
Please don’t give up hope of being able to genuinely treat symptoms with meidcation and compassionate psychotherapy. Yes we’ll get it wrong and have false positives but it’s certainly better ethically than undertreating.
Nick
Nicholas Lalvani
July 2nd, 2009 at 8:54 am
This is what has been happening to many people for years. They seek treatment for anxiety just from a general physician instead of specialised doctors. They would also let you know the duration you have to take these drugs, incase you have an history of health problems, they can guide whether you should take the antidepressant drugs or not.
Leno
July 15th, 2009 at 12:22 pm