{"id":725,"date":"2009-06-24T16:48:06","date_gmt":"2009-06-24T15:48:06","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=725"},"modified":"2009-06-24T16:48:06","modified_gmt":"2009-06-24T15:48:06","slug":"stephen-ginn-on-antidepressants-psychiatrists-only","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2009\/06\/24\/stephen-ginn-on-antidepressants-psychiatrists-only\/","title":{"rendered":"Stephen Ginn on antidepressants: psychiatrists only?"},"content":{"rendered":"

Recently I saw\u00a0a\u00a0patient who has problems with use of multiple recreational drugs and alcohol. The patient had never seen a\u00a0psychiatrist before, but\u00a0has\u00a0been taking an antidepressant\u00a0for the past few years.\u00a0This is prescribed by a\u00a0hospital physician. I almost never prescribe medications outside a psychiatric remit, but\u00a0antidepressants 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.<\/p>\n

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\u2019 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?<\/p>\n

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<\/a> and ICD-10<\/a>. These definitions are so broad however that they stand accused <\/a>of pathologizing everyday sadness and have in part lead to the ridiculous notion<\/a>, useful to some, that one in four of our population suffers from a disorder of their mental health.<\/p>\n

Standing aside whether widely used criteria are worthy, most doctors \u2013 including psychiatrists – pay little heed to operational criteria, and instead simply going to a doctor once or twice and stating that you\u2019re “not quite yourself” is most often sufficient for a prescription of antidepressants, which is a de facto diagnosis of depression. It\u2019s 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\u2019s supposed mental distress to be framed in more concrete terms: \u2018I\u2019ve got a lot of trouble with my housing\u2019 being an unfortunate favourite. If the first doctor won\u2019t 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.<\/p>\n

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\u2019d have said to them, but in this rights-based society if I think this and a patient thinks differently, who\u2019s right?<\/p>\n

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\u2019m 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\u2019t teach us at medical school how to know the limits of our business, so we\u2019ve been simply blundering on. If all doctors can prescribe antidepressants, then all doctors should be part of the conversation about when we\u2019ve gone too far and we should tell people that they\u2019re a lot tougher than they think.<\/p>\n

Stephen Ginn<\/strong> is a psychiatrist in training working in London. He writes the blog Frontier Psychiatrist.
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Recently I saw\u00a0a\u00a0patient who has problems with use of multiple recreational drugs and alcohol. The patient had never seen a\u00a0psychiatrist before, but\u00a0has\u00a0been taking an antidepressant\u00a0for the past few years.\u00a0This is […]<\/p>\n

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