Advice From the Trenches

Antidepressant Anxiety: One reader wonders if medications are prescribed properly

Dear C and Dr. B,

Twenty-five years ago my marriage crashed and burned, leaving me in a deep state of depression. A therapist put me in contact with a psychiatrist who, after trying a few medications and tweaking dosages, prescribed 50mg a day of Zoloft. My PCP (primary care doctor) continued to prescribe Zoloft over the next two decades with very little inquiry into how effective it was or how it was affecting my general health.

The anti-depressant did help to lessen depressive moods and decrease anxiety during emotional or health crises. But during day-to-day living, it left me emotionally flat, with both less gloom and less joy. Because of this, I’d tried on several occasions to stop taking Zoloft. The advice given by my PCP was little more than “don’t stop abruptly, go slow.” I tried many withdrawal strategies – all were unsuccessful. It was only after reading about the technique of micro-dosing that I almost got myself off Zoloft. But months of COVID isolation left me with extreme anxiety – so, back to the magic blue pills. 

After all this, I believe that 1) doctors are overeager to prescribe anti-depressants rather than suggesting alternative therapies, 2) patients receive little, if any, instruction on their physiological function, dosage and side effects, and 3) there is a lack of useful followup with patients who have been taking these medications for extended periods of time. PCPs are not equipped to offer information, and often the information gleaned online is pure quackery. Thoughts?              

Randall

Dr. B says: If you go by the DSM5 (Diagnostic and Statistical Manual of Mental Disorders), then most people who would meet the criteria for major depression in fact never get diagnosed or treated for Major Depression. Current scientific studies actually show vast under diagnosis and under treatment for depression in the USA.

Our current psychopharmacologic model of treatment for mental illness doesn’t differentiate between a nurse practitioner, PCP or psychiatrist. All are licensed to diagnose and treat depression. As for medical follow-up and education, providers should be giving out this information if they are prescribing medications. I see this as a failure of your specific treatment providers, not the system in general. The current recommendation is that if you have had more than three episodes of major depression then you should stay on the medication that helped you forever, at the dose that keeps you at baseline functioning. This is because if you have had three previous episodes, there is a 90% chance of another. Medical depression “Major Depression” isn’t just sadness; it’s a severe decrease in functionality along with a list of other “symptoms”  that makes the threshold for “the disease,” according to the DSM5. 

Antidepressants decrease emotional stimuli, and they increase your brain’s ability to be flexible. They also seem to decrease toxic empathy, which is related to depression. Medications do not reformat your brain. The moment you stop them, in about 2 weeks your brain will function exactly the same as before – thus often symptoms return as you yourself experienced. It is the current recommendation that counseling should accompany psychiatric medications. Feeling better and being better are not the same thing; medications do not create skills. If skills are not acquired, any feeling better you might have achieved from medication will be temporary. Studies show that if you just take medications alone and acquire no skills to address your life’s issues, then in 10 years your life quality will be worse than before you ever took the medications in the first place. 

C says: Doctors love to trot out these ideal scenarios whereas the prescribed course of medicine is faithfully followed and additional therapy is maintained over time. What they seem to ignore is that this rarely happens with psychiatric meds. Americans tend to use their own judgement when it comes to mood altering drugs, which antidepressants most definitely are. They want the quick fix – if a pill makes people feel better, most of them see no need to work any further at it. We all just want to get back to whatever we were doing before. 

The fact is that more than 50% of antidepressants are prescribed by doctors who aren’t trained in psychiatric medicine and who will NOT follow up. This is most definitely a flaw in the system, because the system allows non-specialized doctors to dispense psychiatric medications. Those studies Dr. B mentioned, which show that taking medications alone will result in a life quality that is worse than before, are the ones that portray the reality of antidepressant use in America today. 

Life IS pretty depressing right now, what with the constant political and racial conflict, economic stress and COVID out of control. What people really need is to learn better coping skills and develop stronger community ties to help deal with life’s problems – but there’s a fortune to be made off of those magic pills that send people immediately back to work to keep earning and consuming. Until the profits drop off, I doubt if any doctor who wants to keep their job will dare point out the unpleasant truth.

To hear Dr. B’s second perspective on this issue, visit drbrilliantcliche.wordpress.com

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