Wednesday, January 6, 2010

Hard Truths

Finally, a position on antidepressants that manages to be both blunt and nuanced. Jonathan Rottenberg, Ph. D. at Psychology Today, discussing recent meta-analyses of antidepressants, conveys the unfortunate news: the primary issue with the treatment of depression is not access, but rather the very limited effectiveness of our treatments.

I've seen many patients who, having been on antidepressants perhaps five or ten years previously, say something like, "But I'm sure newer and better drugs are coming out all the time." At this point I have to resist the temptation to blurt out, "No! They're not!" The menu of options has certain grown bigger as compared to 10 or 15 years ago, but not necessarily better. And then there are those sexual side effects...None of this is a counsel of despair, but in general expectations of antidepressants have been out of control for some time now.

All of this is true as well of medications for anxiety, bipolar disorder, schizophrenia, and substance abuse. Yet the temptation is often to throw the kitchen sink at these disorders when nothing seems to work. Doctors used to be notoriously reluctant to be honest with patients with cancer or some other terminal diagnosis. Even when everything has been tried with a given patient, I think that in psychiatry there may be a similar reluctance to speak what sometimes is the truth: "I don't know that I can help you." The difference is that in psychiatry there is no pathology report or CT scan demonstrating that a patient is in fact beyond help. In psychiatry it is merely...a feeling one gets.


Anonymous said...

The efficacy of psychiatric treatment will always be based on the patient's degree of observable functionality, not on measureable shifts in pathological parameters.

Dr X said...


Huh? Perhaps I don't understand what you're suggesting, but estimates of the efficacy of treatment are based on the practioner's observations and the patient's subjective report of thoughts, feelings and behaviors.

Anonymous said...

Dr X,
Yes, I would partially agree with that. Behaviour is more amenable to change than feelings and thoughts. Therefore a patient’s ability to function within range of what is considered psycho-socially healthful--in spite of persistent negative thoughts and feelings—is a more practicable measure of treatment efficacy. Aren’t chronic psychiatric illnesses more about management and amelioration rather than cure?

Novalis said...

Anon, I originally took you to mean that we shouldn't stray too far from the basic meaning of an illness, i.e. its impairment of a patient's life experience, as opposed to emphasis upon symptoms or rating scales. This raises of course the basic problem of a patient's condition worsening or improving without his being aware of it.

the alienist said...

One of the most frequent things I do in my practice is help patients decide if their symptoms are "normal" or "sick." It is very easy to fall into the fallacy that everything unpleasant is wrong or bad. I find it important to work with my patients to realize that some of the discomfort and distress we experience is actually beneficial and expected in certain situations. Other types of misery are outside of expected reactions to situations or take on a form that suggests psychological or physical pathology.

I wonder what would happen if only the latter group were studied in psychopharmacology research?