IT’S NOT THAT my own clinical perspective is rosy. More than once, Freud wondered whether psychoanalysis might be an impossible profession, with unsatisfying results a given. In general-practice psychiatry, we still live with failure.
The sequence I have sketched, restored resilience leading to useful elaboration, occurs often enough. But few patients arrive simply “depressed.” Many have depression in the context of paranoia, alcoholism, narcissism, social phobias, or Asperger’s syndrome. And then the prospect is less sanguine.
If you have trouble reading social signals and communicating your own intentions, then an uptick in optimism may only lead to more rejection and disappointment. Complex patients have complex brains. One way or another—less restored resilience, less successful elaboration—medication is unreliable in patients with multiple diagnoses. Or perhaps the success is only less apparent. A patient’s mood lifts, but impairments remain.
Two conditions related to major depression—psychotic depression and recurrent depression that represents a form of bipolar disorder—are unlikely to respond to antidepressants alone and may worsen in response to them. Those variants cover a lot of territory, which means that we can’t always use these helpful tools or we need to employ them sparingly.
The bipolar subtype can be frustrating. Patients will experience severe depression, and the kernel of manic potential that remains active may make their suicidal impulses dangerous. Antidepressants may provide short-term relief but at the risk of inducing mania, the dyscontrol that encompasses impulsivity, euphoria, irritability, contempt, terror, and disastrous bad judgment. Doctors try to prescribe mood stabilizers first and then introduce antidepressants, but with excruciating depression we do not always have the luxury of time. We may feel impelled to act—and sometimes antidepressants simply make these patients worse.
The result is constant fiddling. I will be raising and lowering drug doses and monitoring responses through frequent phone conversations whose content will extend to advice, exhortation, and frank cheerleading. We’re trying to avoid disaster.
In my time together with patients, face-to-face, I aim to create a quiet space. My intention is to prevent the enterprise from taking on a frenetic air reflective of aspects of the ailment.
These cases occupy a fair amount of any psychiatrist’s mental real estate, which is why we often feel that we’ve exhausted the available therapeutic resources—why we don’t protest the claims that antidepressants are ineffectual.
A tiny fraction of what doctors do finds direct representation in research. I have pointed to problems in candidate-drug trials. They collect an atypical group, needy people with time on their hands and an incentive to exaggerate, along with patients unresponsive to treatment. But even academic studies tend to be selective. They may exclude people with suicidal thoughts, drug-abuse histories, or ongoing depressive episodes that have been too prolonged or too brief. Some of my Brown colleagues interviewed 346 depressed patients in an outpatient practice and determined that, depending on the exclusion criteria, as few as 29 would qualify for entry into an outcome study.
All that the controlled trials with their select patients tell doctors is whether a given antidepressant is a tool suited to our use. It’s practical observation that fills in the details.
It would be easy to create a false impression. Most of the clinical day is calm. I will see people who are pessimistic and reclusive. Here, antidepressants’ shortcomings will be of a different sort. They will have helped by halves, interrupting, say, an acute episode, but leaving depressive personality traits in place. These patients may bear a heavy burden of history—abuse in childhood, recent losses. Psychotherapy looks like a good expedient, but the pace of change will be deliberate, much as it was when I entered psychiatry.
And then some patients need to come off medication. After six years on an SSRI, good years, years of blissful relief from battering by a recurrent mood disorder, a patient develops a condition that may be a late drug side effect. There are many, each uncommon, each worrisome. Patients have sleep disorders, hormonal disorders, blood-element disorders, movement disorders related to parkinsonism. Is the antidepressant to blame? We will not know, but we will taper it and perhaps not start another.
One patient says, “It’s like being forced to move to a country with no electricity. It’s not that humans never lived like that, but in our world, it’s deprivation—no electricity, and it’s not my house that was powered, it’s my mind and body.” The testimony is to efficacy, now lost. We will return to that time-tested remedy, psychotherapy. We will look to bright lights and daily exercise. All the same, the patient will feel deprived. She may suffer what recurrently depressed people do suffer, painful and disabling episodes.
The difficulties of the daily work make the occasional quick, complete, and lasting responses memorable. Antidepressants provide dabs of light in what remains a gray pointillist canvas.