THAT’S MY EXPERIENCE. I find antidepressants useful up and down the line. I have never had much truck with the distinctions the field has lived with: major depression, dysthymia, minor depression—and there are others.
For fifteen years, starting in the 1980s, I taught an introductory psychotherapy course for beginning psychiatry residents at Brown. For each meeting, as reading I assigned a case vignette—a description of interactions between a doctor and a patient—excerpted from a textbook on one or another school of therapy. In class, we reasoned back from practice to theory. What can we deduce about the account of mind that informs the treatment?
I fantasize about doing something parallel for my own work—sifting through old charts, rethinking sessions, in hopes of getting outside myself and pinpointing what drives me. When it comes to prescribing, I’m guessing that I’d find that it’s worry.
Severe depression worries me. Patients risk losing their jobs and alienating loved ones. There’s suicide to guard against, and concern about injury to brain, heart, glands, and the rest. I hope to display calm, but I’m in a rush.
Since the days of Ray Osheroff, it’s been malpractice to let overwhelming depression fester. I throw the kitchen sink at it: antidepressants, yes, but also psychotherapy and bright lights, along with less proven remedies like exercise, vitamins, and fish oil. In the acute phase, I may move to multiple medications.
I’m not focused on numbers needed to treat. The patient and I will try this and that until we find a way through. We’ll speak daily. I’ll enroll family members. I may consult with colleagues. I’m reasonably confident that my patient will make progress—confident about prognosis, if we can get through the here and now. There are utterly untreatable depressions—but today, few.
My judgment about what demands assertive treatment does not rely on symptom counts.
I think of a patient, Troy, who sought no care for a bout of depression that led him to questionable decisions in his work life, kicking over the traces, jettisoning stressors. He wanted to be free, free to ruin his career if he chose. In one sense, he was right about delaying treatment: his depression resolved spontaneously. Only then did he consult me, at a friend’s insistence. Over the years, I had run into Troy at public gatherings, and now, in my office, I could see a difference. He had been left with impaired concentration and a reclusive social style. I guessed that the residual state was “physical,” or “brain based.” I insisted on medication. I had noted only the two symptoms, but the picture was concerning. On antidepressants (and the kitchen sink), Troy emerged himself again. He reengaged, apologetically, with colleagues he had alienated.
Experiences such as this one make me mistrust symptom scores and value empathetic assessment. Randomized trials are good at counting. Practicing doctors are good at looking and feeling. Some “mild depression” is severe.
In tough cases, the decision to prescribe is easy. With more indolent depression, I like to give psychotherapy time, and here’s where worry earns its keep. In a treatment that’s seemed routine, I’ll find myself newly uncomfortable, in session or after hours. The mood’s too fixed, the lack of motivation too paralyzing, the self-doubt too corrosive, the obsession too consuming. Like Miss Clavel in Madeline, I wake in the night. Something is not right.
Years after a divorce that threw Olivia into prolonged depression, she allows herself to be coaxed into dating again. The new boyfriend, Lyle, is a less successful, less imaginative colleague in her line of work. Contempt allows her to enter the relationship. Lightly committed, she will not be hurt. The problem is boredom. Olivia considers the timing of a breakup and the means. How can she let Lyle down gently?
Disengagement proves difficult. Lyle displays a depth of attachment that Olivia had not reckoned with. Unexpectedly, she is charmed after all. At the moment of Olivia’s drawing near, Lyle breaks it off abruptly, decisively. He had imagined she would treat him better. He confesses to thoughts of joining someone, a specific someone, who will.
Olivia enters a state of diminishment. The constant feature is rumination about Lyle. How could he encourage her return to openness and then do her harm? In session, she is in tears.
The sequence cries out for psychotherapy, connecting the current abandonment to the prior divorce and, before it, the loss of her mother in Olivia’s childhood. But Olivia scarcely has the resources to participate in conversation. She recycles recriminations against herself.
Olivia does not recall her ambivalence and condescension toward Lyle. In her memory, she was always adoring. She focuses on failures of strategy and execution: If only she had been—something—more open about her feelings, or more controlled. The topics I think need discussing—narcissism, mistrust, the fear of being unlovable—are never in the mix. Instead, Olivia ruminates over her word choice in minutely recollected conversations. She weeps.
Some psychologists would call Olivia’s suffering grief. Others would reference a post-traumatic state. Depression is near enough.
Olivia complains that her friends misremember the course of the relationship. They seem to be pulling back from her, losing sympathy. How disastrous, I think, if she drives them away. Olivia is doing less well at work, too, but the pending social catastrophe—what if she loses her friends’ support?—is what troubles my sleep.
Once in Paris, I met the editor of a book series called Les empêcheurs de penser en rond, “preventives for circular thinking.” That is the effect I seek.
I turn to medication. Ruminative depression is where SSRIs excel. Lately, colleagues have suggested—I am agnostic, but I do not dismiss the claim—that weepiness is a useful marker. Antidepressants interrupt tearful episodes.
On Zoloft, Olivia is bereft but not consumed by loss. She can bear to encounter Lyle’s friends. She can read a book.
Would I prefer that Olivia turn better than well? Some patients do. Olivia’s response is favorable enough: we can talk again.
Often, I refer to antidepressants as cotherapists. They’re the good cop to my bad. Zoloft provides calm, and a new freedom to explore. I gesture toward a difficult possibility: It’s the humiliation that hurts, more than lost love. How could that jerk—so beneath her!—blow her off? Olivia considers. Doubts about Lyle filter back into memory. Friends express relief at Olivia’s restored perspective.
I have no intention of keeping Olivia on medicine. I’m hoping for some months of stability and then a chance to taper. I would love a change in circumstance—the beginnings of a less defensive choice in romance. Perhaps we can come to see the time with Lyle as helpful, a good start in the renewed effort to let men in. The contretemps contains lessons about what relationships require.
As for Olivia’s early progress: Was she moderately depressed? Has she “responded”?
I have no notion. Zoloft eases my worry. I can see a way back for Olivia.
Lots of doctors assess medications this way, and I think rightly so. The formal literature says—in some general sense, without precision about efficacy—that a drug works. In prescribing, we see how, according to our own needs, our needs for our patients.
I’ve harped on the response rate that Lisa Ekselius recorded for patients given antidepressants in primary-care practices: 90 percent of the great majority who follow through with treatment, with good results for 75 percent and more of those who start the drugs. They make dealing with mood disorders vastly easier, through the factors that Per Bech points to: improved mood, self-regard, and competence.
Antidepressants are handy tools. Because they potentiate psychotherapy, depression has become highly treatable. What appears useful is the whole package: medication, psychotherapy, and elaboration in the world.