When I entered my clinical practice in the early 1990s, I was at the cusp of the introduction of the first blockbuster anti-depressant. I was very curious about Prozac. I let myself be wined and dined by the drug reps; they were so eager, young, and enthusiastic about their new product. I read Peter Kramer’s Listening to Prozac. I received multiple free samples of drugs to give my patients. I became intrigued. I asked each patient, regardless of the presenting complaint, how their mood was: “So, how are you really feeling?” I discovered that almost everyone had just experienced a spate of bad days. When I asked those who had chronic health care problems – they all said they were depressed most the time.
I explained enthusiastically how there was finally a solution in the new generation of antidepressants which had just come out. These were improved in scope and side effect profile. Where once anti-depressants like Imipramine and Amitriptyline created tremendous weight gain, dry mouth, urinary retention, agitation and mental fogginess, the new meds hardly did. And their promised effects! Who wouldn’t want to take a medication that would make you feel good, social, interested and well, not depressed anymore? I signed people up and had a practice full of people taking the new wonder pills. These were exciting early days as each person who took them came back feeling decidedly better than they did the week before.
Months later, the same patients were coming, but some with a distressing refrain, “These pills, they were working great, but not anymore. What now?” I wondered if we should increase the dose or switch to another drug. A few people worriedly told me that whenever they forgot their meds, they experienced the weird ‘zaps’ to the head. I waved away their concerns, telling them that these antidepressants caused no withdrawal symptoms. I clarified this over the drug lunches that I continued to go to. I told patients that all the bad press we were starting to read about ie restless legs, agitation, even suicidality – that was due to a Scientology campaign to turn people away from psychiatry and psychiatric medication. All was good, I assured each person, I would find another pill, since new medications appeared on the market year after year: Luvox, Zoloft, Paxil. But clearly, the honeymoon was over. I was less sure of what to expect as people came back to report to me week by week.
Two years later, I found that my happy people were no longer happy. By now, most had tried the four or five medications available by then, and some were even on a few meds at once, and at doses higher than we initially thought was acceptable. A new term was becoming commonplace: the psychiatric cocktail. I learned about patients whom we physicians called “non responders” who needed special “tweaking” of their cocktails, and we referred these patients to psychiatrists. Psychiatrists no longer took on patients for therapy but were interested in managing these complicated concoctions. By now, they were experimenting with off label use of drugs that had nothing to do with mood, other than by hearsay: People who had epilepsy never got depressed, so anti-epileptic medication could be used to augment the failing anti-depressants.
By now, I had read the research on antidepressant withdrawal: The medical world finally acknowledged this phenomenon calling it the “discontinuation syndrome”. Sure enough: Whenever someone tried to get off these meds, esp. at the higher doses, the nausea, dizziness, zaps in the head, the rebound anxiety, depression and insomnia had them reaching for their medication docket. The meds did not seem to make people feel better (after the initial six months) but at least they were not feeling as awful as they were when trying to get off them. And getting off them was a going concern for some people: Over the years, a high percentage of patients had gained weight, found themselves lethargic, emotionally flat, no longer were as motivated as they had been in the past to get things done. Sexual interest waned. People tended to isolate.
Were these meds just as problematic as the first generation of meds after all? Rather than anticipate good news each time I saw a person in follow up, I began to dread hearing more disheartening stories of side effects and disillusionment and outright fear.
A few years ago, patients started to trickle in with new diagnoses, exclaiming that it was discovered that they were not depressed after all, but rather were bipolar 11 or Adult Attention Deficit. That was why the meds were not working. The alternative newer medications seemed to be working as well as the first batch or even better. By now cautious, I read about the side effects of these meds, and found that they distorted lipid profiles that made people more at risk for heart disease and diabetes. Thinking ahead about the aftermath of the honeymoon period for these meds, I winched whenever a patient asked to be started on a trial of the new medications. Was this just going to be a replay of excitement and disappointment of the antidepressant saga?
Patients were not interested in my warnings. They were coming to see me for hope, with the general expectation that we all have the right and the means to be happy. Peter Kramer in Listening to Prozac said it well: Why not have a world of cosmetic pharmacology? Where you can manufacture medication in order to feel good all the time? Over the years of prescribing these drugs, I have seen unrealistic expectations develop that we should always feel emotionally stable, and if we are not feeling even keeled most of the time, we should be diagnosed as “clinically” depressed or anxious.
This is a very troubling expectation to have in the addiction field, where mood is characteristically unstable, esp. in new recovery. People are now being diagnosed with conditions that force doctors to prescribe these meds, even if they prefer to wait out the post acute recovery. In the last 10 years, it has become “bad medicine” to NOT treat with medication. The wisdom of Dr. David’s Healy’s statement: “A good doctor is one who knows when NOT to treat” is now considered old fashioned and suspect to professional censure. It is instead considered good medicine to treat “preventatively”, even if the person is not depressed or anxious. Best to give meds, just in case the person may get depressed, with blatant disregard to the side effects or long term affects that most people experience. Now, I often prescribe medication, feeling slightly sick at the hype, the false promise, the professional obligation to be part of this larger social phenomenon that I no longer feel enthusiastic about.
Perhaps what is most heartbreaking to me is seeing people in new recovery on meds attribute the sweet feeling of sobriety to their medication. Almost every one I see who gets clean feels better. It is the rare few who are not on meds who know that their good feeling is simply because of their sobriety. Many of these people attribute their success to their recovery program and to their higher power – the power of their faith. But the majority who are on medications alternatively take their daily meds each morning, grateful that a medication has made them feel good. Their program and need for a higher power seems secondary to the morning ritual of taking their pills. It seems to me that the meds have become their higher power.
When I started medicine in the 1990s, medications were meant to be temporary bridges until the person got past their rough patches. Now, the climate is such that we encourage people to be on them for life, indeed to encourage people to take medication to prevent the anticipated rough patches of the future. The higher power that we used to call upon for those moments of despair and anguish – that every one of us feels – is often rejected for the quick solution of taking medication. In our secular society, a focus on a higher power has been relegated to the few who are willing to stand out, seen as slightly odd, somewhat suspect. We have medicalized our spiritual needs, diagnosing them as pathological and we treat these human longings now with medications. Unfortunately, while medications do work in the short term, like any other external solution, they do not have the lasting staying power that community, service and a sense of meaningfulness (aka higher power) provides.