Take a Pill: When is an antidepressant the right thing?

Almost everyone that I see at some point or other asks: “Should I be taking something?”

The answer is a complicated one in most cases. Clearly if a person has chronic mental illness, or very long and continuous depression, or equally unmanageable anxiety, then a medication is a good idea.

But most of us are not in this category, and go through periodic periods of low mood, or may find ourselves at a place in our lives where we are so anxious about the pressures that we face that we are truly suffering. So the question arises: “Isn’t there a pill for this?”

I’m not qualified to prescribe medication myself, but I often work in conjunction with psychiatrists, and there are occassions when — typically after a reasonable amount of time talking about what’s going on in the inner life of a client — that I will come to the opinion that they may benefit from taking an SSRI, by which I mean one of those relatively new wonder drugs like Prozac, Zoloft, and Paxil that we all know so much about.

But I always offer these qualifications:

In my experience, some people have never really had the experience of feeling good for a sustained period. They’ve never enjoyed themselves, truly. They can’t have a cup of coffee, or laugh with their family, or take a joke, or find beauty in the song of the birds in the morning. They just have never been there. I find often that for patients like this, a brief period with the help of an antidepressant where they have some relief almost awakens in them the capacity to see the world through fresh eyes. It’s like a real vacation, and you come back afterward and tell yourself, “I’m going to try and enjoy life a bit more.” So in these cases, a period of medication in combination with talk therapy can be enormously transformative. It opens up self-discovery. We’ve all heard people say: “I feel like myself for the first time in my life.” That truly is the glory of Prozac.

But here are the qualifications, and they have been backed up by a recent issue of Consumer Reports. The problem is that these drugs, and the newer drugs like Effexor that also boost levels of norepinephrine, are not the targeted wonder drugs that they appear to be in the ads you see on TV. Really, everyone responds to these drugs in idiosyncratic ways, and so it is very common for patients to go from Prozac, to Paxil, to Effexor, to Wellbutrin (not an SSRI) in an attempt to find the right fit. You just have to put up with this, because there is no telling how you are going to respond.

Then it seems to me that after a period of time —say one year — the effects seems to wear off. I suspect what really happens is that the habits of mind, the underlying anxieties, the life approach and perspective that are the source of the problem, re-assert their hold on our inner lives. So then you up the dose, or switch.

Finally, these drugs have side-effects. The two most common side-effects are weight gain and loss of sexual interest. As Consumer Reports notes in its study, “our findings suggest that they can be a lot more common than what’s reported in the package.” As many as 31 percent of people who take SSRI’s find a drop in sexual interest or ability, according to the magazine. I’d say it’s closer to 50. And 33 percent of the respondents stop taking medications because of the side-effects. For women weight-gain seems more of an issue. Men, of course, need to get and maintain an erection to have sex and you can’t fake that.

So often patients get on the treadmill. They feel terrible, they feel uninterested in life. They take Prozac, they regain an interest in life. They get a boyfriend or girlfriend. They don’t want sex. They go off their medication, and so on.

The upshot is that these drugs have limitations. As Consumer Reports concludes, respondents who engaged in talk therapy for a reasonable amount of time did just as well in dealing with their anxiety or depression s respondents who only took medications. Slightly more successful, is a combination of talk therapy, with limited medication use.

Categories: General
Alistair Highet

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