Taking the tablets

I’ve been putting off writing about this topic. Even though I know it is something I really should talk about. I’ve used the excuse of the failure of British Telecom to sort out my intermittent broadband connection, which can be real a problem living alone on an island. But I cannot avoid it any more. So I am going to say what I think about antidepressants.

In the spirit of presenters at the American Psychiatric Association currently taking place in New York, let me begin my presentation with a few disclosures, so that you are fully aware where I am coming from:

I am a psychiatrist.

I don’t practice now, I’ve retired, but throughout my entire professional life I prescribed antidepressants regularly.

 

I have spoken at meetings funded by pharmaceutical companies and they have funded a couple of small research projects for me over the last two decades.

Neither my talks, nor my research have been promotional. I’ve never been involved in any research trial of a medication. At meetings I’ve generally been the acceptable psychosocial meat in the biological sandwich- squashed between presenters talking about the latest research into the biology of depression, much of which I’ve had a great deal of difficulty really understanding, even as an academic.

Last, but not least, I’ve taken antidepressants for most of the last 25 years. I’ve been continuously on them for 20.

My treatment record reads a bit like a history of the pharmacology of depression- and the promotion of antidepressants. Tricyclics (dosulepin), SSRIs (paroxetine and fluoxetine), SNRIs (venlafaxine and duloxetine) and adjunctive therapy (Lithium) with some antipsychotics thrown in.

So those are my disclosures.

What can I say about the rights and wrongs of taking medication?

First of all, just that: It is neither right nor wrong. I number among my friends people who will not take medication, and others who do. I don’t try and impose my view on them. Neither do they try and do that to me. It’s a matter of personal choice. But I hope it’s a fully informed choice when you make it.

Secondly: I dislike a great deal of what is written in the press about medication, because it often diminishes my experience of both having personally benefited from it and of seeing many of my most severely depressed patients do so too. Suggestions I would be harmed by it (which I haven’t been, though I’ve certainly experienced a great many side effects and had to withdraw from Seroxat- so I know about withdrawal symptoms) have proved incorrect. Some of the items in the media of late diminish the whole experience of severe depression by telling me everything can be solved by my going out for a run (radio 4 today) or taking up gardening.

Thirdly: Just because I’ve taken medication it doesn’t mean I haven’t had episodes of depression, but they haven’t been as severe as they were before I went on it. They are certainly not ‘happy pills’. I wear black most of the time and my friends will tell you I am not known to be pathologically over-cheerful. My mood dips, usually in response to how I cope with life events, and when I’m on medication it rights itself a little faster, but at least it bounces back. It used to take a lot longer, and I would get much lower, when I wasn’t.

Fourthly: Even Skeptics will acknowledge there is some evidence for antidepressant medication in severe depression. My approach clinically was always to work through the advantages and disadvantages of particular treatments and add my own opinion. As an expert, my patients expected me to have one. But the choice was theirs. If they were severely depressed, I’d ask that they not completely dismiss medication as an option, but to hold it in reserve for a while. I would do all I could to help them with their preferred option first. But if that didn’t work could we re-evaluate the decision at a later date?

Fifthly: Medication has its risks as well as its benefits. There are no easy options when your mood is very low. Side effects can be awful, and there are situations in which antidepressants should be used with extreme caution. Especially in younger and older people. A combination of venlafaxine and lithium gave me a prolonged Q-T interval in my ECG, which in lay terms means I had a greater than average chance of dropping down dead. I recovered on it, but it had to be stopped.

Sixthly: there is no place for the use of medication alone. Most people get depressed because they have problems, and if they don’t have them before they get down, persistent depression will cause them. It’s difficult living with a person with chronically low mood. Our physical health suffers too. We cannot work.

Talking of one form or another is an essential accompaniment to medication; anything on the broad spectrum from an honest and open conversation with a GP who listens to you and provides continuity of care to a longer term psychological therapy to help deal with some of the issues which increased your vulnerability to depression in the first place. Whatever is most appropriate and needed at the time.

Lastly: If the life events and problems which originally contributed to your depression have not resolved, you may benefit from staying on medication. Not everyone is able to make the changes in their lives that are needed to stay well. I’ve spent my life working in places where people lead very tough lives. There is nothing to be ashamed of in staying on medication, and I’ve argued the point with GPs who wanted to ‘wean’ patients off tablets prematurely. (Weaning is such a demeaning and unwarranted term anyway- it suggests a degree of infantilism).

I don’t know what would have happened if I hadn’t taken medication, but I can tell you things were not looking very positive. There are times when engaging in talking therapy is very difficult. When you feel as though there is a weight pressing down on your chest, making it very hard for you to breathe or carry on. The idea of going out for a run….well….need I say more? It feels impossible to be sure of your next breath. Antidepressants helped me to get to a point where I could use psychotherapy effectively. I’ve been able to keep going, write, research and hopefully help others. So I cannot put off honestly saying what I think and hope you will listen.

That’s all I can ask for.