ASK DR LAURO

Regarding my article last week, which addressed the recent scare concerning the antidepressant Paxil, I received several comments from readers.  Some were very thought provoking and I have chosen two of these to serve as the basis for my article this week. 

Letter #1:

Dr. Lauro:  This is the type of thinking that pushes the ever increasing use of Ritalin and other medications used to control behavior in children and adults when all many (patients) are missing is self-discipline.  John.

 Letter #2:
Dr. Lauro:  I agree with your article regarding the low suicide risk of Paxil used with depression.  But I also think there are other things that contribute to whether a patient should be "afraid" of Paxil.  I am under the impression that Paxil, and other serotonin-type antidepressants, have been tested only for temporary usage, and are to be used along with other treatments, such as counseling.

It seems that these meds are prescribed for long-term usage without a need to get a patient to work toward getting off of them.  I understand the importance of treating depression, but I know these meds are also used long-term by patients for anxiety.  I know there are extreme cases where patients must use these meds their whole life, but it seems to me that if one is not careful, they can become a kind of crutch.  Vicki.

Dr. Lauro responds:

 The use of antidepressant medications, in my opinion, really is not that controversial.  The medications are generally safe, effective, non-addicting, and have very few side effects in most people.  I wish those readers,  who are “up in arms” over my suggesting that antidepressant meds are useful and safe, could listen to so many of my patients for whom these meds have literally been life-savers.  And I am just a family doc; I am not a psychiatrist who, in his practice, would see 10 times the depressed patients I see! 

 In my original article on depression I made a point that I would like to reiterate because both of the above letters tend to address it.  The clinical syndrome of major depression is thought by most experts to be a neurotransmitter imbalance in certain areas of the brain, which control our emotions.  This “chemical imbalance” results in deficiencies in neurotransmitters like serotonin and norepinephrine.  In these patients it is simply not true that they are lacking self-discipline, as the first letter suggests.  Patients who are depressed already carry the stigma that they are somehow “weak” and that they should address their disease not by giving in and taking medication but rather by simply “gutting it out” or by simply developing greater self discipline. 

 I liken this situation to a diabetic who lacks insulin.  Could those patients cause their pancreas to secrete more insulin by developing more self-discipline, by thinking positively, by telling themselves that they don’t really have diabetes?  This is the situation that patients with major depression face every day as the ill-informed public looks down their noses at them for being “weak.”

 By the way, if you want to make a depressed patient sicker and push him to suicide, don’t give him Paxil, just tell him (or subtly imply) that he is just a big baby and that he could control his depression if he really wanted to by developing more self discipline!

 The second letter is very thoughtful.  It makes several good points, which I want to address.  First of all, the treatment of major depression with antidepressant medications should never be “short term”.  The medications can produce a significant rebound depression if only taken for a few weeks or months.  Most psychiatrists I know like to use these meds for 9-12 months and then, if the patient is doing well and consents to stopping the meds, tapering the patient very slowly off of them, watching for rebound depression. 

 Studies that I have seen indicate that even with this slow titration off the antidepressant, many (as much as half) of the patients will not feel as well off the meds and will need to reinitiate them.  This, by the way, is not addiction!  It is simply a return to the pretreatment levels of neurotransmitters, which were low in the first place.  There is no withdrawal syndrome (if you taper the meds slowly over a few weeks), and thus we do not call this a withdrawal or addictive effect.

 Many patients will take their meds for 9-12 months and then be able to discontinue them and never have significant depression again.  Somehow the brain seems to have been able to heal itself and start producing more neurotransmitters on its own.  Why this happens to some patients, but not all, is a mystery.  It is my opinion, and studies seem to support this, that a patient who takes the medications and gets better is more likely to be permanently improved versus those patients who simply try to “tough out” their depression and never get back to feeling well.  This latter group of patients may go on for years with significant depression.

 Do some patients need these medications for life?  Yes, they do, and if you talk to them they will tell you that life is not worth living without them.  These patients are not weak, they are not faithless, they are not wicked, and they are not “big babies”.  They have a true clinical disease.  Thank heavens it responds to medication in most cases.

 Regarding counseling, it is true that patients who take meds and receive counseling have a slightly higher rate of success.  However, the meds are so effective in some patients that the results are almost miraculous and the need for counseling just isn’t necessary.  And besides, many insurance companies unfortunately do not cover ongoing psychotherapy.

 You might find it interesting that studies show that counseling alone, without medication, is not as effective as medication alone for major depression unless the counselor is specifically trained in the discipline known as “cognitive behavioral therapy”, which can be quite effective in treating depression.

 A final thought:  one reader accused me (and all doctors) of simply being puppets of the big pharmaceutical companies and being more interested in lining our pockets by making patients drug dependent for years and years by prescribing these meds while never trying to just get them better.  Let me assure you that I am no longer even practicing medicine (bad back—call me “weak”), I don’t get paid by any pharmaceutical companies (now or in the past), and I (as well as most physicians I know) really care about our patients. Best wishes.  Dr. Lauro.