It’s bad, but it’s not that bad

I thought I would start things off with a New York Times piece about the general state of mental health treatment in the United States. The gist of this piece is that the treatment offered is quite poor to say the least, and that is when treatment is accessible at all. I think most people that have any contact with medical professionals, whether as patients or providers, understand that there has been an increasingly pervasive culture of pharmacology. Certainly there are a number of factors that have led to this thinking. Scientific methods have become more advanced (which has fostered an increasing sense of false security about our understanding of the brain), pharmaceutical giants have become more powerful and insurance companies find it more cost effective to authorize a brief visit to a medicating physician than regular visits to a therapist for instance. But consumers are just as complicit; people expect and demand quick fixes. For problems with a medical etiology this can be feasible (e.g., one has an infection, antibiotics are often an effective treatment). For mental health issues, this is rarely the case.

But back to the NYT piece. It goes on to state that pharmacological treatment is often completely ineffective and even the old stalwart of psychotherapy often fails. First, medication. Depression, while certainly a real illness, can often be treated by non-emergent means. Personally I usually advocate for a therapy first method before trying psychotropics. Here, I agree with the NYT piece that most depression will not be treated effectively by anti-depressants unless it is fairly severe. One has to look at consumer expectations again here. In my experience, I have found that many people today are simply unable to tolerate “feeling bad,” even if these feelings are caused by relatively routine stressors. The stressors can certainly seem catastrophic to the person experiencing them (and to casual observers). For example, having a spouse die who was your main support. It is reasonable to expect that this would produce profound feelings of sadness along with ancillary symptoms of sleep and apetite disturbances, impaired concentration, decreased energy and so on. There are reasonable things to expect from a traumatic event. But again, for many people the first reaction is to eradicate this feeling entirely and it usually starts with medication. Now medication can certainly help with some of the aforementioned ancillary symptoms if they are severe enough (inability to sleep for example) but it will not adequately treat the depression. Most consumers are misguided in believing that the anti-depressants will restore their mood to a level prior to some stressor(s) or traumatic event. Not so. Short of some science fiction like invention of completely erasing your memory of the trauma, no drug will be able to treat that. Nor should it.

By that logic, most of us should be taking anti-depressants as we go through life, which is routinely compounded by traumas large and small, stressful events, unforeseen changes, many of which are unpleasant and painful. Is that realistic? Of course not. There needs to be some acceptance, and expectation, that occasionally we will feel depressed and downright terrible as a result of these events. That is the human condition. To expect otherwise is wrong. I’ve seen plenty of people in the ER that have come in almost immediately after some trauma (I use this term loosely; it could mean witnessing a murder, breaking up with your partner, having your beloved dog die) asking for relief. Aside from the fact that anti-depressants take a considerable amount of time to work properly (several weeks is typical), it encourages a way of thinking that completely bypasses one’s natural mechanisms of coping through pain. The answer becomes: “I don’t have to feel this if I take this pill.” Perhaps. But I still argue that it is wrong. Unfortunately, most physicians and psychiatrists are trained to do just that. You have a constellation of symptoms that resemble depression, never mind the etiology, here is a medication that will relieve your pain. Except that it usually does not do that and once again, it completely bypasses a person’s mechanisms for coping with pain on their own.

What we need to focus on instead is providing a means for people to communicate their pain and grief, helping them engage their coping mechanisms and if they lack these mechanisms or have maladaptive ones, equip them with something adaptive. There are very concrete ways to do this (cognitive behavioral therapy for instance).

Now lest one think that I am completely opposed to medication, far from it. There are many instances when depression, in more severe forms, demands anti-depressants. In these cases people will often respond well to such medications. Usually this kind of depression is removed from experiencing any particular traumatic event, stressor or external event.  More often than not however, changes in mood are precipitated by such events. Some of these events are not in our control, but many others are. And that is an important factor to understand. Aside from coping, tolerance and awareness, there must also be acceptance of responsibility. Here is an example. I assessed an adult male who presented for depression and some vague suicidality. As we talked, it became fairly clear that his depression was directly precipitated by his failures in a romantic relationship. He had a girlfriend of several years, broke up with her as he met another woman who ultimately did not reciprocate his feelings and he was left with neither woman. When I saw him he felt guilty, remorseful, sad, and somewhat angry at himself (and to a certain extent the women). Was it reasonable to expect that one would be depressed over this? Yes. Is an anti-depressant needed? No. What is needed is what I mentioned earlier. One needs to learn to navigate through these unpleasant and unwanted feelings and accept that they have been cause by external forces, most of which were caused by the individual in question. If the only course of treatment is to prescribe an anti-depressant, then there is a complete failure. The depression will not remit and the individual will gain nothing from this experience. He will likely continue making the same choices leading to more failures, which will lead to more, or worsening depression.

I will explore some more of these points later on as there are some important points raised by the NYT article. One that comes to mind immediately is our lament about the difficulty of accessing mental health treatment. If most of these treatments are largely ineffective or misguided then we need to look at not just treatment being more accessible but by improving the treatment. Clearly, there is still a very long way to go for either of those two things to happen.

Advertisement