Sad

Okay, maybe it won't be about Viagra. The papers I was going to read from have been filed somewhere with the rest of the housemoving stuff and consequently be seen again in this age of the earth.

As an aside - I was at the local Good Samaritans shop looking at the second hand books and I bought myself a shirt, a nice subdued purple one to wear to work, for only two dollars. I was thrilled at this, but when I bought it home Sarah pointed out it was one I myself had donated only a month back.

Anyway - been reading about depression, and thinking about the whys and wherefores of the medications.

A lot of my patients are depressed. This will not surprise a lot of people, but the fact is most people on the methadone programme are not depressed. Some are anxious, some have schizophrenia and the related illnesses, a lot of them have PTSD, but there is a (small) number of opiate injectors who are happier and calmer than most other people I know: people who just really really like the feeling that heroin gives you. They have their problems, of course, but the problems seem to be the normal domestic ones plus a few that revolve around getting and keeping the stuff.

And forget what you've heard about drug users being unmotivated. Most of my patients have levels of motivation that would put anyone in the Fortune 500 to shame. In fact, the parallels don't stop there, but that's a subject for another post.

Anyway - depression. Whenever the topic of depression is brought up, antidepressants get mentioned. Patients either say they are depressed and need antidepressants,

And the more I hear about anti-depressants, the less confident I am about them.

I'm not saying they don't work. I think it's quite likely that they do, I have seen people who are quite profoundly depressed start to get better after taking them. I think they can be a valuable part of the therapy some of the time in some people with some conditions.

But there's a lot going on. See, earlier this year, probably the most important paper on anti-depressants of the last five years came out. The authors used freedom of information laws to get hold of data that is usually inaccessible - data from studies the drug companies perform and then either don't publish or suppress, depending on your level of paranoia. When you look at all the evidence, not just the stuff the manufacturers choose to tell you about, details leap out at you.

Antidepressants do not work any better than placebo for most people - people who are in the initial stages of moderate depression. They work a bit better for severely depressed people. They work better than placebos for people who are very very depressed - but it might even be that that is because placebos don't seem to work on severely depressed people.

Now, for a start, placebos are damn fine medications - they are efficacious and cheap to produce. They are relatively safe, although some quite serious reactions have occured - in one clinicla trial, almost a quarter of the people taking placebos discontinued because they couldn't take the side effects any longer. And I believe there have been cases of dependency. Sooner or later there'll be a string of deaths and the stuff will have to be withdrawn.

Anyway - placebos certainly work well in depression - in most trials, people who get anti-depressants and people who get placebos both tend to improve quite dramatically over a course of therapy. I'm not saying that people don't get better if they are given anti-depressants, I an not saying prescribing them is a bad idea... I am just saying it's clearly a lot more complicated than we thought.

I don't know. Another thing - a lot of things work as well as the antidepressants. Exercise works as well as sertraline/zoloft (he says, typing while the exercise thingy sits unused a few metres away). Plus good exercise gives you back the libido and body that depression and antidepressants took awy. Swimming with dolphins is apparently an efficacious anti-depressant therapy, but few pharmacies stock them. One intervention I found useful for some of my earlier patients was getting a divorce.

And that's the other thing. There are assumptions behind the whole anti-depressant thing that bother me. There seems to be this model in some people's head that says "My patient is depressed - she suffers froma mental illness that distorts her perception, her concentration, her motivation, wrecks her sleep and appettite, profoundly disturbs her emotional state. Depression is caused by abberant concentrations of neurotransmitters in the brain, by chemical errors. We can give medication that will correct these chemical errors. When we do, the depression will resolve, and the person will be happy."

I find it difficult to take this train of thought seriously, let alone believe it. It does not accord with what I see. I could write a book on what is wrong with it, but ofor today, the assumption that the normal state is happy, that most people live lives and believe things that under normal circumstances mean they should be happy - it's like those grotesque, shape-changing half-animal creatures, those ones that scream when you shine a light on them. The ones that had that reign of terror that frightened everyone half to death back in the eighties... what were they called again?

Oh yes, Republicans.

Anyway. Most people's lives, I suspect, are not set up to produce ongoing happiness. Most people. Most good people I know worry about what they have done and what they have failed to do, sins of omission and commission. Most people, I suspect, think of others as being happier and more confident than they are. Most people have more responsibility than power.

I don't know. I don't know that we should even if we could, pathologise or medicate away what I suspect in a fair percent of the depressed people I see are normal emotional states. I don't know that we always do people a service by pathologising sadness, or frustration, or rage. What is are we saying when we say to someone "this is not normal, this is an illness, you are an ill person?" Are sorrow and pain part of wellness and normality? What about ways of coping with this without transforming someone from person to mental illness patient? Where is the borderline between discomfort, distress and disease, and what does it cost us when we cross it?

Anyhow. I do not have answers to these questions. I don't know who has. I don't know if my senior doctors do, or if my patients do - I suspect any answers will be individual, true for one person at one time, not easily transferrable. I don't know who holds the truth here, but the more I read, the less certain I am that it's Pfizer and Glaxo Smith Kline.

Thanks for listening,
John