A patient I’ll call Schuyler, 31, had been using one antidepressant medication or another for more than four years and wanted to stop. As I mentioned last week, getting off prescription drugs is a fairly common reason people make appointments with us at WholeHealth Chicago.
Schuyler had started her antidepressant after a series of painful events best described as “life.” Her father had died unexpectedly, a longstanding relationship was going nowhere, she hated her job, and she felt increasingly sad about everything. Finally, at a friend’s urging, she made her first appointment with a doctor listed in her insurance plan. During her visit, she talked about her depression and poor sleep. Not surprisingly, she left the office after 20 minutes with prescriptions for an antidepressant and a sleeping pill. She was nervous about using the sleep drug and threw away the pills, but did start taking the antidepressant.
After a few weeks, Schuyler thought she was feeling better and when she returned to the doctor to follow up, he was pleased with the results and advised her to continue taking the antidepressant. And so she did, automatically renewing her prescription for months at a time. The only contacts she ever received from doctor were a suggestion to switch to a generic form of the antidepressant to save money and a Pap smear reminder. Nobody ever suggested counseling night help.
Now, four years later, Schuyler wanted off the antidepressant but had some concerns. She’d read about withdrawal symptoms, yet was fearful her depression might return. She also told me she’d experienced some of the side effects she’d read about, including virtually no sex drive and a persistent 20 extra pounds, mainly tummy fat. Despite healthful eating and regular exercise, the weight wasn’t budging an ounce.
Keep in mind that European doctors think American physicians have always been too quick with antidepressant prescriptions. If they spoke as a group, European doctors would say “Try something conservative first, like counseling and/or St. John’s wort.”
And this week, according to the Journal of the American Medical Association (JAMA), it turns out they were right all along. Despite thousands of controlled studies showing the effectiveness of antidepressants over placebos (dummy pills) to treat depression, virtually none of the studies seriously took into account the severity of the individual patient’s depression. “Mild,” “moderate,” and “severe” were lumped together as “depressed.” Period.
If you see a psychologist or a psychiatrist about symptoms you both would agree constitute depression, you might be given a short test called the Hamilton Depression Score, first published in 1967 and still considered the gold standard to determine the absence or depth of depression. You can take the test here , with mild-to-moderate depression scoring 18 or less; severe, 19 to 22; and very severe, 23 or higher. Experienced therapists who don’t formally give the test are actually completing it for you in their minds as you answer their questions.
In the past, just about everyone with symptoms of depression–even those with a score of 18 or under–was prescribed an antidepressant. But this new study in JAMA showed that until you get into the realm of very severe depression (23 or higher), the effect of an antidepressant for depression (not anxiety, but depression) is actually no better than using a placebo.
Of equal importance: the study showed that of patients who seek treatment for depression and are actually given the Hamilton test, just 30% score 23 or higher.
What this means is that the remaining 70% of patients with non-severe depression who were prescribed an antidepressant and felt better for it were likely having a placebo response, meaning they would have done just as well taking a sugar pill (provided they thought they were taking a real antidepressant).
Perhaps these patients so anticipated they’d get well on the antidepressant that they did (power of the mind) or perhaps they also had some counseling to help them through the rough spots. Or possibly–and this is very common–enough time had elapsed so that what triggered their depression initially had become less traumatic over time.
But the key point: 70% of patients prescribed antidepressants didn’t need them in the first place.
Back to our patient, Schuyler. Since she wasn’t at all depressed when she came to see me, there was no reason to refer her to a psychologist or even consider Hamilton testing. We did review the emotions and psychological symptoms she remembered experiencing during those dark days. We also discussed how the stress of all that likely exceeded her serotonin stress-buffer and how the antidepressant may have helped shore up her stress buffer. Or it may have done nothing and she simply got better. What Schuyler told me actually helped her most was an overall change in her circumstances (new job, expanded circle of friends, new and supportive boyfriend). She simply wasn’t the same person now.
Abruptly stopping virtually any long-term prescription med can produce side effects, so I wrote down a schedule for Schuyler in which she’d be drug-free in one month. I also scheduled an appointment with our nutritional consultant Marla Feingold to help with her work on the unwanted pounds.
Finally, I recommended she read the chapter on depression in my book, The Triple Whammy Cure. Although I believe antidepressants are very valuable for severe depression, in the book I offer a variety of low-tech lifestyle therapies to boost mood. I also discuss the herb St. John’s wort, widely used in Europe for just the diagnosis we’re talking about: mild depression, insufficient to merit an antidepressant with its knapsack of unwanted side effects.
Be well,
David Edelberg, MD