"My antidepressant isn’t working any more," she said when I met her 6 months ago. And she seemed pretty depressed. She was an attractive thirty something who had a good job, her own home. It didn’t take too long to find out that she’d just ended a live-in relation with a man she initially thought was "Mr. Right" but wasn’t. But there was more. "This is the third time it has happened." When I asked her what broke them up, she said, "He wanted to go clubbing all the time, and I could see he was flirting with other women." She added, "Just like the others…"
She was the youngest of three girls. Her older sisters [and her mother] were beautiful, popular, social. She was skinny, plain, shy, and smart. She never dated in high school, but got a tech school business degree and had a responsible, well-paying job. The person sitting in the room with me was anything but skinny and plain. I guess she anticipated my question because she volunteered, "I guess I was a late bloomer." When I asked her where she met men, she said, "You know – at the clubs." She was the ugly duckling who had turned into something of a swan, and was delighted with the attention she got at the clubs and bars where people meet around here. She was well aware that her childhood had been filled with intense envy of her sister’s social successes, and that she really enjoyed hooking up with the "coolest guys" in the bars as an antidote to her old wound.
Each of her attempts at a long term relationship had started that way, meeting the "coolest guy" in the bar. And each had gone sour when he still wanted to be the "coolest guy" in the bar, and she was filled with her old envy and jealousy. She was pretty smart, and saw where I was going with my questions. So we talked about the self-defeating cycle, and that she might reconsider what kind of person she got hooked up with. I had little doubt that there would be no shortage of applicants. I don’t recall if we changed her antidepressant, but I do remember telling her that I was skeptical that it mattered – something like that.
The second time I saw her three months ago, she didn’t seem at all depressed. She needed a refill, still afraid to stop the medication. "It’s working again," she said. I asked how things were going. As predicted, there was another "Mr. Right." When I asked where she met him, she said blushing, "The club," but she added, "He’s not like that. He’s a good one. I heard what you said." From the sound of the things she said about him, it seemed like she was right about that.
Last week I saw her for the third time. She was fine – still with the same guy. He was fine. They were fine. She said, "Is there anything you can take for your sex drive? I read something about testosterone patches." I felt like an idiot because I hadn’t asked her before about decreased libido [on Celexa 20 mg]. Sure enough, it had started after she began the SSRI. So we agreed that the thing to do was taper her off of the Celexa and she thought that was a fine idea. She hadn’t connected the libido problem with the medication.
I haven’t worked in a clinic since my residency days. So when I first started as a volunteer, I didn’t exactly have the rhythm of how to be there. I was appalled at the medication regimens even here at the edge of the universe, but I found that "stopping meds" often feels to people like you’re trying to take something away from them. So I learned to tread lightly in that arena and wait. With the antidepressants, I realized that most of the clinic patients saw them as "for life." Many had tried to stop at some point, but felt awful and interpreted that as their "depression coming back." Having used these drugs so little in my own practice, I had no idea how common withdrawal syndromes were, and over time, I learned to always taper people and explain the withdrawal. Many don’t need the taper, but they figure that out on their own. I guess I think it’s better to be safe than sorry.
I see a lot of people who have been on most of the SSRIs at one time or another, changed in situations like this ["My antidepressant isn’t working any more"]. That’s how they get on so many meds, or have had their medications changed so many times. They feel bad in spite of taking an "antidepressant" and go to the doctor who adds to it or changes it. I think some of the doctor’s motives are a wish to help, but some of it is for the doctor too – doing something ["Here, try this"], an action. I’m responding to recent comments here  about some of the crazy medication practices one runs into frequently – combinations of medications that make no remote scientific sense. I think the main reason is doctors chasing symptoms with prescription pads.
In Atlanta, there’s a big "natural foods" store in the latter-day-hippie district. We often went there for spices or other hard to locate ingredients. One day I was looking through the Indian spices which were next to the "natural remedies" section. A guy was talking to the lady behind the counter, enumerating symptoms. She had a remedy for everything he brought up. I lingered to see if he would stump her, but he left satisfied with a basket full of potions and herbs. I recall that moment sometimes when I look at all the medications people are on. I don’t know how much herbs help beyond the placebo effect, but I think it’s often safer at that latter-day-hippie district "natural remedies" counter than in some doctor’s offices.
I grew up in such a different world than the one I read about in our journals or hear about from people like Tom Insel in that TEDx talk in the last post. Mine was a Darwinian world, where what we are is the product of countless eons of natural selection. It’s inconceivable to me that some 20+% of us evolved to have bad brain circuits or lousy chemicals. It was a Freudian world, where emotions were signals from the interior – messages selected by the ages for a reason. When I came to psychiatry, I had to learn that wasn’t always the case. There really are some psychiatric Diseases like Melancholia, Mania, Schizophrenia, etc. where the emotions didn’t work right, weren’t signals, but caused a problem all by themselves. But in an everyday clinic world, it would never occur to me to see this young lady as having a mis-wired brain with screwy circuits or a chemical problem. So the modern notion held by so many patients and doctors that the primary problem was the "depression" [noun] that she felt just doesn’t fit the world as I understand it, not for people like her. What patients want is to feel better, and I have no complaint about helping with that if I can. But if I can figure out why someone doesn’t feel good in the first place and we can learn something in the process, I feel more like the doctor I’m supposed to be rather than someone behind the natural remedies counter.
I actually know more about this patient than I put in this vignette. I just can’t exactly recall what she said that let me know it. She wasn’t that much of an ugly duckling as a kid. But her position in the family and her envy of her sisters actually kept her out of the social scene – something of an angry withdrawal because she couldn’t be like them. The even bigger problem was with her mother, who seemed disappointed that she wasn’t a prom queen type like she and her other daughters had been, and she put my patient down a lot. The sparkle she saw in men’s eyes was what she had longed for from her mother and never got. When she saw her boyfriend have any "sparkle" for any other, the old longing bubbled up uncontrollably.
She was quick-minded and just talking about the relationship between her childhood dilemma and her current frustration obviously clicked with her. I had used the line from the country song "looking for love in all the wrong places" and she repeated it the second time I saw her [rural Georgia is "the country" those songs are about]. I have no illusions that the old story won’t replay in her life, but I hope she’s a little more equipped to hear it for what it is next time around. I had two reasons for mentioning her.
The first reason was about how in this over-medicated world, I’ve found that you can’t just talk science to get people’s medicines right or gone altogether. You often have to give them something to put in their place – in this case, a bit of understanding with the return of her libido as value-added [like any reader at this point, I hope for her sake it comes back – not 100% guaranteed].
But my second reason was that she was the last patient of the busy morning, and on the way home I was thinking about the DSM-5 and the things I write about here. What was her diagnosis? I’d say "that patient who still felt like an ugly duckling even when she became something of a swan" – maybe I’d add "who was still looking for that-look-that-says-‘cherished’ that her mother couldn’t or didn’t give her" – maybe I’d say something about "the destructive power of envy." I’m making things up here just to make the simple point that I can’t think of any way to fit her into the DSM framework. Is that Major Depressive Disorder? Minor Major Depressive Disorder? Treatment Resistant Depression? Adjustment Reaction of Adult Life? Normal with Unhappy Features? Where I work is a free clinic for the uninsured, but what if I had to code an insurance form? What would I put? And should psychiatrists even treat such people [neoKraepelinian Tenet #6. the focus of psychiatric physicians should be on the biological aspects of illness]? No answers will be coming from me. I don’t much like the questions.