a lot better than that…

Posted on Saturday 16 March 2013

"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 [1][2][3] 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.

When I was a young Internist, I didn’t know how to deal with the kind of symptoms this patient brought to the table, and a surprising number of patients had them. I might have gotten to the recent break-up with a boyfriend. But beyond that, I would’ve been clueless. Back then, I’d never thought about envy in my life, or really even considered the continuity of the past and present. I would’ve rolled my eyes at a phrase like "that-look-that-says-‘cherished’." I was a scientist. In the ensuing forty years, some good teachers taught me how to listen and lots and lots of patients taught me what to hear. My real worry as an old man is that there’s not much listening/hearing going on these days. I personally think a lot of the inappropriate labeling and medicating that goes on is simply because neither doctors nor patients quite know how to do the right thing and end up "prescribing something" or "taking something" out of a combination of hope and frustration. We can do a lot better than that…
    March 16, 2013 | 3:17 PM

    An anti-depressant for being bummed out because you keep making the same errors while being “childish” (being in a regressed state with childhood’s feelings (that we all experience from time to time)) is at best, irrelevant.

    “The Right Guy” is also a construction doomed to failure— not too much removed from “Prince Charming” (who will come and take her away from all that is squalid and mean in her world). Relationships are about relating, not choosing an object as if it were a commodity or an appliance.

    March 16, 2013 | 3:48 PM

    Treatment Resistant Depression, or, personality issues that can’t be medicated.

    Can’t Medicate Life, true?

    March 16, 2013 | 5:23 PM

    fyi – post on neurosceptic


    When Does Depression Become A Disease?
    By Neuroskeptic | March 15, 2013 9:30 am

    When does sadness cease to be a normal emotional response, and become a mental disorder? Can psychiatrists ‘draw the line’ between healthy and sick moods, and if so, where?

    An important new study offers an answer: When does depression become a disorder? Using recurrence rates to evaluate the validity of proposed changes in major depression diagnostic thresholds (free pdf).

    When does depression become a disorder? Using
    recurrence rates to evaluate the validity of proposed
    changes in major depression diagnostic thresholds

    (World Psychiatry 2013;12:44–52)

    March 16, 2013 | 5:59 PM

    Actually, in this story, she was the commodity. One can rarely convey such things in a vignette like mine, but I think her use of “Mr. Right” was closer to what you might mean. What she had gotten was a series of bees drawn to honey. It felt good but went nowhere, and actually wasn’t what she wanted either. And I obviously agree with your point about meds for “bummed out.” My point is that when people show up on them, getting them off is no small task. And I rarely see a medication virgin any more.

    I voted for number two.

    I saw that article. It makes sense. But I think that about anything that puts the Major back in Major Depressive Disorder. In practice in the real world, that category is about as precise as saying “bad tummy ache” or “real unhappy.”

    I’m an old therapy type who would still look at recurrences to see if I could find something in the person’s life/personality that just keeps coming up. In this case, the clue was “just like the others.” Either all men are jerks or there was something about her way of choosing that was amiss.

    March 16, 2013 | 6:23 PM

    Along with the supposition that any amount of unhappiness is certifiable, is the belief that no amount of stress, trauma, and horror can drive a person temporarily over the edge and into the abyss. When a person is being driven to madness by real and consequential stressors, and the mental health community declares all that pain meaningless and irrelevant— insists that there’s just something wrong with the brain of someone who is suffering more than they can humanly handle— then they are very nearly saying that life is meaningless. It’s as if they are saying that a good human is an automaton or a sociopath that can be subject to anything; then function well, smile, and satisfy the managers, customers, professors, the staff in the lock-down ward—whoever is above them in the pecking order—even if those above them in the pecking order can’t be satisfied, even if those above them have a pathological disregard for their impact on those below them or can only be satisfied when they make others feel pain, insecurity and fear.

    It appears sometimes that what has risen to the top and shaped bio-psychiatry is a pathological distaste for people who won’t or can’t toe whatever line is thrown at them. It seems to be ruled by shallow minded conformists.

    March 16, 2013 | 6:58 PM

    Dr. Mickey, for the woman you describe, let us not forget the role her iatrogenic sexual dysfunction might have played in her self-image and her relationships.

    March 17, 2013 | 1:41 PM

    This man had an immediate severe adverse reaction to one dose of Lexapro http://www.youtube.com/watch?v=3_4gLZrqlik

    He immediately quit the drug, but has had to deal with symptoms identical to withdrawal syndrome (autonomic dysregulation) — including strokes — ever since.

    We have several such individuals, who most likely are genetically predisposed to hypersensitivity to serotonergics, as members on SurvivingAntidepressants.org

    There is a group in Auckland of 12 such individuals. How rare is this supposedly rare reaction, really?

    March 17, 2013 | 1:51 PM

    For those who doubt the necessity of tapering off antidepressants, see how bad antidepressant withdrawal syndrome can be by looking at some of the YouTube videos associated with antidepressant withdrawal, some of them in the right column next to the young man’s video above.

    March 18, 2013 | 10:12 AM

    Just to comment on the willingness of non-psychiatrists to dispense antidepressants I offer this brief story. Several years ago, hubby was looking for a new endocrinologists to (primarily) aid in his treatment of diabetes (56 years Type 1). Because all of the lab work had not been completed at the time of initial exam/interview, this Georgia endo would NOT write a prescription for syringes or bG testing supplies. But, as hubby was leaving the office, the doctor grabbed up a couple of sample boxes of Lexapro and encouraged hubby to try this. It was a mood elevator (and our only take-away, since no psych or emotional problems had been mentioned) was that this “freebie” was like a lollipop; after all, living with T1 diabetes for 56 years was certain to have had SOME kind of effect on hubby’s mental state! [Needless to say, husband resumed his search for a new/better endo.]

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