Other Projects

Only As a Last Resort: Antidepressants in the Treatment of Depression

“First, do no harm”.  This is part of the Hippocratic oath that all doctors take when they begin to practice medicine.  Ignored throughout the centuries, this basic promise is the cornerstone of health care.  Do not make the patient worse.  Do not, for the sake of helping others, harm a patient.  The ends do not justify the means.  If all else were equal, the therapy that harmed the least would be the preferable course of action.  The consequences of “First, do no harm”, are simple to extrapolate.  Why, then, do we treat depressed people with chemicals instead of talk therapy?  Why is our first course of action to risk doing harm to a patient, instead of using the least harmful course of action?  With all things being equal, harmful medications should not be used.  In fact, with the promise of “do no harm”, antidepressants should be used only as a last resort.

Depression is a world-wide problem.  At my workplace, there is not a single woman in the customer service department who has not been diagnosed with depression at some point in her life.  With the ubiquity of this disease, there’s a definite requirement to define what, exactly, depression is.  According to Hirshbein (2007), depression was originally defined as that disease for which the symptoms were decreased by the use of certain drugs called antidepressants.  As circular as the definition is, it is simply this definition which originally classified the depressive symptoms without any paranoia or drug addiction.  In short, depressive symptoms include persistent sadness or apathy which interfere with ordinary life for two weeks or more.  At my place of work, every female customer service employee has been diagnosed with depression.  Every single one is currently taking antidepressants.  They are not fun to be around.

One can argue that these women are better off now than they were when they could not get out of bed, or when some of them were trying to commit suicide.  I would agree that the worst “harm” results in a dead body.  But if there was some treatment which showed the same results as drug therapy, but didn’t include the side-effects of drugs, or the dependence on drugs for these women to live their lives, wouldn’t that therapy be preferable?  Studies show similar results to both Cognitive Behavioral Therapy and drug therapy, and yet still the preference among doctors is to prescribe the drugs.  In fact, even in cases when a first drug didn’t work, Thase et al. (2007) found

Patients who switched treatments were likewise about as likely to benefit from cognitive therapy as those who were switched to sertraline, sustained-release bupropion, or extended-release venlafaxine. In contrast to the augmentation groups, the difference in speed of remission was not statistically significant. The major difference between switching to cognitive therapy and switching to another medication was that participants who received cognitive therapy alone were spared the side effect burden of a second course of pharmacotherapy. (p. 743)

So even after the first course of medication failed, therapy was still as effective as drugs without the side effects. Why would a doctor do harm and risk side effects when a perfectly reasonable alternative exists?

Of course, psychiatrists will say that they cannot risk the health or well-being of their patient while waiting for cognitive behavioral therapy to start working.  The patients could commit suicide while undergoing the therapy, and the psychiatrist would then be guilty of a negligent homicide, or at least a malpractice suit.  Of course, the patient must be treated.  There is no argument with that point.  But where is the evidence that medication is even effective, or that the suicide rate is any higher for Cognitive Behavioral Therapy?  On the contrary, Thase et al. (2007) state: “In controlled studies of acute therapy, less than 50% of patients with major depressive disorder remit during the initial course of antidepressant medication,” Additionally, their data shows no adverse effects of the therapy, but two patients experiencing adverse effects on medication.  Both sets experienced suicide ideation, or the idea/plan to commit suicide (Thase, et al., 2007).  If the risks are the same, and half the patients put on drugs won’t respond, anyway, why would a side-effect-causing chemical be a doctor’s first choice?  Medicine seems to have the protocol backward when it comes to treating depression.

Nor is the risk over when a patient stops taking the medication.  The deleterious effects of what was once called “antidepressant withdrawal” (and is now euphemistically referred to as “Discontinuation syndrome”), prompted a pamphlet by the Criminal Justice system.  Because people coming off of antidepressants are prone to disruptive cognitive effects, law enforcement had to be made aware that the poor patients did not know what they were doing, and were not showing criminal behavior (Spiller & Sawyer, 2007).  Why would any sane doctor (or patient) risk this?  In fact, according to some studies, therapy is actually preferred by patients over drug therapy, but drug therapy is far more prevalent (Thase et al., 2006).

It is clear that if Cognitive Behavioral Therapy is as effective as drug therapy, and if there are fewer side effects with Cognitive Behavioral Therapy, the choice for treatment should lean toward therapy.  Not only do patients prefer therapy, but it is actually less dangerous for them to try therapy before exposing themselves to discontinuation syndrome or horrid side effects.  Doctors, in the course of doing no harm, should only prescribe antidepressant medications as a last resort.

References

Hirshbein, L. D. (2006).  Science, Gender, and the Emergence of Depression in American Psychiatry, 1952-1980 Journal of the History of Medicine. Vol. 61, April (electronic version).

Spiller, H & Sawyer, T. S. (2007). Antidepressant Withdrawal Syndrome and DUI Evaluation. Forensic Examiner, 16(3), 50-54.  Retrieved February 22, 2010, from Criminal Justice Periodicals. (Document ID: 1326496531).

Michael E Thase, Edward S Friedman, Melanie M Biggs, Stephen R Wisniewski, & et al. (2007). Cognitive Therapy Versus Medication in Augmentation and Switch Strategies as Second-Step Treatments: A STAR*D Report. The American Journal of Psychiatry, 164(5), 739-52.  Retrieved February 22, 2010, from Research Library. (Document ID: 1275371561).