Her breast cancer diagnosis came out of the blue, just as she was preparing to start a new job. Fortunately, it was surgically removed and she is done with radiation.
“Doctor, she has gone all quiet,” reveals her mother.
At this, the patient bursts into tears. Her red eyes and helpless expression send a surge of sympathy through me. Although the physical effects have been mercifully small there is no doubt that the diagnosis has taken its toll on her.
“The cancer is gone. Why would she feel like that now?” her mother puzzles.
“It’s very common for the trauma to sink in after treatment finishes,” I reply reassuringly, turning towards my patient.
I suggest seeing a psychologist whose short-term help is likely all she needs to recalibrate her emotions. I mention community support groups and I hint at the therapeutic benefit of time. She nods along politely but her face is a sea of desolation.
“Doctor,” her mother hesitates, “is there, like, a pill for that? You know, to make her depression go away.”
The patient looks crestfallen and I feel a little responsible for seeing her through her despair. To talk to her will require many more appointments and her own initiative, which seems low, but signing a prescription for an antidepressant would take merely the flourish of my pen, and constitute decisive action. You could say that in this moment, the promise of a solution provides a glimmer of hope for the patient and therefore, a temptation for the doctor.
The co-founder of the Cochrane Collaboration and a medical researcher, Professor Peter Gotzsche, is in Australia to speak about the dangers of antidepressants. I imagine he would groan at the story above, while warning the unsuspecting public that antidepressants are associated with real harm including death. He says that the risk/benefit ratio is firmly skewed towards the risk.
The impulse to prescribe a drug or an intervention without necessarily expecting a sizeable patient outcome is an all-too familiar one for every clinician. Antibiotics are a prime example. CT scans for the lower back are another. So are a variety of blood tests, cardiac investigations, some forms of surgery, and yes, even chemotherapy. Some would call this doing deliberate harm but I actually think it’s more nuanced. Despite the rhetoric, most doctors are driven by the desire to treat their patients well and remove suffering. The science of medicine has moved a long way forward but the evidence base remains thin for many common conditions, so any data has to be interpreted in the best interest of the individual. The best doctors are those who balance published data with clinical acumen, combining gut instinct with good communication. In other words, they use head and heart.
If the modern doctor is spoilt for choice when prescribing, the modern patient delights in the offerings. These days, patients scour the web, print reams of advice and cut out reports of miracle cures before their first appointment. If their needs aren’t met the way they want, they can also become abusive, file complaints, and easily walk over to the next practice. This is not a justification for pandering to unreasonable demands but we can’t deny that it plays a part in how doctors behave. No one likes being sick but it isn’t uncommon for the modern patient to believe that the failure to get better rapidly signals a doctor’s shortcoming.
Someone recently asked me, “Are antidepressants outright bad for you?” In my opinion, the answer is not binary. As in all of clinical practice, I would say, “It depends.”
I am not a psychiatrist but unfortunately mental illness is so common that no clinician can avoid it. On my medical rounds, I see abundant use of antidepressants. My heart sinks when the patient can’t remember a time when he was not on one of these drugs without ever having a formal diagnosis of depression made. Often, the drug was started on shaky grounds and subsequently, no one felt confident stopping it for fear of unleashing the full wrath of mental illness. But a careful history suggests that the patient was likely experiencing a normal reaction, such as grief after bereavement or upset over being fired from work. A sympathetic ear, reassurance and time may have been enough to heal the pain.
But counterweights to these instances of dubious antidepressant prescription are the patients whom everyone gives up on and whom psychiatrists rescue – patients gripped by depression, tormented by psychosis and bewitched by mania. You have to witness some of these dramatic turnarounds to believe that sometimes, pharmacological therapy is as important as tactful conversation.
Elderly people can fall prey to inappropriate prescribing but they can also benefit from these drugs. My geriatrician colleague has a practice filled with complex elderly patients, many with early dementia. She describes a particular group that presents with physical symptoms such as abdominal pain or a persistent facial itch. Typically they have been investigated for years, at enormous cost and inconvenience, before they are sent to her as a lost cause. There is no test left to do but she finds that a small dose of an antidepressant helps return these patients to a quality of life that had become a distant dream. It emerges later that the patient may have been depressed for a long time but no one thought to ask. It’s her turn to be exasperated when others stop the antidepressant and lecture the patient about the danger of mixing old age with antidepressants, especially when cessation of treatment causes the patient to bounce back into hospital.
Gotzche raises the troubling spectre of nursing home residents “knocked out” by antipsychotics. Elderly patients are a staple of every medical ward, including mine. Demented patients who exhibit strong aggression are a very difficult and distressing group to care for. In hospital especially, but also in familiar surroundings, they become volatile. I have seen patients attack their spouse, slap a nurse and bite a doctor. Agitated, they fling food and soil the floor.
I would think that, with consent from the family, administering a touch of sedation goes a long way towards protecting the patient’s dignity and shields family members from bewilderment, shame and heartbreaking memories of their loved one’s descent into a void. A decent society will always balance medical care with compassion for the whole person.
Finally, with rising identification of mental illness, I would be loath to entirely dismiss the role of pharmacotherapy for fear that vulnerable people might mistakenly take this to mean that there is no treatment for depression. Sometimes, the search for a pill is the opening one needs to introduce better forms of help.
Yet, there is much to be distilled from Gotzche’s research. Doctors must be judicious when prescribing antidepressants. They cause real harm and a litany of side effects that have a lasting impact on patients. A pill is not a substitute for a conversation and it is our ethical responsibility to do better.
Patients should also exercise caution, knowing that their demands influence prescribing habits. One can argue that the education and power imbalance in the relationship makes it hard for patients to tell doctors what is right or wrong, but the focus should be on a greater understanding of what drives us and our emotions and realising that there are times when there just isn’t a pill to fix things. The best patient advocate is the empowered patient.
Susan Sontag famously described illness as “the night side of life, a more onerous citizenship”. On my ward rounds I am acutely aware that I, and others, are fairly hopeless at tapping into this existential, night side. And maybe, with all the pressures of modern medicine, this will be our weakness. But it’s not too much to hope that when asked, “Doctor, is there a pill for this?” we can sometimes truthfully answer, “Actually, there isn’t.”
After thinking about what I was really trying to achieve, this is how I concluded my conversation with my distressed breast cancer patient. I reassured her that her dejection and perplexity were a normal response to a traumatic life experience. I told her that I saw many women like her and the majority of them improved, but if she didn’t I would seek expert guidance. I can’t say she looked convinced and at the time, I felt inadequate for somehow letting her down. But when she came back three months later she had worked her way through things, returned to work and felt decidedly better. We both did.