R / x for Depression as Close as Doctor’s Prescription Pad : Medicine: Physicians say the new drugs enable them to treat the mental problem, often without sending the patient to a counselor. But therapists warn against relying on pills as the main remedy.
The closest thing to a couch in Dr. Mike Doyle’s barn-red clinic is his padded waiting room bench. There’s no psychiatric text in sight, just the usual doctor’s gear: examining table, stethoscope, scale.
But for many patients who are “down in the dumps"--the 62-year-old healer’s term for depression--this is their first and last stop for relief.
They turn to Dr. Doyle and his handy prescription pad. This family doctor is not reluctant to prescribe easy-to-take antidepressants like Paxil, Zoloft and, the pioneer, Prozac.
No fuss, no therapy--just pills.
Doctors like Doyle say the new drugs enable them to treat depression--the most common mental illness--many times without sending the patient for extra counseling or psychotherapy.
“It is becoming the norm for family physicians to make the decision, ‘Do you need intensive therapy? Or therapy that can be given by the family physician: encouragement and support?’ ” said Dr. William H. Coleman, president of the American Academy of Family Physicians, who practices in largely rural Scottsboro, Ala., where therapists are thin on the ground.
Especially when a patient’s chronic despair has no apparent reason, Coleman sees no need for therapy that examines the past. “I don’t see this backtracking through all that,” he said.
Could this trend augur a dusty end for the therapist’s couch? A detour from the talking cure, that arduous, expensive and time-consuming journey toward self-understanding and change? Mental health in a bottle?
“It’s an American solution,” Ellen McGrath, a psychologist in Laguna Beach, said of doctors who dispense mind medicines and give therapy a back seat. “It’s temporary. A quick fix.”
“There’s no question that it helps and it works better, but it’s only part of the solution,” she said.
While many therapists welcome the doctors’ increased interest in recognizing and alleviating depression, they warn against relying on pills as the main remedy. While that may be the right treatment sometimes, ideally, they say, the depressed patients should be evaluated to find out if they need talk plus medication, or no pills at all.
Depression often recurs. Taking an antidepressant for four to six months or more, they say, will not deal with underlying problems.
“We are very glad that primary care physicians are interested and are looking to identify signs and symptoms of depression and mood disorders,” said Vivian Jackson, who handles clinical social work issues at the National Assn. of Social Workers. “That is a plus.”
But, said Jackson, mood disorders are a mix of biological, psychological and social factors. Doctors should think of referring afflicted patients to a psychotherapist as readily as they will consult a specialist for surgery, she said.
Family doctors and internists interviewed around the country said they do keep therapy in mind when treating patients. But they’re also mindful of the need to keep costs down, and of many patients’ aversion to the label “mental illness” implicit in sending them to psychotherapy.
Besides, many times the improvement they see in patients on the new antidepressants seems to make counseling unnecessary, if not irrelevant.
“If you tell them, ‘You’re depressed,’ they’ll tell you, ‘But I’m not crazy,’ ” said Dr. Marjorie Bowman, who practices in Winston-Salem, N.C., and chairs the department of family and community medicine in Wake Forest’s medical school. “There is just a major stigma to labeling somebody depressed.”
The stigma is felt not only by the patient, she said. “It can have major problems with insurance, so there has been a fair amount of reluctance on the part of physicians to put down depression on their billing form.”
How much Bowman prods a depressed patient to seek therapy varies. If the patient’s family has a history of depression, she won’t push as hard as she does someone struggling, say, with a child-custody fight or big-time work problems.
“Get them feeling better . . . that’s what it’s about,” she said.
Doctors in general practice have always been on the depression front lines. Generally, it’s the family doctor or internist or gynecologist who first encounters the patient who comes with physical complaints that the astute physician recognizes as signs of depression.
But in the not-distant past, a doctor may have overlooked or even shied away from a diagnosis of depression. That would leave the patient to struggle along on their own, maybe find their way to a psychiatrist, or sink until they wound up hospitalized in a psychiatric ward or, in extreme cases, committed suicide.
Antidepressant medicines have dramatically changed this, as has increased understanding of depression.
Like knowledge of the brain’s exquisite machinery, drugs to treat mental illness are relatively recent in medicine, dating back only to the 1960s.
Until Prozac’s debut six years ago, the favored drugs for treating depression were known as tricyclics, which go by brand names such as Elavil, Sinequan, Tofranil. They work fine, except that some patients find their side effects unbearable: dry mouth, dry skin, blurred vision, constipation, weight gain, dizziness, a drugged feeling.
Depressed patients don’t need to be masochists too; people won’t take a drug that makes them feel worse. The tricyclics also need close monitoring and sometimes day-by-day adjustment. Overdoses can kill.
The arrival of Prozac in 1988, and drugs like it that followed, mark a fine-tuning of these mind medicines. Known as SSRIs, for selective serotonin reuptake inhibitors, they don’t need such close attention.
They too may produce side effects, but milder ones. The chief complaints--typically disappearing after the first weeks--are nausea, jitters, insomnia, sexual difficulties--though any long-term effects are unknown. And it’s virtually impossible to take a fatal overdose.
Most important, patients take their medicine.
Evidence of these drugs’ popularity is clear in figures compiled by IMS America, a market-research firm. Taking a kind of Nielsen rating for drugs, the company regularly surveys doctors on what they’re prescribing.
Psychiatrists issued 1.9 million prescriptions for SSRIs in 1989 and 5.6 million last year. According to IMS, prescriptions for SSRIs written by internists, family practitioners, general practitioners and osteopaths nearly kept pace, multiplying from 2 million in 1989 to 5 million in 1993.
Meanwhile, except for psychiatrists, doctors lost enthusiasm for tricyclics, writing 4.5 million prescriptions in 1989, down to 3.4 million in 1993. Psychiatrists stuck with the tricyclics, writing 4.2 million prescriptions in 1989 and 4.7 million five years later.
Mike Doyle is one of those doctors who have embraced SSRIs. “Mainly because people take them and they work,” he said.
A jowly man with a deep crease of concern in his brow, hair in silvery waves, and sympathetic gray-blue eyes, Doyle doesn’t go in for Freudian jargon.
The patient who comes to see Doyle with depression usually doesn’t know that’s what really ails them. They say they’ve got a bad stomach, or a backache or a weariness no sleep can quench. With gentle, practiced prying, Doyle extracts more information.
“What did you have for lunch?” he asks.
“I didn’t feel like eating,” they’ll reply.
“Is there lead in your pencil?” he asks husbands.
“Are you still having the same fun in the bedroom?” he asks wives.
Soon they’re confiding, say, that they join social clubs and then they don’t show up. And, frankly, some days they can’t get out of bed and go to work.
After eliminating any physical cause, Doyle will say something like: “Look, you’re down in the dumps. Some people call it depression. But let’s just call it ‘down in the dumps.’ ”
Then he’ll prescribe an antidepressant, expecting to put them on it for at least two to four months.
With only 10 to 15 minutes to spare each patient, Doyle doesn’t provide psychotherapy. Should the patient wish to talk about problems, maybe a childhood trauma, or a work or marriage crisis, he’ll suggest they consult their priest (or minister or rabbi). Only if the antidepressant doesn’t lift them after a few months will Doyle prod them to seek psychiatric help.
“Mental illness still carries a stigma,” Doyle said. “I don’t care what status of society you’re in. Seeing a psychiatrist implies that there’s something wrong with them . . . that can’t be fixed. The mind is a funny thing. Many people don’t understand, including many doctors.”
Is this the future of psychotherapy? Yes . . . and no.
Between the new mind medicines and the new skills of the family doctor pressed to keep costs down, the treatment of depression may be entering a new era. But some say family doctors will have to be better prepared for the challenge, and will never replace trained mental health professionals.
“In the future, I think we will be more aggressive about training primary care doctors in recognizing anxiety depression,” said Dr. Robert Nesse, vice chairman of the Department of Family Medicine at the Mayo Clinic in Minnesota.
“The doctor’s office will be the place of diagnosis and, for a group of patients, the place of treatment. But I strongly feel the role of the psychiatrist and psychologist will still be there.”