Monday, December 13, 2004

The response we hope for...

This e-mailer calls herself "a success story of antidepressants." But the decision to take Zoloft wasn't easy for her:
...The night before I started taking the zoloft, I had second thoughts. I did more research on line and scared the hell out of myself reading about the specific side effects of zoloft. I talked with my husband and he thought I was crazy to take drugs since there was no way to really tell if I needed them. But I knew I needed to do something. I went ahead and took the pills and have been on it for 8 months. After 2 weeks I could tell a major difference...

Now Zoloft is not an easy fix. It does not solve all my life issues. I still struggle with with the same things I have always had to deal with. Life in general can be stressful...Sure, counseling may have helped me, but that counseler was not there when the waves of tears would come. He was not there when the anger came. You might say that it is all in my head and that a placebo may have worked, but I truly believe that my depression, anxiety and panic are physiological. And zoloft is a good solution for me.

Now my ultimate reason for my long explanation is to point out that antidepressents can do good. When people talk about the exessive use of something, the negative side effects, then I think it tends to lead people who can benefit away from that solution. No one should feel guilty for needing help. Just because something may be abused does not mean that it does not do any good.

Vertical Mattress, an orthopedic surgeon, joins our conversation about pitfalls in prescribing antidepressants.
Maurice Bernstein makes an interesting point about personal problems and predilections affecting our judgment. He said, "if that drug is working great for me, maybe it will be helpful for my patient." The flip side of Bernstein's statement is that, "well maybe if I have this disease [depression], and someone else seems to feel similarly, then they have the disease, too." From this you get widespread recognition of what seems like a totally new disease. New categories of illness are created and spread like wildfire. Culture and illness spread in nearly identical ways.
The "bias" towards diagnosis isn't so much an error in judgment as it is reasoning from relatively little evidence, something that surgeons and psychiatrists seem called on to do all the time. I have a long-standing frustration with the quality of much surgical research. My field of orthopedic surgery is no worse than any others, but most published articles in the major journals are still small series outlining new techniques. Most comparisons are underpowered to show even a large difference between two groups, meaning that, unless one of the treatments is so far better than the other as to be obvious, the study has no value. There's still a mentality of "I've seen this work so I'll do it." As long as the old dictum, "primum non nocere" holds, I guess this sort of tiny little scrap of evidence-based medicine will continue to have its place in our work."
So psychiatry isn't the only field with small, inconclusive studies! Dr. Bernstein cautions us about occasions when our reference point is ourselves. The situation described by V.M. can lead us to fall back more on our personal experiences. Many docs have left an examining room saying, "That patient sounds like me...that patient has what I have..." We're more than ready to offer anything that helped us. Dr. Bernstein's comments should remind us that when we sense that recognition, we should look harder, think harder, and think again. Have we really considered the possibilities? As Medrants says, "When diagnosing, keep an open mind..."

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