Ordinarily Well: The Case for Antidepressants




RONALD REAGAN CAME to office. His budget director, David Stockman, announced a ban on social research. The ukase covered much of my portfolio, including the effects of poverty on health. I left the government.

Baby in tow, my wife and I landed in Providence, Rhode Island, where I had been invited to head the outpatient psychiatry departments for three hospitals, including the principal general hospital. Here, too, Reagan played a role. My mandate was to create services for the flow of patients expected to burden clinics as, with budget cuts, community mental health centers lost funding. I would be doing public psychiatry in the private, not-for-profit sector.

With few resources for independent outpatient work, I tasked my staff with supporting the medical and surgical departments. The doctors were fine with our offering psychotherapy, but what they wanted most was for me to prescribe for their patients. The psychotherapeutic medications were considered effective but hard to use.

My strongest connection was with the gastroenterologists. I lectured on ulcers and helped with research on the acceptance of hepatitis vaccines. As a result, I was referred a cluster of patients like those Kuhn had treated, with hard-to-diagnose GI complaints. These men and women, employed in unrewarding service-industry or line-manufacturing jobs, came with stories of disrupted childhoods, conflict-ridden marriages, workplace abuse, and money troubles. They experienced their problems as physical, and they mistrusted talk.

My patients had failed to respond to a series of drugs targeting bowel motility, and sometimes anxiety as well. I am writing of what were considered tough cases, “somatizers” with mood disorder. Although the tricyclics caused stomach and intestinal side effects, the GI patients did well on them. Antidepressants allowed patients to face adversity without being thrown into despair. Not every case was successful, but the successes could be dramatic. They reinforced the lessons I had learned with Adele and Stephan. Antidepressants helped patients who had failed to respond to treatments they believed in, and the benefits were broad.

I described the experiences of those years in a monthly column for a psychiatric trade paper and in my first book, Moments of Engagement. Psychotherapy remained my main interest, but there was no avoiding this related issue, how prescribing colored that effort. I described a woman with psychosomatic complaints who blamed her troubles on her family. On medication, she shocked me by saying of an impasse, “It wasn’t just my husband, it was me.” How many therapy sessions—and what delicacy—would it have taken to earn that insight?

I made note of a tendency in the social workers I brought on staff. They arrived mistrusting medications and the young doctors who managed their use. Then, not long into their tenure, they would begin to demand that I prescribe. Because drugs sometimes accomplished within weeks what psychotherapy did (or failed at) over years, social workers had become a tribe in danger of losing faith in its own customs.

What I wrote at the time (really) was “The issue is not efficacy nor evidence.” The improvement that caught the social workers’ and my attention might have little to do with items on the Hamilton scale. A patient would be relieved of a hard-to-define impediment and go on to create a new social environment and then flourish.

I have nostalgia for those days. I retained values from medical school—favoring psychotherapy, urging my staff and my patients to give it more of a chance. And then there was something pleasant about prescribing malgré soi. I am a fan of Rex Stout’s mysteries. The setup is that his detective, Nero Wolfe, never leaves the house on assignment—except in the novel you are reading, the unique case that requires extraordinary means. My use of antidepressants was that way, always in despite of misgivings. And then there would be uplift, if the remedy turned out to be a right one after all.

If I dismissed questions of evidence and efficacy, the profession did not. Starting in 1982, clinics at the University of Pittsburgh, George Washington University, and the University of Oklahoma began enrolling patients—250 in all—for the depression-treatment study that Gerry Klerman had championed. It had four arms, testing interpersonal psychotherapy, cognitive behavioral therapy, imipramine, and placebo pills.

In 1986, a researcher presented preliminary data. The New York Times relayed the conclusions in a story headlined “Psychotherapy Is as Good as Drug in Curing Depression, Study Finds.” The article’s key paragraph read:

The study found that two relatively new forms of psychotherapy, cognitive behavior therapy and interpersonal psychotherapy, achieved results comparable to a standard antidepressant drug, imipramine, in reducing the symptoms of depression and improving the functioning of patients. All three therapies completely eliminated serious symptoms in 50 to 60 percent of the patients treated for 16 weeks.

The explanation continued, “While 50 to 60 percent of the patients who received either the psychotherapeutic treatments or the drug reached ‘full recovery’ with no serious symptoms, fewer than 30 percent of those given the placebo reached full recovery.”

The field’s largest experiment—the Treatment of Depression Collaborative Research Program, or TDCRP—had validated every method. Think of it: full recovery in most patients. On reading the account, I experienced relief. As always, my thought was, It might have been otherwise.

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