After a disturbing article about the side effects associated with withdrawing from antidepressants appeared in the New York Times (link is external), I asked a psychiatrist friend why patients were not being helped to avoid this problem.
“It is very labor intensive,” he answered me. “To taper someone off antidepressants very slowly, which is the only way to do this, the patient should be seeing the physician or nurse practitioner two or three times a week. The medical caregiver must spend enough time with the patient to evaluate the side effects, and adjust the withdrawal rate accordingly. “
“But certainly there would be time in a 30 or 60 minute appointment to do this,” I naively replied.
He looked at me, wondering where I had been the last few decades. “Many psychiatrists have to see four to six patients an hour,” he said. “Not all do this,” he went on, “but if their schedule is that crowded, they may not have time to fine-tune the withdrawal schedule and/or even hear about the side effects. “
Having absorbed that piece of unfortunate information, I asked whether such short visits would prevent the physician from having time to discuss other aspects of the patient’s health such as weight gain or loss, whether the patient was getting annual care like a flu shot, regular dental care or routine screening examinations like mammography. “If they are depressed, isn’t it possible that the only doctor they see is their psychiatrist?” I asked him.
He confirmed that this was so. He had worked for many years as an internist before specializing in psychiatry. He was particularly sensitive to other medical problems of his patients and was able to make sure his patients saw the appropriate medical specialist when necessary. But again, the short visits, and absence of internal medicine training might cause medical issues to go undetected by the therapist.
Certainly the weight gain so common with most antidepressants would receive little attention from the psychiatric professional in an abbreviated visit, but patients can find weight-loss programs to join without physician referral. The program may not address the reasons for the weight gain, for instance, a side effect of the medication, but at least organizations such as Weight Watchers offer sensible, healthy diets. But where does the severely depressed patient who stops eating for four or five weeks go to for help? Who will convince the patient that it is important to eat, even though the depression takes away all desire to do so? Who will make sure that nutrient needs are being met, and that the depressed patient who lies in bed for five weeks does not finally emerge from the depression with muscle wasting from inactivity?
If the patient has family or friends who will take responsibility for the health needs of the patients with depression, then they will make the phone calls and appointments necessary to get them medical care they need; whether it be it for a bad case of the flu, high blood pressure or poor nutrition. However, many people with depression are socially isolated and may be un- or underemployed, and not plugged into a comprehensive medical care system. Thus the only interaction the patients have with a medical care provider is during the scheduled appointment with the psychiatrist every six weeks, or three months, or even after longer intervals.
Of course, the absence of generalized medical scrutiny or support by a psychiatrist is hardly unique. If one goes to a dermatologist to make sure a freckle is not a melanoma, it would be rare indeed if the physician checks the patient’s blood pressure, blood sugar, or asks if the patient is eating four servings of vegetables every day. The issue is the freckle, and not the general state of health of the patient. Yet oftentimes seeing a dermatologist for that freckle-melanoma issue follows a visit with an internist. People with mental disorders who are, for example, in the throes of the depression or bipolar disease, may never get to see the internist.
Perhaps the solution is to combine the visit to the psychiatrist to get a prescription renewed with at least an annual visit to a primary care physician. So, if medical problems exist, they can be identified and treated. Better yet, frequent contact with a seriously depressed patient by a nurse practitioner or physician assistant would ensure that the patient is eating appropriately and not voluntarily confined to bed. Moreover, when the patient is in remission, follow-up medical care should be provided to accelerate the speed of recovering nutritional status, to increase muscle mass, and to identify any other medical issues that may have arisen while the patient was depressed.
Much attention has been given to providing preventive care and early identification of medical problems that can be resolved before they become very difficult, if not impossible to treat. For example, high blood pressure should and can be treated in order to decrease the risk of a stroke. Certainly, if a patient is rapidly gaining weight due to the side effects of an antidepressant or mood stabilizer, the weight gain should be halted before it potentiates diabetes or cardiovascular problems. But these “should do” suggestions are not being implicated for many suffering from mental disorders because of cost, logistical difficulties and probably, to some extent, inertia and reluctance on the part of the patient. Perhaps it is time to turn “should do” into “will do.”