fordCecilia Ford, who has been a psychologist in private practice in New York City since 1987, has addressed emotional issues for Women’s Voices in many articles over the years. This week, she addresses a reader’s concern about the routine prescribing of drugs (without talk therapy) to people experiencing mild depression.

3780141418_5760802614_zDear Dr. Ford:

Can someone explain to me why the treatment of unhappiness, disappointment in life choices, or disappointment in others has become a disease that requires drugs? I live in a city of 500,000 people with a university and a medical school. In spite of these advantages, the trend here seems to be “Treat everyone with a drug before trying old-fashioned talk therapy.” And, I have seen some really bad results when patients have brief conversations with a psychopharmacologist who then prescribes one or more drugs and sees the patient again in one month. 

My son was disappointed in career choices and then disappointed when his long-term relationship ended.  He could have seen a life coach, for God’s sake, or a psychologist to talk about how these choices came about and how he could find a new way to think and live.  Instead he was given a drug that caused him to gain weight and to feel lethargic.  He then lost the job he had, along with his health insurance, and had to find a clinic where he could be seen for less money but still be given the prescription for this drug.  Then he couldn’t sleep and had increasing anxiety.  Soon he was on three drugs and living back at home.  Finally, his father and I found a talking therapist who discussed his case with the original psychiatrist.  She then helped our son withdraw from these medications, while helping him to understand how and why he had made some life choices that had led to disappointments.  He then entered group therapy and finally came out of his state of mild depression.  He has a decent job now that has opportunity for professional growth. He has reconnected with old friends and has taken up daily exercise and athletic activity, which he finds helps his mood.  He told us recently that he felt that he was lost when he was on those drugs but now feels that he had just gone through a series of normal disappointments.  Why has the treatment of mild depression become so drug -riented?  Is there any chance that this will change?


Dr. Ford Responds:

Dear Lydia,

I understand your concern. This is a very serious and complicated issue that has stirred much debate among professionals, the media, and the public. While it’s true that the use of psychiatric medications has changed the face of mental health treatment in recent years, there is much controversy about whether or not this has been a good thing or a bad thing.

The answer is that both sides have valid points, and the issues are complicated by the fact that psychiatry is such a particularly individualized and nuanced branch of medicine. There are as many scenarios as there are patients, and the use of drug treatment, including what drugs and the length of time they are prescribed for, must be carefully evaluated on a case by case basis. This is a decision that is best made by a person with specialized training in psychiatry—ideally, one who has further training in the area of psychopharmacology.

Unfortunately, that is rarely the case. According to the Psychiatric Times, in 2010, 255 million prescriptions were given for these drugs, and almost 80% of those were from “medical professionals other than psychiatrists.”

Too often, the scenario involves a GP handing out an SSRI (selective serotonin reuptake inhibitor: Prozac and Zoloft were among the first) at the first mention of distress. Even when psychiatrists are consulted, as in your son’s case, psychopharmacology is often the first treatment offered. Worse, it frequently is the only treatment prescribed, though study after study has provided evidence that drug treatment alone is not as effective as a combination of that with psychotherapy.

However, careful clinicians should always do a full and lengthy evaluation before prescribing any medication for any ailment. The ideal course when dealing with mild depression is to try a period of psychotherapy alone before even considering drug treatment. In the words of, Peter Kramer M.D., clinical professor of psychiatry at Brown University, who became known as “Dr. Prozac” after his widely misunderstood book was published:

“It is hard to locate the judicious stance with regard to antidepressants and moderate mood disorder. In my 1993 book, ‘Listening to Prozac,’ I wrote, ‘To my mind, psychotherapy remains the single most helpful technology for the treatment of minor depression and anxiety.’ In 2003, in ‘Against Depression,’ I highlighted research that suggested antidepressants influence mood only indirectly. It may be that the drugs are ‘permissive,’ removing roadblocks to self-healing.”

However, Dr. Kramer is an ardent proponent of the importance of treating depression, and warns of the dangers of letting it go unattended. The Psychiatric Times reports that  “depression is the single leading cause of medical morbidity in this country . . . . It is also deadly, contributing to many of the 35,000 suicides that occur annually in the US.”

Reaction against the use of antidepressants, including the adoption of a “black box” warning on their use for treatment in adolescents, has led to some doctors to resist prescribing them when they are necessary.

Your son’s case illustrates, painfully, some of the many things that can go wrong when a person presents with a “low mood” in a clinician’s office these days. For one thing, drug treatment was prescribed much too quickly. Secondly, the side effects of weight gain and lethargy (if they last more than very briefly,) should be seen as signs that a different approach (or at the very least a different drug) is indicated. From your description, however, it sounds as if  it took a long and tortuous route for your son to get to the treatments I would have tried first: talk therapy, exercise, and connecting with friends.

Having said that, there are definitely times when I am in favor of the use of drugs. There are some cases when a mild, situational depression can “take hold” and may be causing the patient to feel so low that taking steps to improve his situation seem futile or too difficult. In these situations, a brief course of antidepressant therapy (as an adjunct to talk therapy) can provide the energy and optimism to make the changes necessary to improve things. Once positive changes are in place, the drug treatment can be carefully discontinued. Another scenario concerns people who have been suffering from a mild level of depression (and/or sometimes anxiety) for a long time, and a trial of psychotherapy alone is not working well enough. Indeed, antidepressants have been proven to work statistically significant number of cases, and to withhold their use, as I have seen happen, is to allow a patient to suffer needlessly from a painful condition for which there is a known and effective treatment.

How, you ask, did the “drug-oriented” approach get so popular? There are many reasons, one of which is that “big pharma” has billions invested in their continued use and popularity. And patients, when confronted with the offer of a small pill to solve their problems are quick to accept. Who wouldn’t? In contrast,  psychotherapy requires time, commitment, and facing difficult emotional issues. Most of us, even when our problems are not severe, would have to admit they did not just appear “overnight.” By the same token, a good, healthy, and lasting solution to life problems cannot be achieved with the quick fix of a pill at breakfast.

Dr. Cecilia Ford


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