Primary care doctors as well as psychiatrists give out antidepressants more than other kinds of medicine.

At the time I started training in psychiatry, we memorized the antidepressant side effects for early chemical classes derived from antituberculosis drugs and became overjoyed when the SSRIs came out.  Actually something safe and effective and pretty “clean” of risks and side effects and interactions!  First Prozac, which was FDA approved a day I was getting off call and grabbing a few hours of shuteye to be awakened by the morning news proclaiming that the new “safe” antidepressant would be a “wonderful advancement for psychiatry.”

A morning review of call with my preceptor who exploded with joy to tell me how lucky I was to be studying psychiatry as it made psychiatry “more powerful.”

Sir William Osler, a wonderful medical educator of the late 19th and early 20th century, spouted many quotable aphorisms.

He said, of any New remedy, “Use it while it still works.”

I have followed the medical literature assiduously as we learned that Prozac and Zoloft and Paxil and their successors were not as effective as we thought.

In the last few years I have dutifully memorized strategies to “augment” antidepressants, sometimes dragging my beloved patients into kicking and screaming fights with insurance companies to help them touch that delightful Holy Grail we call “relief.”

I have seen the ascension of the age of “meta-analysis” — humongous studies that combine together results of other studies and have such a heavy-duty message that they get reviewed for doctors who have lives that don’t always allow time to read journals all day.

(Forgive them please.  Some have families and such.)

Okay.  So antidepressants do not seem to kill depressed folks who already have a heart problem any more than they are likely to die from having a heart problem.

But people who don’t happen to have a heart problem are a little more likely to die if they are on antidepressants.

Some pull out reasons from the air to try and explain this, like a small “anticoagulant” effect from Prozac and its descendants.  Of course, other things induce a bit of anticoagulation, like (would you believe) anticoagulants, old and new.  I have even seen studies saying drinking enormous amounts of fluid (with allegedly normal kidneys) can do this.

One of the invited reviewers was Peter Kramer, the author of the classic “Listening to Prozac.  He pointed out, to his credit, that people who already have a heart problem may be more likely to die from it than people who don’t have a heart problem.  I mean, there could be some kind of statistical artifact.

At any rate, here is the original study.

So what can my beloved patients and readers do if someone prescribes them an antidepressant?

Learn all you can about the advantages and risks.  Read online.  Pump your prescribing doctor as well as your pharmacist.

Ask embarrassing questions.  My favorite one is “if someone prescribed this medication for you, for your depression, would you take it?  Why or why not?”

Me, I’ll generally say “yes.”

It may help to remember that I am dead set convinced a competent course of psychotherapy can change someone’s brain chemistry.  I have seen people who looked so different after a course of psychotherapy that I could not recognize them and this is rare for me.

The key word is “competent.  Sometimes it seems like the world is against us.  With insurance limiting the number of sessions, and less credentialled therapists being cheaper.

I remember a classic and wonderful series of articles in a Journal called “The American Psychologist.”

They showed, to my satisfaction, that the two best predictors of whether a person could heal from a course of psychotherapy are:

1.  The desire to get well.

2.  The belief that the psychotherapist they have can make them well.