Bob–
I had an interesting case today.
A friendly, 24 year old, very slender and slightly distracted Vietnamese woman who has a 18 month-old daughter. She has a tumultuous life, lots of boyfriend problems (not the father of her toddler), and has been trying to get through cosmetology school. Five months ago, she came to see me complaining of unintentional weight loss, lack of appetite, disinterest in life and frequent crying. This seemed centered around her boyfriend and school troubles. Being less informed then, less gun-shy about psychotropics than I am now, I diagnosed her with depressive disorder and started her on the lowest dose of Lexapro.
She did remarkably well. At her one month follow up, she was noticeably cheerier, had gained back 5 lbs (which for her was a good thing) and reported that her overall sense of well-being was much better. We decided to continue the medication at the low dose, and see her back in three to four months, which was today. When I asked how she was doing on the medicine, she said, “It doesn’t seem to be working as well. I’m getting moodier. Like, maybe I need a higher dose.” Three months ago, that’s what I probably would have offered. But instead, I delved deeper into this moodiness. “Well, like a lot of the time I feel pretty good, but then little things will freak me out, and it’s getting on my boyfriend’s nerves. Like the other day he told me, ‘You’re, like, totally turning bipolar!'”
Ah, what an opportunity. I told her that I’ve been doing some research, and while I’m glad she had a good response to the Lexapro 5 months ago, that I was increasingly concerned about the long-term effects of this type of medicine, one of the major ones being that it could indeed cause otherwise mildly depressed people to develop erratic mood swings and lead to a diagnosis of bipolar disease. I asked her about her life now, and what else she was doing to address her depression. She was not exercising regularly, but she was doing yoga at home, and mostly she had graduated from school which alleviated a lot of her stress. I said that, in my opinion, instead of increasing the dose, we should try to wean off of the medicine over the next month and see if her moodiness improved. She said, “Yeah, I wanna to get off the medicine, because, like, I’m not sure it’s helping anyways, and, I especially don’t want to be on something for, like, life.” I warned her that she may face a couple of tough weeks as we withdraw the medicine, but that long-term, I believed that she would be much healthier and happier off the med, especially if she continued to work on the non-medical approaches to depression and had realistic expectations for how her mood fluctuations relate to her life events. I recommended a counselor for her, and I’ll be seeing her back in four weeks.
I hope things go well for her. Of course, we can never peer into alternative destinies, but it’s not hard to see that, prior to reading your book, I likely would have increased her dose of Lexapro, which may have helped her depression short-term but worsened her mood swings long-term, eventually leading to diagnosis of bipolar disorder with all of its accoutrements (lithium, zyprexa, benzos) and a lifetime of disability and worsening symptoms. I admit to feeling significant guilt in knowing that there are probably dozens of patients out there who I have unintentionally guided down this deleterious pathway throughout my young medical career. But no more. Today, she chose an alternative pathway for herself, and while I don’t predict that her life will become a bed of roses, I thinks she will do well overall. She seemed excited to hear that she may not need medicines to feel well, after all.
I’ve wondered if, in your current position, you sometimes feel like a distant observer of this battle for mental health, helpless to effect change on the front lines. But the common thread in all of my vignettes is your book, which sparked a revolution in my head that is spilling over daily to my patients, and in the case of this young woman, it may have indeed saved her from a lifetime of iatrogenic suffering. I hope you take some genuine satisfaction in that.
Mark
