The TV screen stayed black. Except for the occasional car whishing by outside, the room was silent. I stared at the white ceiling, unable to get out of bed. Two weeks earlier, on 9/11, my sister had died at the World Trade Center, where she worked. I had helped plan a memorial service for her and empty her apartment. Then my body gave out.
For the first time in my life, I didn't feel like doing anything—reading, writing, or even listening to music. I went to psychotherapy, and visited a synagogue, a church, and a Buddhist sanctuary, where we walked in circles and rang bells.
I didn't think an antidepressant would help me, but I decided to try one. Perhaps I should have experienced my grief longer, as a "growing experience." But I soon felt better, and was glad. I also changed how I thought about disease and treatment.
Last month, The Journal of the American Medical Association published an article that argued that for patients with mild or moderate depression, antidepressants work no better than placebos. Countless patients wondered if they should stop their medication. Others have insisted that Americans are overmedicating themselves.
What should we make of all this? First, some facts: antidepressants have clearly been shown to work for serious major depression. Most evidence shows that they are effective for dysthymia: milder but chronic depression that continues for two years or longer. The question is whether they work for milder depression that may be shorter or less intense.
That's important, since major depression affects almost one out of five people at some point in their lives. And most people with depression do not have severe forms of it.
My own sense, based in part on my own personal experience, as well as that of patients I have treated, is that antidepressants can definitely work for milder depression—not for everyone, but for many. Why, then, the debate and apparently contradictory findings?
In part, the answer hinges on what we mean by "milder" depression. Experiences of depression vary enormously in intensity, length, and impact: from momentarily feeling blue to more major symptoms. Medications, which take several weeks to work, will neither help nor be appropriate for a few days of depression that result from passing disappointments.
Just as Tolstoy wrote that "every unhappy family is unhappy in its own way," I would argue that every unhappy individual is unhappy in his or her own way. Depression, even if moderate, can last from minutes to years, and can change your ability to function in life radically—or not at all.
The JAMA article included minor depression but did not examine degrees of impairment in daily functioning or quality of life, or durations of symptoms before treatment was begun—all of which might influence these drugs' effectiveness.
Alas, this debate is polarized, with strong advocates—each with their own biases—on both sides. Drug companies want to market drugs as widely as possible. Many psychologists and social workers, who don't prescribe drugs, fear that increased antidepressant use will rob them of clients.
The debate about these medications obscures larger social issues as well. In general, most patients with major depression receive no treatment. Many patients have difficulty telling a doctor that they feel depressed because of fears of stigma and shame. Of those who get treatment, most obtain it from primary-care doctors, not mental-health professionals. Yet general practitioners receive little training in psychiatry. Many insurance plans cover little, if any, psychotherapy.
We need to educate physicians better about psychiatric symptoms and treatment, improve public attitudes, increase insurance coverage for appropriate mental-health treatment, and conduct research to understand more fully who exactly may benefit from various treatments.
Patients with milder depression may benefit from antidepressants, but won't know until they try them. Studies examine large group averages—not individuals. Still, caution makes sense. These drugs are not panaceas.
The meds I took worked for me. Eventually, I turned on the TV, and read, and wrote. But I still wonder how, and who else, these drugs may help.