MIND MOVES: When is it appropriate to wean a person off medication?
THE ROLE of antidepressants in the treatment of depression has been one of the most divisive issues on the mental health landscape. The debate has pitted mental health professionals against one another, patient against patient, and created heated conflict within families where medications are prescribed and not taken, or visa versa.
While there is a consensus that human beings can and do become depressed, people can hold radically different views as to what constitutes an effective remedy. Extremists on one end of the scale view antidepressants as indispensable to any serious attempt to free someone from the misery of depression, whereas those firmly positioned on the other end of the scale view them as a temporary crutch that may relieve distress but that never gets to the root cause of the problem.
At some level this entire debate has become tiresome. After virtually tearing each other's eyes out, opponents inevitably reach a consensus that what they want for any "patient" is to help them to feel better, that the solution for anyone's depression probably involves multiple strategies rather than any one remedy, and that yes, antidepressants are being over-prescribed to people with low-intensity depressions that have been clearly triggered by their life circumstances.
When irreconcilable differences persist, it is more often because people are not talking about the same thing. The term depression refers to so many different nuances of human experience.
It lacks scientific precision and is thus of limited value - except among ordinary mortals who seem to know full well what they mean when they finally admit to one another that they feel depressed.
Some people are depressed because they have no secure base in their life; some because of horrendous early life experiences that have left emotional scars that need time to heal; some people are depressed because they have had too many losses, heartbreaks, failures and setbacks, and they feel crushed by the accumulative weight of such stresses. Some become depressed because their inner rage against life is so intense that it implodes; and some people become depressed because they are physiologically run down.
I have never doubted that antidepressants can be of help to some people with severe depression, especially for those who were so overwhelmed by distress that they can't think about their lives in a clear way. But I would like to invite psychiatry to speak to us about coming off antidepressants.
I have encountered many people who find it disconcerting that after 10, 20, 30 years of taking antidepressants, when they are by all accounts doing well in their lives, their doctor seems reluctant to consider ever weaning them off medication.
With every visit to the doctor, their prescriptions continue to be renewed. It seems that the longer this practice continues, the more reluctant the doctor becomes to end it. Why fix something if it's not broken?
From the patient's point of view, however, being on medication can affect how they see themselves. What they may have viewed as a painful chapter in their life has turned into a chronic affliction from which they will never be free.
They may feel reluctant to challenge their doctor's wisdom. Or their sporadic check-up appointments have become so brief that there is not the time to raise the issue.
"Sometimes," a service user said recently to me, "it's just easier to keep taking the tablets and not rock the boat."
I respect that doctors have their own good reasons for maintaining a drug regime, even when the patient is doing well. But it would be good to hear these spelt out.
And, more importantly, to hear under what conditions would they consider it appropriate to wean a person off medication.
We are meant to be adopting a "recovery-oriented" approach to care rather than one that is content to merely maintain a person in a stable condition.
Part of this surely involves helping someone to recover a sense that they are strong and sane, with all their foibles and vulnerabilities. So that their self-image can progress beyond perceiving themselves as "broken" to where they feel they are in charge of their own life, at ease in their own skin. Is it possible for people on antidepressants to hold out the hope that one day - having worked through the issues that contributed to their depression and recovered their inner strength - they could manage to navigate the ups and downs of their lives without medication?
• Tony Bates is founding director of Headstrong - the National Centre for Youth Mental Health (www.headstrong.ie)
