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Mindful : October 2013
I don’t offer magic bullets, so it’s important to see that there’s a good fit between what the patient wants and what I can offer. Sometimes people will say to me, “I don’t wa nt to look at what ’s going on inside myself. I just wa nt a pill to ma ke it better.” I under- sta nd that. But unfortunately for most people, there is no pill that can make it better in that simple way. Often, what seems to be better turns out to be very incomplete. I don’t know how ma ny people have said to me, “Well, I don’t feel so bad since I’ve been on the medication. But I don’t feel much of anything either.” We don’t go for long processes these days. Well, you either treat depression as a disease to be suppressed or you treat it as a painful opportunity to grow and change. What I’ve obser ved over the past 40 years or so is that if you treat it the second way, it most often becomes exactly that: an opportunity for growth and change. If you treat it the first way, maybe people won’t feel quite as much pain, but they don’t usually ma ke the kinds of cha nges they may need to put their lives on a firmer footing. Patients often feel diminished by taking medi- cations. They think, “Oh, there’s something wrong with me. My doctor says I have a chronic disease and I have to be on these drugs forever.” Depression comes to be thought of almost like insulin-depen- dent diabetes, and with that comes a kind of resig- nation. But it’s not like insulin-dependent diabetes at all. There’s no evidence that people do better if they’re on the drugs for long periods of time. There’s actually little evidence that antidepressants are more helpful than other approaches. In fact, a num- ber of studies show that they’re only a little more effective than placebos. So we’re making people dependent on medica- tion, and we’re foreclosing possibilities for learning and change. To me, the use of medication is only a last resort. If the pain is unbearable, and nothing else works, then okay. We somehow think that life isn’t supposed to be difficult? That’s true. We’re supposed to be able to function well and cheerfully under any circumstances. We’re not supposed to feel the pain that is inevitably there in life. The approach is: let’s not look at it. Let’s suppress it. It’s more like being mind-less. So how did we get here? One factor is that the economic incentives in the health care system favor talking to people less a nd giving them medication more. Just as the economic incentives push obstetricians into doing more Cesar- ean sections than are needed, many psychiatrists see more people less frequently, for less time, for more money. → There’s little evidence that anti- depressants are more helpful than other approaches. In fact, a number of studies show that they’re only a little more effective than placebos.