I'm curious about everyone else's opinions on this, so I thought I'd throw it out here.
Whenever I get a patient in an ICU who becomes depressed over a catastrophic illness, alot of the doctors will prescribe an antidepressant for them. Now I could be absolutely dead wrong on this, but this concerns me a bit. I'm wondering if it is truly appropriate to prescribe these medications for people who have no history of depression who are now depressed, but who have darn good reason to be depressed. They are trying to cope with a loss, and I'm not real sure if treating a situational depression with medication is a good idea.
Most of my coworkers disagree with me, they say it helps them deal with the short term depression. However, my own personal experience with antidepressants (which I've been on almost every one known to man), they have at times some pretty powerful side effects. Also, these things usually take time to become effective, and we usually are not able to evaluate their effectiveness in an ICU setting.
So am I wrong to be concerned? I would think coping with a loss is something you have to work out, along with some kind of counseling or support, and not necessarily medication as the very first line of defense. I could completely understand using them if other things such as counseling or talk therapy did not help, but not sure if it should be prescribed right away. But if any of you feel differently, and have some experience personally with these things, let me know. I'm willing to change my view on this if I'm wrong :)
I sure wouldn't want a pill for situational depression. In my case, that'd only put off trying to deal with the reality, because the pill would just put me in some detached little world of not-caring for awhile. I've gotten depressed before, and getting out of it without meds was the best thing for me. I came away from it with a clearer understanding of who I was and what I wanted to be. But that doesn't work for everyone and I certainly respect that.
I remember a few years ago when my mom got sick. The doc wanted to prescribe Zoloft for her "depression." I refused after Mom told me she wasn't depressed, just sick. I insisted on having her go to the ER and having some labs done. Turned out she had a very low H&H and K level. After she was treated, the "depression" lifted.
So yeah, I'm pretty cautious about suggesting antidepressants or antipsychotics. If someone's checking out to be OK, on the other hand, I have no problem asking for a psych consult.
My opinion on SSRI's is well known here. But that said, these drugs can mask underlying medical problems. A case in my state is of a 42 year old women, went to the doctor for depression and headaches. Paxil was prescribed. Behavior became bizarre,suicidal,non functioning over 6 months. Final problem was numbness down one side of her body! Yup, you guessed it, BRAIN TUMOR!! Now too advanced for surgery.
These drugs should only be used in cases of severe,debilitating mental illness in conjunction with therapy. We are human beings who learn through adversity,grief,saddness. These are normal emotions that when not worked through will effect every aspect of your life.
Specializes in Med-Surg, Geriatric, Behavioral Health.
Folks here bring up some very relevant points. Depression can be multifactorial in cause, and often is. No one thing causes depression...unless a significant medical health problem is present and is overlooked. The brain tumor is a good example. Low H+H and electrolyte imbalances are things to consider, especially in the elderly. If one looks at the DSM-IV, the criteria of depression has multicriteria that are somatic in nature. The rationale is that clinical depression or major depression is thought to have a organic, somatic base...disruption in sleep, energy, motivation, appetite, sex drive, concentration. When these things are disrupted, a person doesn't feel very well and may have depression and/or an active disease process going on. However, and here is the however, what are the causes? Stress, the life butter that clogs our arteries of living day to day, can cause hormone elevations/depletions and changes in the body...such as elevations of cortisol...which over the long haul taxes the body. There are other physiological disruptions that often occur as well. Disease, such as the brain tumor, cancer, diabetes, anemia, electrolyte imbalances, hypothyroidism, pain and others ailments, place folks at a higher risk...emphasis being adequate screening for physical health problems is very important, especially in the elderly and in the "significant new onset" signs of depression... so that the physical health problem is addressed and not overlooked by simply saying "you have depression, here take a pill and you'll feel better" and miss an actual disease in process. Much of the signs of depression have an organic, somatic picture which overlap significantly with signs and symptoms of genuine health problems. So, the presence of disease needs to be evaluated first, ruled out and intervened upon. The body is very smart, but at times is very dumb. It lets you know when things are not going well, but has only a "limited language" to communicate it. This is why there is so much overlap of symptoms of physical health problems and the signs of depression. What is the cause(s)?...a thorough assessment is the first step before anything should be tried. Again, it is thought that genuine depression is a physiological process...look at the organic, somatic symptoms of the DSM-IV. That is why the lifting of depression is often measured by these clinical, somatic indicators. If these indicators of somatic health return to baseline, the person generally "feels better" and has a "better outlook" on life. I mentioned stress earlier. No amount of medication will ever help a person cope better with stress unless it numbs him/her out or deadens his/her senses...this is NOT coping and it is NOT living. Emphasis here is the need to adapted better to stress by learning new or better coping techniques. Meds can't teach that and it is not something one learns overnight. It entails change. Some folks are receptive to this and some are not. Folks with Personality Disorders are the epitome of not wanting to change to adapt better to stress or simply unable to...it is the hallmark of their illness. Folks with Personality Disorders typically do not adapt better with stress until they begin to mellow out in their 40's, becoming older and wiser. Situational stress (and situational depression aka the situational blues) is best resolved by improving supports, taking care of one's physical health and bodily needs (such eating, bathing, sleeping), and learning and practicing new behaviors to adapt during the stressful situation. An antidepressant is inappropriate during situational stress and blues. It is during these times that folks most often pick up the bottle, smoke, or take a "chill pill" such as an antianxiety med...not good. But, our culture allows and actively endorses the quick fix to ease the aches of life...that is why advertising is such a thriving business, as well as the pharmaceutical, tobacco and alcohol industries. Although our country complains about the nastiness of tobacco and alcohol and the health risks involved, banning it out right will never occur...too many taxes are generated...profit. I know this is a long post, but I did want to put my additional 2 cents in. Interesting discussion.
I work in LTC and I see antidepressants given like candy to our residents. Ok, granted, they could use a boost, but how about giving them one with different activities they might enjoy? Or various things to do?
When I was in the hospital for the first time as an adult with asthma I completely freaked out. The meds they had me on ( this was over 10 years ago and I don't remember which meds they were) had me so wired I was threatening to leave AMA and convinced I was going to die.
Then the best thing happened to me. A nurse walked into my room after I got off the phone with my husband, I am sure she had heard me screaming to come get me and that I was leaving AMA. She told me it was the meds and that I would feel better once the high doses were out of my system. It calmed me right down. All of a sudden I felt like someone understood and that it was going to be OK soon. Sometimes what is really needed is compassion and understanding not drugs.
I think we need to really look at acute versus chronic problems before passing out pills. However I think some docs believe that they have to write an Rx for every problem that comes up.
Julie, I agree that it would appear that antidepressants are over prescribed. Working in an ICU in an acute care facility I see them given frequently. I see patients who are so anxious that they have panic attacks and stop breathing. These people are the sickest of the sick and are familiar with the hospital due to multiple illnesses. Over time their diseases have caused over stimulation of neuron receptors and inflated the amount of serotonin that is linked to our interpretation of sensations of fear and isolation. I agree that non pharmalogical (ie. communication) interventions are needed in many instances, however it is not best practice to deny a patient his or her physiological needs.
*Clinical depression is one of the most common mental illnesses, affecting more than 19 million Americans each year.[1] This includes major depressive disorder, manic depression and dysthymia, a milder, longer-lasting form of depression.
*Depression causes people to lose pleasure from daily life, can complicate other medical conditions, and can even be serious enough to lead to suicide.
*Depression can occur to anyone, at any age, and to people of any race or ethnic group. Depression is never a "normal" part of life, no matter what your age, gender or health situation.
*Unfortunately, though treatment for depression is almost always successful, fewer than half of those suffering from this illness seek treatment.[2] Too many people resist treatment because they believe depression isn't serious, that they can treat it themselves or that it is a personal weakness rather than a serious medical illness.
Treatments for Clinical Depression:
Clinical depression is very treatable, with more than 80% of those who seek treatment showing improvement.[3] The most commonly used treatments are antidepressant medication, psychotherapy or a combination of the two. The choice of treatment depends on the pattern, severity, persistence of depressive symptoms and the history of the illness. As with many illnesses, early treatment is more effective and helps prevent the likelihood of serious recurrences. Depression must be treated by a physician or qualified mental health professional.
I work in LTC and I see antidepressants given like candy to our residents. Ok, granted, they could use a boost, but how about giving them one with different activities they might enjoy? Or various things to do?
I used an antidepressant briefly after the bombing here as an adjunct to debriefing, to help with PTSD symptoms. The combined therapy worked very well, and I would have to say that I would recommend it to others who have been faced with an overwhelming traumatic event. Nor did I experience any side effects.
Early intervention with PTSD makes it much easier to treat.
I always loved psyche nursing. In nursing school several years ago, the psyche clinicals were very successful and incredibly interesting to me. I always try to use that 6 week acute and chronic psyche clinical experience in my own practice in the ICU.
I'm curious how antidepressants relate to addiction. Of course we have zyban or wellbutrin to stop smoking. Is it generally true that antidepressants are prescribed for addicts dealing with the side effects of withdrawal of alcohol, or other drugs? Could the withdrawal be called a "situational" thing?
I've seen what's required to treat serious dt's in alcohol withdrawal, but I've never really seen serious drug withdrawal. Is it appropriate to give antidepressants, and drugs like xanax, valium , or ativan, for this or is it just trading one evil for another not really helping the person develop the true coping mechanisms they need to be whole again or whole for the first time? Are these drugs given for the safety of the patient or are they just another crutch?
I would really like thoughts or experiences with this. Psyche nursing is something I considered in my future. I haven't ruled it out yet. As much as I absolutely love it, I can't do ICU forever!
Specializes in Med-Surg, Geriatric, Behavioral Health.
Ah, the chicken vs egg controversy regarding substance abuse and depression. Many times, it is difficult to say what initiates what. However, the standard practice, at least from my past experience in mental health and detox is that during detox...folks are detoxed off "all" substances that have a potential for abuse, even their benzodiazepines. The rule of thumb in alcohol detox is that when signs and symptoms of withdraw are occuring, the person needs slammed hard and fast with benzos to prevent escalation of the alcohol withdrawal. Getting slammed hard and fast at the onset also reduces the overall detox time the person needs to be in detox...length of stay. Otherwise, the detox length of stay usually is longer because the withdrawal is not adequately treated. We used Valium as our med in alcohol detox, works so much better than Librium. If need be, a person was slammed with 20mg of PO Valium every hour on day one of detox to tx withdrawal (depending on the persons liver enzymes, this dose may be cut in half), then tapered accordingly. The max is 2oo mg of Valium /24 hour period during alcohol detox. Valium worked very well, with folks having a good tx outcome. In a detox setting, this is safe due to frequent assessment and intervention. Cross addiction from ETOH to benzos is a real concern, so most patients "after" detox are NOT prescribed Benzos after detox. An excellent med, which is not addicting, from my experience in detox has been the use of Neurontin for generalized anxiety. Neurontin was also found to be highly effective in the use of detoxing heroin and other opiate user's and managing their anxiety, as well as with alcoholics. Neurontin is an anti-seizure med, but has been used for other purposes as well. I believe it is an excellent alternative to Benzos in addressing anxiety, especially in addiction prone persons. The max dose of Neurontin is 4800 mg/ 24 hrs. Antidepressants have their place in addiction in that many folks have struggled with depression, but turn to substances to self medicate. Anti-depressants are not addicting and are therefore safe in addiction. But, all of this is from a detox point of view. This is the easy side. Tx after detox is where the hard work begins, staying clean from all mind altering substances as a goal. However, anti-depressants have their place here too in that people are supposed to begin working on their issues and their addiction. Many of these folks have genuine depressions, so the anti-depressant has its place as well as counseling. Many of these folks have been so destroyed from depression, substance, or both. I hope this was helpful.
"Anti-depressants are not addicting and are therefore safe in addiction."
65% (as per official drug company clinical trials) go through a "discontinuance syndrome". So while they aren't addicting in the true sense, those that take them can have significant withdrawal symptoms.
Mystery5, totally agree with your philosophy. That which does not kill me only makes me stronger. People often want a quick fix, it takes way too much time and energy to explore the depths of one's emotions and grow from this, much easier to be a victim. But I also know there are times when antidepressants are the way to go, but too often the people who need them use them beyond the time they require them. For some reason the doctor's don't seem to know the right questions to ask or the right advise to give, could it be they don't have the time or education about depression to properly advise those to whom they prescribe?
Specializes in Med-Surg, Geriatric, Behavioral Health.
I do want to respond to Isyorke's post. It does raise questions. I guess the simpliest answer to antidepressants and a withdrawal syndrome is that most meds, even non-psychiatric, may have a withdrawal period for persons if abruptly discontinued. Unfortunately, this happens all too frequently to my liking as I've seen in the mental health field in the past, where one med will be discontinued and another added/substituted in its place. This is also true if a patient discontinues his/her own med for whatever reason. However, regarding antidepressant withdrawal, I liken this to most meds, even non-psychiatric meds, all have the potential for side effects, adverse reactions, and withdrawal periods. Does this make a med addictive. The answer is No. I needed to respond to this, to sort of balance out the equation on this.
UM Review RN, ASN, RN
1 Article; 5,163 Posts
I sure wouldn't want a pill for situational depression. In my case, that'd only put off trying to deal with the reality, because the pill would just put me in some detached little world of not-caring for awhile. I've gotten depressed before, and getting out of it without meds was the best thing for me. I came away from it with a clearer understanding of who I was and what I wanted to be. But that doesn't work for everyone and I certainly respect that.
I remember a few years ago when my mom got sick. The doc wanted to prescribe Zoloft for her "depression." I refused after Mom told me she wasn't depressed, just sick. I insisted on having her go to the ER and having some labs done. Turned out she had a very low H&H and K level. After she was treated, the "depression" lifted.
So yeah, I'm pretty cautious about suggesting antidepressants or antipsychotics. If someone's checking out to be OK, on the other hand, I have no problem asking for a psych consult.