Why Don't I Get Better When All I Do Is Medicine?

I am not bipolar but am on 200 mg of Lamictal and 50 mg of Zoloft.  I have tried many meds and I never feel good.  I have read alot and done alot of research.  I have found that there is no proof of chemical imbalances or that these meds work better than a placebo.  Why don’t doctors try more natural solutions, and more talk therapy.  I would like to know your thoughts on this.  Thank you.

No . . . THANK YOU!!!  I don’t agree with all of what you say, but I agree with your underlying sentiments, that too often there is little done EXCEPT to throw medication at a problem.  As far as your initial assertion that there is no proof of “imbalances” in the brain, I disagree.  While direct measurement of neurotransmitters in brain tissue is not currently possible (I personally would NOT volunteer for that particular experiment), there is indirect evidence of neurotransmitter abnormalities.  Researchers do this by measuring the metabolites (the break-down products) of neurotransmitters in urine.  It is not an exact science and has not (and probably never will) reach the point of being a true test for depression.  But, if you gather a group of depressed patients and a group of non-depressed patients together and measure their urine metabolites, you can detect a statistical difference.  Not particularly helpful to me in the office, however.  PET-scans have been able to show a consistent reduction in the activity of parts of the brain, but this, too, has limited benefit.  Bottom line is, if you show up in my office with the clinical symptoms of depression . . . you are depressed.  Doesn’t take an Einstein to do this job.  

But what do you do next?

The standard of care is currently to go through an algorithm of medications.  An algorithm is a decision tree that helps you decide what you do next, given a set of circumstances.  You come in with depression and meet criteria, you get an antidepressant.  Usually an SSRI like Zoloft.  If that doesn’t work, then you get a trial of a different SSRI.  If that doesn’t work there is a next step . . . then a next step . . . then a next step . . . etc . . . etc.  Most people respond with the first antidepressant tried.  Some people, however, seem to not respond no matter what is tried.  Or, you get a partial response.  Some symptoms gone, others still in place.  It can be very frustrating for both patient and psychiatrist.  But the use of an algorithm is vitally important.  Without it, there is a randomness to the use of medicines that, in the long run, will not be beneficial to the patient.  It is important that each medicine tried be given in as high a dose as possible and given enough time to work before calling it a failed medication trial.  Too often I see patients who have had multiple brief medication trials with sub-therapeutic doses.  This can leave the patient with persistent symptoms and great frustration . . . and a hopelessness about their situation.  When they come into my office . . . I have to start all over again.  Doubly frustrating for them.  But even when the psychiatrist follows a coherent algorithm  and the patient is very cooperative, there can be residual symptoms of depression.

Thus, the importance of the second part of your comment . . . why more “natural” solutions and talk therapy are not tried enough.  I know of no psychiatrist who does not advocate non-medication management of symptoms of depression.  Getting people to follow through on these recommendations is another story altogether.  Use of therapy, exercise, nutritional supplements, meditation, spiritual practices, various cognitive strategies,  etc have all been found to be  beneficial.   But it requires WORK on the part of the patient . . . perhaps when they feel unmotivated and disinterested.  In the brief time I have with my patients I try to advocate for these practices, but patients rarely follow through.  But they are quick to come back to me and complain that the medicine is not working.  

Like all good things in life . . . a little work is often involved in the development of good mental health.  But it is something that must come from the inside and cannot be forced upon a person.  I am open to any ideas you might have to motivate positive behavior in my patients.

–Dan Hartman, MD

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