Stress During COVID-19: Is There a Pill for That?
Part 2: Are antidepressants the answer to keeping it together during COVID-19?
Posted Jul 29, 2020
During COVID-19, many are struggling with maintaining their mental health and are wondering how to keep it together. Jennifer King Lindley recently reached out for an interview about these issues for her article, "Everyone Is on Antidepressants Right Now. Is That OK?" This is Part 2 of our interview, with some edits. (See Part 1: "Is It Normal to Feel Anxious and Depressed During COVID-19?").
What’s your take on the leap in antidepressants and antianxiety meds during the pandemic? These are important medicines in some cases, but might they be being overprescribed?
While the Diagnostic and Statistical Manual of Mental Disorders (DSM) is a catalog of disorders, psychiatrists don’t just treat disorders in clinical practice. We focus on the mental health part of the health-illness spectrum as well. But this means that, “on paper,” clinicians sometimes “lower the bar” to diagnose conditions like major depression, adjustment disorder, or post-traumatic stress disorder (PTSD) in order to justify treatment or for insurance billing purposes. In this way, sub-syndromal depression may be diagnosed as major depression, normal responses to stressors may be diagnosed as adjustment disorder, and traumatic experiences that don’t rise to the level defined above may be used to diagnose PTSD. It’s in those situations were “overdiagnosis” and “overprescription” of medications might be rightly claimed.
But there are two further things to consider. First, we know that both overdiagnosis and underdiagnosis can and do occur, depending on the setting. Second, the short-term use of medications to treat isolated symptoms—say, a “sleeping pill” for transient insomnia in the absence of a full-blown psychiatric disorder—shouldn’t be necessarily regarded as “overprescription.” It can often be extremely helpful. Longer-term use of antidepressants for subsyndromal depression on the other hand, in the absence of major depression, is less “evidence-based” and often ineffective—or to be more clear—not any more effective than a placebo. When we factor in side effects, that’s when claims of “overprescription” make more sense.
As far as the rise in prescriptions for anti-anxiety and antidepressant medications during COVID-19, the data I’ve seen indicate a spike since February, especially for anti-anxiety medications. But those data don’t really tell us anything about whether there has been a corresponding spike in psychiatric disorders like major depression or anxiety disorders that would be required to know if these medications are being “overprescribed” or not.
Anti-anxiety medications have seen the sharpest rise during COVID-19, which is not unreasonable, especially when we consider that the data still show an overall decline in the use of anti-anxiety medications since 2015. But according to this report, antidepressant prescriptions have gone up since 2015 and during COVID-19. It’s unlikely that this reflects commensurate increases in cases of major depression and it could very well reflect overzealous prescriptions. Though we should note that despite their name, antidepressants are also effective for the treatment of many other psychiatric conditions including anxiety disorders. So, it’s a bit unclear what these recent prescribing patterns really mean and I would be cautious is trying to interpret them without more information.
Should this be put in a broader context? Do we as a society tend to medicalize bad feelings and believe they need to be cured? Does a bad event like losing your job and being stuck in your apartment alone change brain chemistry/wiring?
Modern psychiatry relies on a “biopsychosocial” model that seeks to integrate biological, psychological, and social perspectives to understand mental health and mental illness. Ideally, such perspectives are complementary and result in a more complete view of what’s going on with a patient.
These days, psychiatry is sometimes criticized for “overmedicalizing” or “overpathologizing.” It’s true that modern psychiatry is a branch of medicine, and that psychiatrists are medical doctors who go to medical school before doing their specialty training; but it’s not true that we only think in terms of brains, neurotransmitters, or biology. In fact, many of us chose psychiatry as a medical specialty because of just how much “psychosocial” there is in the way we approach our clinical work.
At the same time, the reality is that psychiatric symptoms like anxiety or insomnia can often respond to medications, regardless of any supposed cause or connection to a social stressor. By the same token, the benefits of psychosocial interventions—like psychotherapy or removing someone from a traumatizing environment—can be understood in biological terms. A biological understanding of the brain acknowledges that the things that psychiatrists focus on—like mood states or cognitive processes like learning—are reflections of physical states of the brain, though saying that such processes are reflections, or can be “embodied” in physical terms, isn’t quite the same thing as saying that they’re caused by brain physiology. For example, when we learn, memorization and skill acquisition are reflected in physical changes in the brain, whether chemical or structural. But those changes don’t just happen from downloading a program like in The Matrix— they occur through exposure to teaching, active listening, taking notes, thinking about the concepts, practicing, and the like. So “bio-psycho-social” isn’t an “either-or,” it’s an attempt at an integrative model.
As for wanting to be “cured” of bad feelings, that seems like a pretty natural reaction that’s not necessarily related to “medicalization.” Medicalization is more about how we approach the “cure.” In some cases, trying to ablate the way we feel isn’t very effective. With anxiety, for example, avoidance often actually makes things worse. So while medications can be helpful in treating anxiety, “exposure” therapy may be an important component of treatment. The same might be true of “working through” grief—no one should expect a pill to remove the pain of losing a loved one. Psychiatric medications aren’t “happy pills” and aren’t designed to make us “emotionally numb.” Many people end up using drugs like alcohol, marijuana, opiates, stimulants—or even psychiatric medications like benzodiazepines (e.g. Valium, Ativan, etc.)—in the name of “self-medication.” But that kind of frantic effort to escape from enduring troubles, which often results in an addictive spiral, isn’t how psychiatric medications are meant to be used.