Everyone seems to be getting into the act when it comes to prescribing or having an opinion about psychiatric medications. We are reaching out more and more for pills to cope with the everyday stresses and common struggles that are a part of being alive in this day and age. It appears to be too easy to go to a doctor and have them dispense an antidepressant or antianxiety medication. All we have to do is ask and we shall receive a “magic” pill that will alleviate the suffering.

Frontier Psychiatrist has a must read post titled “Antidepressants prescribed by psychiatrists only?” It lays out the complex dynamic of who is prescribing psychiatric medications and how nuanced the diagnostic process is for disorders such as depression, which is one of the most common given to patients seeking help. This brings up a point that I think is vital to our system of mental heath care and how we perceive ourselves, who is the gatekeeper for treating what disturbs us? Here is a portion of the post:

The notion that there is a very common disease called ‘depression’ that can be addressed with the use of antidepressants is very prevalent in our society and although psychiatrists are ‘experts’ in it, the general abandon doctors show with antidepressant prescribing would suggest that its treatment is something on which all doctors have purchase and is not just the preserve of shrinks. Yet can this be a good idea? Many doctors’ insight into this area may be no more nuanced than that gleaned from their teaching at medical school, which from my recollection was simplistic and dogmatic. Is low mood such a problem that we cannot but afford to have all doctors tackling the problem, or has the diagnosis gone feral and now needs to be tamed by expert tamers with chairs and whips?

In truth ‘depression’ is a very difficult thing to define and any doctor who says that they can reliably differentiate it from sadness is deluding themselves. Our current best shots at a definition, or at least the one that most people agree on, are the vague aggregation of symptoms offered by DSM-IV and ICD-10. These definitions are so broad however that they stand accused of pathologizing everyday sadness and have in part lead to the ridiculous notion, useful to some, that one in four of our population suffers from a disorder of their mental health.

Standing aside whether widely used criteria are worthy, most doctors – including psychiatrists – pay little heed to operational criteria, and instead simply going to a doctor once or twice and stating that you’re ‘not quite yourself’ is most often sufficient for a prescription of antidepressants, which is a de facto diagnosis of depression. It’s illuminating often to ask people who say that they are ‘depressed’ what meaning they attach to this; the selection of responses I have had range from those equating to mild dysphoria to those expressing unremitting misery. It is also not unusual for a question about someone’s supposed mental distress to be framed in more concrete terms: ‘I’ve got a lot of trouble with my housing’ being an unfortunate favourite. If the first doctor won’t provide you with antidepressants, the second surely will. Doctors we feel they must help and antidepressants allow them to avoid admitting the boundaries of their efficacy.

I have focused a number of posts throughout this blog on the diagnostic process, scope of practice, defining critical thresholds of risk, the use of psychiatric medications and asking ourselves the question “how sick are we?.”

We have all witnessed a number of medical doctors, psychiatrists, clinical psychologists, marriage and family, trauma and addiction specialist therapists as well as laypersons who have been prescribed medication, or had a friend, family member or acquaintance who has, jump simultaneously into the mix about who should be taking what medication. We see the boundaries have blurred in terms of who in fact needs these kinds of treatment and who must learn how to cope on their own. An inordinate amount of time and resources are being wasted and so much confusion is being spread when it comes to the treatment of everyday maladies that just require some good common sense and a little bit of old fashion stoicism. But, holding this diagnostic boundary requires trained professionals with specific expertise who can tell us when we have crossed the line into a mental disorder that requires medication. The language and standards of practice that come with mental disorders belong to them.

Although the author of the post won’t go so far as to say he is advocating that psychiatrists or some medical doctors should be the “gatekeepers” for these types of medications and when they must be used to protect someone from harming themselves or others I am. Without specificity, nuance, trained minds that understand the complexity and degrees of intensity of disorders like depression and anxiety regulating for us we all think we are so sick, too disturbed, needing a more radical form of treatment for what seems to ail us. The question that should remain in each situation and for the culture as a whole is how sick are we?

(See also Garth Kroeker’s post “Psychologist’s Prescribing Antidepressants.”)