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I know it’s a weird question, but let me explain. I trained in a dynamically oriented programme and I remain dynamically inclined. I feel like I conceptualise depression differently from most colleagues. But out of training now, the pressures and demands of daily practice are different. I see low mood and anxiety every day, but rarely what I would conceptualise as “pathological”.
Generally the evidence shows that for mild or moderate depression, lifestyle change and various forms of cognitive and behavioural therapy are preferred and first line, and medications have an equivocal role. Only for sever depression or significant neurovevegetative symptoms do medications seem to have a significant effect. I really like the way it’s put in the latest NICE guidelines.
When I see patients I look for changes in function and impairment, *new* onset changes in sleep, appetite and energy, and lack of mood reactivity. But most just have low mood that goes up and down with normal life or chronically dysthymic (depressive personality). Still, most of my colleagues will start and SSRI if the patient wants, and what gets me, is that some indeed do feel better. Now this can be placebo, and I think it’s one of those things where the med works until the next stress hits and then it “stopped working”. And then of course one can end up in a trap of trying endless med combos for something that may never improve with medications.
My practice is to say, look, I think meds are less likely to give you the effects you’re looking for, try psychotherapy first, but of course most aren’t committed or don’t have access.
So just surveying the group, what’s your threshold to start meds for depression rather than just low mood?
Apologies if this comes across as a niive questions. But I find it hard to reconcile if I’m being more nuanced, psychodynamically and philosophically.
Appreciate input.
Generally the evidence shows that for mild or moderate depression, lifestyle change and various forms of cognitive and behavioural therapy are preferred and first line, and medications have an equivocal role. Only for sever depression or significant neurovevegetative symptoms do medications seem to have a significant effect. I really like the way it’s put in the latest NICE guidelines.
When I see patients I look for changes in function and impairment, *new* onset changes in sleep, appetite and energy, and lack of mood reactivity. But most just have low mood that goes up and down with normal life or chronically dysthymic (depressive personality). Still, most of my colleagues will start and SSRI if the patient wants, and what gets me, is that some indeed do feel better. Now this can be placebo, and I think it’s one of those things where the med works until the next stress hits and then it “stopped working”. And then of course one can end up in a trap of trying endless med combos for something that may never improve with medications.
My practice is to say, look, I think meds are less likely to give you the effects you’re looking for, try psychotherapy first, but of course most aren’t committed or don’t have access.
So just surveying the group, what’s your threshold to start meds for depression rather than just low mood?
Apologies if this comes across as a niive questions. But I find it hard to reconcile if I’m being more nuanced, psychodynamically and philosophically.
Appreciate input.
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