Art Smukler, MD

Antidepressants are medications that are prescribed mainly for depression, anxiety disorders (including panic attacks) and obsessive compulsive disorders. They are also used in pain syndromes, smoking cessation, premenstrual dysphoria and many other off-label disorders. They are BIG BUSINESS — 11 billion in sales in 2010 in the US alone. One in ten Americans are on an antidepressant!

Antidepressants were first discovered in the mid-fifties when researchers were trying to find a cure for schizophrenia. What they found was Tofranil, a tricyclic antidepressant. Sadly, it made schizophrenia worse, and happily, depression better. For the first time, psychiatrists had a tool other than psychotherapy, tranquilizers or electroconvulsive therapy (ECT) to treat the depressed patient. This discovery started the snowball effect, and quickly other drug companies followed suite with Elavil, Norpramin and Trazadone. The problem with this generation of antidepressants was the severity of the side effects.

In 1988, when Eli Lilly introduced Prozac, it was an absolute game-changer — less side effects and more effective. By 1990, annual sales of the “miracle drug” topped 1 billion. It wasn’t perfect, but compared to the competition it was fabulous.

Now there are over a dozen newer antidepressants: Zoloft, Paxil, Paxil CR, Celexa, Lexapro, Luvox, Luvox CR, Wellbutrin SR, Wellbutrin XL, Cymbalta, Pristiq, Viibryn…

So which one is the best? The answer is much less exciting than the question. NONE and ALL. It depends which one works for a particular person, and which has the least side effects for that person. Choosing a particular drug is often a litany of trial and error. There are no blood tests to help us choose the right one.The only real clue we have is if a family member did well or poorly on the chosen drug.

My feeling is that drugs alone are often not the best treatment for depression, anxiety or OCD. What seems to work best is often a combination of medication and psychotherapy. It’s a dual approach that addresses both the physiological and the underlying psychosocial issues. This is a great time to be depressed! Often it’s fixable.

Please feel free to ask any questions and I’ll do my best to answer them. Thanks!

There was a very interesting article in the August issue of Psychiatric Times, “Compartment Syndrome in Psychiatry”, by James Knoll IV, MD.

I have spent a lot of time with a psychologist (in prison), which I had never done before in my life, in order to try to figure out how I could have done it… There are these mafia people who can kill people all day long, do terrible things, and then go home to their families… But the thing is that you can compartmentalize things in your life. Bernard Madoff

Bernard Madoff has apparently been examining his behavior with the help of a psychologist. His observation that one can compartmentalize, not only applies to him, but to many of us. I see it often in the office, and we all see it in the world around us:

In psychiatry, an individual can separate off certain thoughts and feelings, so that those thoughts do not encroach or disturb. This may either be a conscious or unconscious process (Freud). The process may be likened to invoking a mild state of dissociation in an attempt to confine and reduce anxiety (Gabbard).

Today, I saw a couple who sought advice on how to deal with their thirty-year-old son. He would curse at both his parents when he disagreed with them, storm out of restaurants after screaming that his mother was stupid, and then refuse to discuss anything. He has a history of alcoholism and numerous bar fights when he’s drunk. He denies that he has any alcohol problems and won’t seek help. At the same time, he writes long, loving letters to both his mother and father, telling them how wonderful they are and how he’s so lucky to have such giving, caring parents. He is a college graduate, has a good job, and supports himself.

Unlike the normal ambivalence that many feel towards their parents, this man has compartmentalized these feelings of love and hate. If he can keep his hateful feelings out of his conscious mind, he doesn’t have to feel guilty. If he can deny and compartmentalize his drinking, he doesn’t have to stop.

In some people, the compartment divider is like a hermetically sealed, case-hardened ship door. Sometimes the divider is flimsy and both sides of a person’s personality can shift back and forth. In therapy, it’s much better to have a patient with a flimsy door. The aberrant behavior is more accessible to examination and possible change. Unfortunately, patients who compartmentalize can be very difficult to treat. It may take a long time to forge a therapeutic relationship and chip away at the need to drink, have sex, overspend, or steal millions and millions from unsuspecting investors. Anything that feels good is hard to change…

Bernard Madoff did what he did because he could. His psychological compartment was so hermetically sealed that he could look friends right in the eye and get them to invest more money, up until the day he was caught. He seems like a man with only the vestige of a conscience (a sociopath). Most of us, even though we might like money and power, would feel too guilty. Unlike Abe Lincoln, we might not walk five miles to return a nickel, but we wouldn’t come close to being Bernard Madoff.

Thanks!