Mr. K., a lawyer for a large corporation, was overwhelmingly depressed at home and work. The apparent cause was a difficult supervisor at his job. Almost daily his supervisor would criticize some aspect of his work and Mr. K. would be immobilized for the rest of the day. Sometimes he would stare at the wall in a daze… “my father always called me a complainer…you don’t have to love your job; you just have to get it done… I’m a loser … all those years in law school and for nothing…” Placed on Prozac Mr. K. was quickly fixed. His supervisor would enter his office, make his usual derogatory remarks and nothing would happen. Mr. K. could again get his work done in fine form. There were other benefits. His overweight wife lost 35 pounds. For the first time in years, Mr. K. put down the TV remote control. They began having good conversations, the kind of talks they used to have when their relationship was fresh and engaging. Everything became new. Mr. K. realized that for years he had been going out on Sundays because he was irritated by the tumult of his children at home. On Prozac, he found himself playing with his children and having a great time. After ten months on the medication we decided to see how he would do without it. Within a few weeks we were back to square one. His supervisor’s remarks were again devastating him and he was a grouch at home. He made a quick recovery once he was placed back on the medication. After 16 months on Prozac Mr. K. found a new job. He loved it. He came off the Prozac. He did just fine.
There were only a few peculiarities that he commented on when he got off the medication. Although overall he had worked far more effectively on Prozac, for the first time in his life he found himself ignoring deadlines. Once or twice, that had caused difficulties. He bought a Mercedes on the medication. He had always wanted a Mercedes, but off of the medication he considered it a budget buster and foolish.
This case is noteworthy not only because his judgment was altered by the meds, but because, at ten months, when we first tried stopping the meds, he would have seemingly illustrated the statistics often replicated in studies, of patients who have a recurrence without their meds, thus providing one more piece of evidence, seeming to confirm the biological basis of his illness. But, at 16 months, with the apparent cause of his depression eliminated (his critical supervisor), he did just fine without an SSRI. This doesn’t diminish the almost miraculous effectiveness of his original meds, or even that Prozac may very well have helped him gain the initiative to find a new job. However, it does highlight the kind of questions that clinicians should ask themselves about the particulars involved in a specific patient’s illness, as opposed to exclusively focusing on the operative factors in a specific diagnosed illness. This perspective is in contrast to the clinical practice guideline issues by the U.S. Department of Health and Human Services which flatly states that where there has been a prior episode(s) of major depression “maintenance of antidepressant medication treatment should be for at least one year” 32 Statistically this assertion may have a basis but surely there are circumstances when this “rule” should not guide us.
My doctor tells me that I’ll probably be on antidepressants for the rest of my life. That kind of sucks, but it also kind of doesn’t because I like having a brain that works. I wish I’d gotten them years ago.
It’s time to get up and start the day. Man, do I hate not sleeping. I feel fine now, but later I’m going to be cranky.