Yesterday, in a brief article Anxiety vs. Depression at Psychology Today, psychiatrist Fredric Neuman tried to explain why psychiatrists often prescribe antidepressant medication even if the patient indicates that her main problem is anxiety or panic attacks rather than depression.
He states that major depression can often have not a kind of sad feeling as its predominant symptom, but rather anxiety. According to him, when there are also other well-known symptoms such as interrupted sleep, loss of appetite and loss of sexual interest, this specific combination of symptoms can be clear enough for the psychiatrist to diagnose a case as depression: even when the patient would label herself primarily as suffering from waves of anxiety, not from depression.
I suppose he may be right – but only, of course, in those cases where (a) this anxiety or panic does indeed come together with other main symptoms of depression, and (b) where this occurs not incidentally but frequently, throughout most days over an extended period.
Brief as it is, Neuman’s interesting article leaves several important questions unanswered. Here are the two questions that came to my mind immediately:
1. Many people experience anxiety or sudden panic attacks once in while or even frequently. By itself, this may not necessarily be abnormal or an indication of illness; it can for example be caused by actual worries, or by a temporarily overactive self-protection mechanism. Can we be sure that psychiatrists will not jump too easily to the conclusion that such anxiety indicates an underlying depression?
In other words, can we be sure that psychiatrists will not too easily prescribe antidepressant medication – with sometimes far-reaching and undesirable side effects – even in simple cases where in fact it might be better to just address this anxiety by itself?
2. Neuman does define “depression” but did not really define “anxiety”. So this raises the question what degree of anxiety a psychiatrist should consider bad enough to justify the prescription of antidepressant medication. I suppose this applies to anxiety that is so intense that the patient cannot function normally in daily life anymore. But will it also apply to intermittent feelings of anxiety that the patient merely finds unpleasant or disturbing? Where exactly do we draw the border line between serious anxiety and fairly “normal” anxiety?
In other words, can we be sure that psychiatrists will not too easily prescribe antidepressant medication even in simple cases where in fact it might be better to explain to the patient that sometimes anxiety (just like grief) is not a kind of aberration but a natural feeling that we should accept as one of the many facets of life?
Neuman is a qualified anxiety expert (at the Anxiety & Phobia Center of White Plains Hospital) so I hope he will soon give us a follow-up article with a little more of his views on anxiety in relation to depression.
• tip: In my own perhaps too simple view, the best short-term way to counter a frightening, paralyzing, irrational attack of anxiety is this.
Seek out someone else who at that moment can be more rational than you. Do not yet start a talk about possible causes of your anxiety: for this will often just not work in your present panicky state. Instead, together with this other person try to do something, some kind of simple distracting activity.
• footnote: At the bottom of Neuman’s Psychology Today article is also a link to his personal blog, but due to a typo it will send you to an error page. Here is a link that works.
May 21, 1949 –
Dear Dr. Van Setten, Our clinic routinely treats panicky persons who
refuse to report their level of panic in a range from 1 to 10 as we ask
them to do. Some people claim their level is 13 or 100. We do not single
these people out for medication. As I’m sure you know, it is routine
practice for psychiatrists, and other doctors too, to prescribe
benzodiazepines for any level of anxiety. I won’t go into the pros and cons
of these drugs, but I think they are helpful mostly in dealing with
anticipatory. anxiety, rather than the panic attack itself. (Many such
patients feel the drug is helpful to them dealing with the attack, but they
feel immediately better even though they know the drug takes a half-hour or longer to work.) Whether or not I use the anti-depressants depends on the presence of the vegetative signs I describe in my blog, rather than the
level of anxiety. Usually, by the time someone exhibits these symptoms,
there is a considerable level of distress, although that feeling may be
some combination of anxiety and depression. FJN
P.S. Thanks for referencing my blog. Twice the usual number of bloggers went to this page in response.
Thank you so much for your reaction! Of course I do understand your explanation.
I can assure you I’m not one to offhandedly reject all use of antidepressants, or to contest they may be helpful to specific patients in specific situations.
However, I do think that as part of any diagnosis-and-prescription procedure (and the monitoring of effects after prescription), the responsible psychiatrist will always need to make some kind of costs-and-benefits analysis: will the pros really outweigh the cons?
I can imagine that in some cases of relatively mild anxiety, the cons may actually outweigh the pros. It’s because of this I was wondering what it would take for you to tell some specific patient she might to better to address her anxiety in other ways than with antidepressants.
Thank you for your work, and I’m looking forward to read more from you!
You…are…my…hero!!! I cant believe something like this exists on the internet! Its so true, so honest, and more than that you dont sound like an idiot! Finally, someone who knows how to talk about a subject without sounding like a kid who didnt get that bike he wanted for Christmas.