Deprescribing, non-compliant patients, and ambiguous loss

I’ll be sharing some things I cut from my manuscript when I axed 15,000 words… this was to illustrate the point that many of gender medicine’s problems are not at all unique to the field, just taken to an extreme.

Take adolescents treated for depression and anxiety with selective-serotonin reuptake inhibitors (SSRIs). Doctors can be quick to prescribe SSRIs, without meaningfully exploring the reasons why a patient may feel the way she does, or whether her feelings may be a reasonable response to her life situation. Some of these adolescents were indeed in crisis or had exhausted all other options, but others saw their normal human experiences pathologized and their developing bodies and psyches medicalized. Patients and clinicians alike may be drawn to the idea of a biological basis for the patient’s distress, which exempts the patient’s life circumstances from scrutiny, provides permission and excuse, and promises a quick—and ideally permanent—fix.

Defining the problem as a chemical imbalance—which is less a scientific finding than a wildly successful marketing ploy—turns depression into a problem that doctor and patient may believe can only be addressed pharmacologically. SSRIs may be regarded as both necessary and sufficient treatment for what ails patients, who may or may not be offered alternative treatment options or contrasting perspectives on how to understand and address the distress they feel. Clinicians are encouraged to defer questions of the etiology of depression to the future, when a biological basis will surely reveal itself. In the meantime, pragmatism prevails: if it works, it works. Questions of why an intervention works, or in what sense an intervention works, or whether an intervention’s benefits outweigh its risks, recede.

And there are many risks and unknowns. We don’t know how SSRIs affect sexual development, to name just one unknown. Doctors may feel uncomfortable discussing the potential sexual fallout of SSRIs with their young patients, and patients may not grasp what it is at stake. Besides, doctors may believe—without evidence and against rising self-reports of long-lasting side effects—that any negative effects will be temporary, sure to lift when a patient stops taking SSRIs.

Long-term follow-up research is rare, often of low quality, with high loss to follow up, as there is little incentive on the part of clinicians or pharmaceutical companies to understand how patients fare over the long haul. Research may neglect key outcomes, like sexual dysfunction or the loss of intangibles like creativity or the ability to appreciate music or art. Then there’s the possibility that pharmaceutical interventions may turn what might otherwise have been temporary stage of discontent into a permanent state of being. Depression—more specifically, being a depressed person—may become part of a patient’s self-understanding, even a part of their identity, that can be hard to let go of, even when that self-concept may not serve the individual well. 

When patients question whether SSRIs are working, or whether the benefits justify the harms, doctors may try to slot patients back into the framework of depression-requiring-medication or label patients’ reservations and doubts as noncompliance with treatment. Some patients hesitate to return to the doctors who prescribed antidepressants in the first place, obscuring clinicians’ view of the full range of treatment outcomes.

Patients who wish to discontinue psychiatric medications often find themselves on their own, traversing unknown territory, swapping tips with strangers online on how to taper their doses and weather withdrawal. They may regret that they were not offered other ways of thinking about and addressing their problems. They may live in altered bodies from which they feel deeply alienated and about which they experience complex regrets. Many have no idea what experiences they may have missed out on, but they may feel an ambiguous sense of loss, as though entire realms of human experience have been closed off to them.