Excellent article. It behooves us to try to find the reason for patients' reluctance. Many times the reason is personal or emotional and has nothing to do with medical science.
Perhaps we should speak about feeling better and self-actualization.
I am in favor of antidepressants, and take them myself. I would never consider discontinuing them.
I also have been seeing a clinical psychologist for many years, and would recommend individual therapy for support with various issues: death of parents, death of long-time friend who I cared for for 2 years before he died, loss of job, death of favorite pet, etc.
"He wasn’t sure it was the medication that was helping, because so much else had changed at the same time — he’d adopted a dog and started tending his garden — so how could he possibly know what was what?"
This seems key, right? Now that we know how poor the evidence for SSRIs is, that the whole "chemical imbalance" etiology of depression and anxiety that can be cured with a pill was never true, it seems like the first thing you should encourage this patient to do is see if he can taper off this medication while staying well, not "keep doing all the things". We don't have studies that prove the benefits of long-term use outweigh the risks.
I am still grateful that my 13-year-old, who has OCD and a had a crisis last winter, refused to get on Prozac. I had agreed to the prescription after intense pressure from his psychiatrist and school social worker and seeing him struggle so intensely, filled it, but I wasn't going to go so far as to pressure him to take it when he decided not to. He got through his crisis without it, he is still working on his OCD, but at least I haven't interfered with his brain development and future sexual function by giving him a medication that may increase suicidality, may be hard to quit, and is at best going to mask his problem. And yet a therapist we briefly saw online, who spent six sessions "validating" his anxiety and never started ERP before dropping us, had the chutzpah to claim the reason he couldn't work with him was his "medication non-compliance". The American devotion to medicating everything is so messed up.
We may have to agree to disagree that SSRIs are appropriate for patients when paired with lifestyle changes, self-awareness, behavioral approaches .. and that the best medical care comes from meeting people where they are .. when/how/if to taper him off medicines will be a decision he and I revisit, again and again
It wasn’t the data that convinced him - that’s really the point - it was the fact that he wasn’t getting better his hard work on behaviors and lifestyle .. all of it… and he because he realized he needed a pharmacologic tool in his arsenal of tools
You’re right, I misremembered where that line came up in the narrative. He wasn’t concerned with data at all, only with the stigma he had attached to mental illness.
The insight into why people often don't accept advice from people who really know little about them (Voltaire) is useful.
But given:
"So I did what doctors do. I explained the pharmacology and ran through the latest data on SSRIs. I walked him through potential side effects and reassured him about the stuff he’d read online." ...
I wonder if Dr. McBride could explain the pharmacology to those of us who still don't understand it, nearly 75 years after the first antidepressants were marketed, or >40 years after the "SSRIs" were marketed?
Last year, after reviewing evidence about antidepressant withdrawal (first recognized in the 1950's), we recommended that prescribers offering antidepressants to patients should also obtain written informed consent. We proposed a sample form, based on informed consent forms recommended in British Columbia for starting long-term opioids or benzodiazepines.
Readers of Sensible Medicine who might be interested can find the sample informed consent form on the final page of Therapeutics Letter 156 at this URL:
Great listening, well done. I'll quietly agree with the serotonin doubters—the serotonin theory is debunked, and any effect is pretty clearly placebo—but it's precious and wonderful when providers administer (as a student once described it) "a listening infusion." THAT rarest of drugs is what makes you a special and gifted doctor, Dr. McBride. Nice work.
Wonderful piece! Thank you for sharing! My only question is whether you recommended a therapist? Just would love for him to use every tool in the toolbox!😄
1. You are a great storyteller! 2. It is so easy to assume that a patient is non-compliant instead of understanding the story that motivates their decisions.
Thank you for sharing and for Sensible Medicine for promoting this type of insightful "dialogue."
Excellent and realistic account. You emphasized the importance and symbolism of FRAMING the reason for a prescription. I recently retired from a career devoted to pediatric lung transplantation. Adherence to the immunosuppressants prescribed for these patients is essential for them to live. My team tried to educate our patients and their parents. Nevertheless, several adolescents stopped taking their medication (usually cyclosporine or tacrolimus) and died a slow, painful process of chronic graft rejection. The cause of non-adherence in adolescents remains mysterious but includes a disbelief that the warnings of their adult overseers are exaggerated. This is an important topic for research and medical education!
There is added weight given to nonadherence in the transplant setting - it's pretty common for providers (and patients, and patients' loved ones) to feel that not taking anti-rejection meds is more than irresponsibility but almost a moral wrong. "throwing away a gift" "wasting an organ" "taking an organ that could have gone to someone else" The opprobrium makes it even more fraught to get to the underlying causes.
Also stating in your note: "Patient read some [article - guideline - study] that supposedly says ... " and then dismissing it out of hand. Ask for a copy or a link and then explain why you do or don't agree with it.
Perhaps, but there is a whiff of the euphemistic treadmill here. "Nonadherent" was the preferred term to replace the harsher "noncompliant." And "decline" and "choose not to" both carry the implication of active decision, when often the situation is often more passive avoidance or inability than active choice.
I’m curious about when this patient’s SSRI might be stopped, given that there are known confounders—Dr. McBride suggests they will stay the course. I’m a lay person, so all I’ve read about anti-depressants recently is that people take them for years despite the FDA-approval data covering only eight weeks, that the meds sometimes dull even pleasurable feelings, that a percentage of the patient population can’t stop taking them without experiencing withdrawal, and that researchers haven’t figured out how to successfully taper to zero for these people, who end up forming groups online to figure it out themselves. (Is it time for a Sensible Medicine article to rebut the new reputation anti-depressants have acquired, or do I have this about right?)
SSRIs are not supposed to be prescribed and left on endless refill. The degree to which someone needs/benefits from an SSRI in 6 mos or 6 year from the original prescription date is proportional to the degree of risk posed by tapering it. There’s no blood test for that; it depends on the patient, their situation, their coping skills. Etc. and is so individual. So many ppl don’t get off these meds - even when they no longer need them - bc they don’t have a shepherd ie a psychopharmacologist to guide them. And bc it’s not easy to go off them w out guidance
Excellent article. It behooves us to try to find the reason for patients' reluctance. Many times the reason is personal or emotional and has nothing to do with medical science.
Perhaps we should speak about feeling better and self-actualization.
I am in favor of antidepressants, and take them myself. I would never consider discontinuing them.
I also have been seeing a clinical psychologist for many years, and would recommend individual therapy for support with various issues: death of parents, death of long-time friend who I cared for for 2 years before he died, loss of job, death of favorite pet, etc.
Thank you.
“What would it mean for you if you did?”
Damn!!!
Great article about listening to the patient and meeting them where they are. I wish more doctors would do that.
Depending on the reason for depression, DBR might be an option for someone to help them through. This is not talk therapy, or even EMDR, where one relives past traumas over and over again. It actually help the brain rewire. https://iptrauma.org/docs/evidence-based-trauma-therapies-and-models/deep-brain-reorienting-dbr
I've been a patient going through DBR and find it very helpful.
Really well done.
"He wasn’t sure it was the medication that was helping, because so much else had changed at the same time — he’d adopted a dog and started tending his garden — so how could he possibly know what was what?"
This seems key, right? Now that we know how poor the evidence for SSRIs is, that the whole "chemical imbalance" etiology of depression and anxiety that can be cured with a pill was never true, it seems like the first thing you should encourage this patient to do is see if he can taper off this medication while staying well, not "keep doing all the things". We don't have studies that prove the benefits of long-term use outweigh the risks.
I am still grateful that my 13-year-old, who has OCD and a had a crisis last winter, refused to get on Prozac. I had agreed to the prescription after intense pressure from his psychiatrist and school social worker and seeing him struggle so intensely, filled it, but I wasn't going to go so far as to pressure him to take it when he decided not to. He got through his crisis without it, he is still working on his OCD, but at least I haven't interfered with his brain development and future sexual function by giving him a medication that may increase suicidality, may be hard to quit, and is at best going to mask his problem. And yet a therapist we briefly saw online, who spent six sessions "validating" his anxiety and never started ERP before dropping us, had the chutzpah to claim the reason he couldn't work with him was his "medication non-compliance". The American devotion to medicating everything is so messed up.
We may have to agree to disagree that SSRIs are appropriate for patients when paired with lifestyle changes, self-awareness, behavioral approaches .. and that the best medical care comes from meeting people where they are .. when/how/if to taper him off medicines will be a decision he and I revisit, again and again
What is "the latest data on SSRIs" and their pharmacology that convinced him to take it?
It wasn’t the data that convinced him - that’s really the point - it was the fact that he wasn’t getting better his hard work on behaviors and lifestyle .. all of it… and he because he realized he needed a pharmacologic tool in his arsenal of tools
You’re right, I misremembered where that line came up in the narrative. He wasn’t concerned with data at all, only with the stigma he had attached to mental illness.
Very moving piece. Thank you
Thank you! Funny how lots of commentators are categorically opposed to SSRIs
Amazing story. Thank you for sharing. Very profound.
Was the patient referred to psychotherapy?
Yes. I’m a huge fan of therapy when appropriate / needed
The insight into why people often don't accept advice from people who really know little about them (Voltaire) is useful.
But given:
"So I did what doctors do. I explained the pharmacology and ran through the latest data on SSRIs. I walked him through potential side effects and reassured him about the stuff he’d read online." ...
I wonder if Dr. McBride could explain the pharmacology to those of us who still don't understand it, nearly 75 years after the first antidepressants were marketed, or >40 years after the "SSRIs" were marketed?
Last year, after reviewing evidence about antidepressant withdrawal (first recognized in the 1950's), we recommended that prescribers offering antidepressants to patients should also obtain written informed consent. We proposed a sample form, based on informed consent forms recommended in British Columbia for starting long-term opioids or benzodiazepines.
Readers of Sensible Medicine who might be interested can find the sample informed consent form on the final page of Therapeutics Letter 156 at this URL:
https://www.ti.ubc.ca/wordpress/wp-content/uploads/2025/06/TL-156wrapper.pdf
Tom Perry MD, FRCPC
Dept. of Anaesthesiology, Pharmacology & Therapeutics
University of British Columbia, Vancouver
Great essay. So similar to the one I published this week. We need to bring more humanity back to medicine.
Great listening, well done. I'll quietly agree with the serotonin doubters—the serotonin theory is debunked, and any effect is pretty clearly placebo—but it's precious and wonderful when providers administer (as a student once described it) "a listening infusion." THAT rarest of drugs is what makes you a special and gifted doctor, Dr. McBride. Nice work.
Wonderful piece! Thank you for sharing! My only question is whether you recommended a therapist? Just would love for him to use every tool in the toolbox!😄
1. You are a great storyteller! 2. It is so easy to assume that a patient is non-compliant instead of understanding the story that motivates their decisions.
Thank you for sharing and for Sensible Medicine for promoting this type of insightful "dialogue."
Excellent and realistic account. You emphasized the importance and symbolism of FRAMING the reason for a prescription. I recently retired from a career devoted to pediatric lung transplantation. Adherence to the immunosuppressants prescribed for these patients is essential for them to live. My team tried to educate our patients and their parents. Nevertheless, several adolescents stopped taking their medication (usually cyclosporine or tacrolimus) and died a slow, painful process of chronic graft rejection. The cause of non-adherence in adolescents remains mysterious but includes a disbelief that the warnings of their adult overseers are exaggerated. This is an important topic for research and medical education!
Thank you for reading
There is added weight given to nonadherence in the transplant setting - it's pretty common for providers (and patients, and patients' loved ones) to feel that not taking anti-rejection meds is more than irresponsibility but almost a moral wrong. "throwing away a gift" "wasting an organ" "taking an organ that could have gone to someone else" The opprobrium makes it even more fraught to get to the underlying causes.
Excellent. There are a few words our trainees (and often colleagues) need to delete from their repertoire:
Non compliant, non adherent, refuses, uncooperative. Better to say declines or chooses not to.
Also stating in your note: "Patient read some [article - guideline - study] that supposedly says ... " and then dismissing it out of hand. Ask for a copy or a link and then explain why you do or don't agree with it.
Perhaps, but there is a whiff of the euphemistic treadmill here. "Nonadherent" was the preferred term to replace the harsher "noncompliant." And "decline" and "choose not to" both carry the implication of active decision, when often the situation is often more passive avoidance or inability than active choice.
Au contraire. Non judgmental is a more accurate description. The idea is to communicate the information without judging the patient.
I’m curious about when this patient’s SSRI might be stopped, given that there are known confounders—Dr. McBride suggests they will stay the course. I’m a lay person, so all I’ve read about anti-depressants recently is that people take them for years despite the FDA-approval data covering only eight weeks, that the meds sometimes dull even pleasurable feelings, that a percentage of the patient population can’t stop taking them without experiencing withdrawal, and that researchers haven’t figured out how to successfully taper to zero for these people, who end up forming groups online to figure it out themselves. (Is it time for a Sensible Medicine article to rebut the new reputation anti-depressants have acquired, or do I have this about right?)
SSRIs are not supposed to be prescribed and left on endless refill. The degree to which someone needs/benefits from an SSRI in 6 mos or 6 year from the original prescription date is proportional to the degree of risk posed by tapering it. There’s no blood test for that; it depends on the patient, their situation, their coping skills. Etc. and is so individual. So many ppl don’t get off these meds - even when they no longer need them - bc they don’t have a shepherd ie a psychopharmacologist to guide them. And bc it’s not easy to go off them w out guidance