For a number of years after I first got started in psychiatry I wrestled with the dilemma of what to do when someone with severe, disabling depression came in for an evaluation, seemed to be an excellent candidate for treatment with an anti-depressant, but was completely preoccupied with potential adverse effects and focused almost entirely on all of the negative information about the medication (and with the internet it is easy to find reports of negative effects of medications).
I would find myself in the odd position of arguing and arguing in favor of at least considering a medication, especially since many people with this kind of story had tried many different psychotherapies and herbal and alternative treatments without success and were clearly suffering a great deal from their depression.
About four years into practice, the little imp that sometimes sits on my right shoulder during therapy sessions suggested to me that I ask the question “what if it works?” instead of continuing an endless discussion about what if the medication doesn’t work or has bad side effects.
It turned out that for many of these people, a frank discussion about “what if it works?” was important to allow them to really think thoughtfully about the decision to take, or not to take, a medication.
Embedded in the question “what if it works?” is a whole series of thoughts and ideas about what it “means” to have depression and what it might mean to have a kind of depression that responds to medication.
Some people worry that, if taking a medication makes their suffering go away, they will have to wrestle with the idea that their lifetime of pain and struggle was unnecessary. And since this struggle, for some people, represents the central axis of their lives, they would suddenly have to reconsider their understanding of themselves.
Another set of questions that may be evoked by the question “what if it works?” has to do with whether a self that is not depressed because of an anti-depressant is “really” the same self. In other words, is there something that this medication does that might change some essential attribute of personality?
And then of course there are a whole series of connected issues – including the shame and stigma that can easily get evoked by medication treatments for depression.
If you are thinking about medication, I suggest looking at the decision from both perspectives, what if the medication works, and what if it doesn’t.