Middleton and Moncrieff1 make a good case for being cautious about prescribing antidepressants in primary care. The discussion is, however, somewhat one sided. The responsible GP will be aware that there is always a suicide risk if a severely depressed patient is sent away without an antidepressant. Being on the waiting list for cognitive behavioural therapy will not necessarily prevent suicide. Patients who commit suicide have a low concentration of serotonin in the brain.2 An experienced GP will also know of patients who have been symptom free on antidepressants who experience breakthrough symptoms when they try to wean themselves off the drug.
The old RCGP dictum that every diagnosis should have a physical, social, and psychological component is especially relevant to treatment of depression. The physical component must surely be serotonin deficiency in many cases but it would be wrong to treat this deficiency and ignore the psychological and social components which might be more important.
Recent evidence suggests a link between the physical component of depression and nutritional deficiencies.3–5 The evidence for omega-3 and antidepressants working synergistically is especially convincing.6 Recently, when a patient reported breakthrough depression symptoms, I doubled her selective-serotonin reuptake inhibitor dose and added an over-the-counter high dose omega-3. At follow-up, she told me: ‘I feel normal for the first time in over 3 years’. Could this be just a placebo effect?
- © British Journal of General Practice, January 2011