Please consider today’s issue of HIAS as PSA for anyone in the psychiatric system. Until informed choice and physician side-effect reporting is mandatory, the onus is on the patient to understand their body and ask the right questions. What looks like a symptom of a new illness can often be iatrogenic comorbidity, and it is in the best interest of patients and doctors to rule out iatrogenic comorbidity in order to get a clear picture of what’s actually going on.
“Iatrogenic comorbidity” is one of those jargon phrases that make me want to run far far away from research. To me, it’s code for this is an article for those who have letters after their name and if you don’t, you’re too plebian to understand. For regular folk, it’s a term that’s difficult to remember, impossible to pronounce, and seems to have something to do with death.
It has nothing to do with death. In layman’s terms, iatrogenic comorbidity is an illness or disease caused by medical treatment which results in two or more simultaneous conditions in a patient. It is also one of the most important (and overlooked) aspects of treating depression and prescribing antidepressants. If more patients understood what it meant, perhaps more doctors would be forced to take it into consideration.
Let’s break that down even further.
Iatrogenic is an adjective that means, “relating to illness caused by medical treatment or examination.” For example, if a woman has heart surgery and the stitches get infected, the infection is an iatrogenic effect. If the stitches never existed, she wouldn’t have an infection.
Comorbidity means the “simultaneous presence of two or more chronic diseases or conditions in a patient.” For example, an elderly person could have osteoporosis (brittle, porous bones) and dementia at the same time.
Putting the two words together, iatrogenic comorbidity is what happens when medical treatment or examination causes two or more chronic diseases or conditions. In the case of our heart patient, let’s say that she was given antibiotics to fight against the iatrogenic effects of the infected stitches, but that she didn’t know she was allergic to the particular antibiotics. When she takes the drugs, she goes into anaphylaxis. Now, the heart issue, the infection, and the anaphylaxis are all comorbid conditions. A good physician needs to carefully understand what caused what issue in order to properly treat it, otherwise, he might misdiagnose and mistreat.
I am not a doctor, but I imagine it’s generally easier to trace iatrogenic comorbidity in physical illnesses. The heart surgery results in infected stitches which results in anaphylaxis. It’s an unpleasant outcome, but the progression is clear. Mental health, on the other hand, is inherently fuzzy. It is not uncommon for patients to present with comorbid conditions, like depression and anxiety. When medication is administered and more conditions show up, like suicidality, there’s no real way to know what caused what. Did the medication cause the patient to want to kill himself? Or would the urge have developed had the medication not been given? Was it the chicken? Or the egg?
A fancy term for a common problem.
There is a growing faction of psychiatrists and researchers
who are calling for a drastic overhaul of the way we prescribe antidepressant and antianxiety drugs because of the risks of iatrogenic comorbidity. General practitioners, in particular, are being called out
for defaulting to prescription antidepressants rather than recommending therapy. The argument, essentially, is that general practitioners are well…generalists. They are the traffic control of healthcare, designed to guide people down the appropriate specialist highway so oncologists don’t get bogged up with common colds. In theory, this means that GPs should refer someone suffering from depression to a psychologist for further evaluation. In practice, what often happens is that GPs prescribe an antidepressant (or multiple antidepressants) and send the patient on their way.
To put this practice in perspective, I lived in New York City for eight years and never once saw a psychiatrist for my Effexor XR and Wellbutrin XL. Furthermore, my GP only required that I see him once every 12 – 18 months, for a five-minute appointment. So over the course of nearly a decade, I got about thirty minutes of face time with the man who prescribed me daily psychiatric drugs. That’s fucking absurd.
So why is this happening? A general practitioner would never give a patient a script for chemotherapy, so why is it a widely accepted practice when it comes to depression and anxiety?
I would argue that a major factor is that the iatrogenic comorbidity of chemotherapy is much more obvious and well-studied than it is with antidepressants. We know that chemo is a hell of a drug because it quickly makes most people vomit, turn grey, and lose all their hair. The iatrogenic effects of antidepressants though, do not develop in a common, linear way—if they develop at all. The same drug presented to four people with similar symptoms, background, and genetic makeup can produce four very different effects. One person may gain weight and develop insomnia. The second might sleep well but experience PSSD (post-SSRI-sexual-dysfunction.) The third may lose weight and have suicidal tendencies. The fourth may flourish for a few months, but show symptoms of bipolar disorder years later.
In all of these cases, when the patient goes back to their general practitioner because they’re not sleeping well or their weight has changed or they’re suddenly manic, what’s likely to happen? They get a sleeping pill or they’re put on a diet or they add a Lexapro back to their Celexa. Now they’ve got additional medication in the mix, which creates the potential for even more iatrogenic effects. And so on and so forth, until the patient is drugged up to their eyeballs and their system has gone haywire.
Does this happen every time? No. But it happens enough
, and it’s avoidable if protocols are put in place to make it more difficult to prescribe antidepressants. I’m baffled by the fact that a course of some sort of therapy is not considered a pre-requisite to prescribing antidepressants, especially given that research indicates
that over the long term, therapy is just as, if not more, effective than antidepressants. Additionally, the positive effects are more likely to endure and there is little risk of iatrogenic comorbidity.