Tuesday, November 02, 2010

Antidepressants and the Dying

Here is a question on bioethics asked by a ZENIT reader and answered by the fellows of the Culture of Life Foundation.

Q: What are some ethical issues surrounding the taking of anti-depressants? Does their mood-altering effect raise moral problems for people preparing their consciences for death? -- K.N., Augusta, USA.

E. Christian Brugger offers the following response.

A: There are many brands of antidepressants on the market today divided over several drug categories (or classes). An older class known as tricyclics came into widespread use in the 1950s and 60s. Common brand names include Elavil and Pamelor. A newer class known as selective serotonin reuptake inhibitors (SSRIs) came into common use in the late 1980s and 1990s and are still widely prescribed (including the famous drugs Prosac and Zoloft). One of the newest classes of the last 10 years, called selective serotonin norepinephrine reuptake inhibitors (SSNRIs), includes the popular brands Cymbalta and Effexor. In addition to depression, antidepressant drugs are also prescribed for anxiety, bipolar disease, eating disorders and chronic pain.

All three classes work at the cellular level of the brain blocking the absorption of brain chemicals known as neurotransmitters, believed to be involved in mood. The two most common neurotransmitters targeted by these meds are serotonin and norepinephrine.

Some fear that because they are involved in the altering of a person's mood, taking antidepressants is morally analogous to the taking of illicit mood-altering drugs.

I believe this is incorrect. Neurotransmitter medications, at least for depression and anxiety, when effective -- and they often are ineffective even when medically indicated -- ordinarily do not induce a "high," but work rather by restoring mood to a measure of statistical normality in one whose mood has grown flat and darkened, or has been shadowed by anxiety.

Whether or not antidepressants are advisable or promise symptomatic relief for certain individuals is a clinical question; and nobody reading this article should take what I say as clinical advice. My purpose here is to address moral questions surrounding the legitimacy of taking antidepressants for clinically indicated conditions.

The principal purpose of legitimately prescribed medications is therapeutic, that is, ordered toward the restoration of health. People suffering from major depression, dysthymia (low level chronic depression), chronic anxiety, panic attacks or bipolar disease are suffering from real health disorders. Medicine has demonstrated beyond reasonable doubt that these conditions have a distinct biological dimension. Data indicates that that dimension can be positively benefited by antidepressant medications.

These conditions might also have what clinical psychology calls a behavioral dimension. And I firmly believe that one's voluntary choosing and thinking can contribute to the exacerbation or minimization of the effects of many psychic disorders. It is unquestionably the case that for persons diagnosed with these types of disorders, some behavioral changes will be necessary to restoring long-term therapeutic health. But antidepressants can and should sometimes be part of a comprehensive therapeutic plan.

That said, antidepressants can cause significant side effects that burden one's life, affect one's relationships and limit one's range of activity. Moreover, similar to wearing glasses, one's neurochemistry after taking antidepressants for extended periods can establish new levels of normality on the medication. And so people who cease taking the meds will sometimes feel worse than before going on them. Finally, the newer classes of antidepressants are very expensive and can burden one's budget especially during economic downturns such as our own.

In making a good morally informed decision about beginning or continuing treatment with one of these drugs, consideration of these possible burdens should be factored in.

The question above asks specifically about the use of anti-depressants for persons preparing for death. The only uses of the meds for which I am familiar in end-of-life care are for treating the psychic states of those with terminal conditions. Those conditions, involving as they do bodily deterioration, can precipitate or exacerbate the types of neurochemical imbalances that correspond to states such as depression. In other words, as one's biology deteriorates, the biological basis for depression will often increase. Fear of dying might also play a role in one's mental state.

If such persons exhibit signs of depression, not only is it legitimate to treat them with antidepressant medications, it can be, in my opinion, a requisite part of palliative care (i.e., relieving distress involved in the dying process). Studies consistently illustrate that those patients most vulnerable to euthanasia are suffering from (among other things) treatable depression. For persons consigned to a bed because of incapacitating illness, behavioral options may be limited, so medications may be one of the few options available.

If health care workers appear unconcerned about the mood of the dying, then family members and other caregivers should insist that the patient's mood be taken seriously.

If the administration of antidepressants causes severe side effects that inhibit a person from conscientiously preparing himself or herself for death, then patients might rightly forgo their use as "excessively burdensome."

But if a patient is suffering from psychological distress of some sort as a (biological and/or environmental) result of a terminal condition, or if they have a history of mood disorders, and antidepressant medications can promise some relief, then treating them with these medications is no more morally suspect than treating them for chronic pain.