Dexamphetamine and the faltering war against depression and suicide

To the Editor

Why is it appropriate to use psychostimulants for a lifetime in attention-deficit/hyperactivity disorder (ADHD), but decry their use in depression, also a ‘chronic lifelong illness’ in many patients? (Malhi et al., 2016). Why the concerns regarding these medications ‘introduced initially in the 1930s’ that have been used for almost 100 years?

What do we say about patients in whom psychostimulants have achieved previously elusive clinical benefits (ranging from eradication of suicidal ideas to finally being able to think clearly again), just because academic research has been unable to replicate such benefits? Why no mention of the observational article that showed 64% of 50 sequential patients with resistant depression benefitted from the use of psychostimulants (mainly methylphenidate) for up to 6 months? (Parker and Brotchie, 2010).

The authors describe the immediate positives from psychostimulants, which many patients greet with immense relief. Over decades, I have given dexamphetamine to hundreds of patients (including many highly educated patients) for prolonged periods ranging from weeks to years, with overt benefits in the vast majority, and with about five complications. Withdrawal effects, if stopped abruptly, consist simply of tiredness or return of depression.

Why reject using any medication that may stop the relentless personal and family destruction of a ‘malignant sadness’ that may result in death? Would any inquiry accept that the risks of psychostimulants (often based on rumour, but sure to be drastic!) justify the psychiatrist in not telling intractably depressed or suicidal patients of their availability? In legal terms, ‘non-feasance may be as culpable as misfeasance’. Legal opinion emphasises that patients have a right to be informed of all reasonable treatments, even if the individual specialist does not use them.

Let us face reality. We are not winning. Depression is becoming the major source of disability worldwide according to the World Health Organization. This reflects our inability often to obtain total remission of symptoms. Our current antidepressants are unacceptable often, due to weight gain and sexual problems, with the exception of modern but non-Pharmaceutical Benefits Scheme (PBS) medications (Horgan and Dimitriou, 2015). We are the recognised experts in suicide prevention, usually driven by depression, but suicide remains the commonest cause of death and injury in Australia at any age from 15 to 44, male or female, and rates have increased recently! We do not have the luxury of discontinuing any medication an increasing number of practising clinicians find even partially effective.