“… and a small dose of an antidepressant might help”

My association with the psychosurgical unit now carrying out over 80 per cent of these operations in Britain affords an unusual opportunity to assess the management of treatment-resistant affective disorders by a large number of psychiatrists from various parts of the country. The psychiatrists likely to refer patients for psychosurgery would be expected to be those more inclined to use psychotropic medication and physical treatments in general. Nonetheless, our experience is unequivocally of a widespread under-use of antidepressants. Most referral letters state that ‘… just about every antidepressant has been tried …’, but it is rare for the maximum dose of each drug used to be quoted. The letters suggest that with resistant illnesses the prescription of a series of drugs one after another at the usual doses is the therapeutic strategy, rather than giving one drug only in progressively increasing amounts to the limit of tolerance. Of course, the doses recommended by drug companies are understandably cautious and sometimes excessively so. For example, MIMS (November 1982) gives for “Anafranil” (Geigy); “More severe cases, 75 mg daily or more if necessary” and for “Surmontil” (M & B) “50–75 mg as single dose”.