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Into the wrong hands

It was just over 20 years ago that the antidepressant Prozac was first approved by the U.S. Food and Drug Administration. The medication was touted as nothing short of a miracle: Not only was it was highly effective in treating depression, it also caused very few side effects.

The drug’s popularity grew rapidly, and pharmaceutical companies got busy developing a variety of other, chemically similar antidepressants, collectively referred to as selective serotonin reuptake inhibitors (or SSRIs). There are at least half a dozen SSRIs on the market, including Lexapro, Paxil, Zoloft, Celexa and Luvox.

Since the introduction of these drugs, the number of Americans being treated for depression has increased dramatically; the Centers for Disease Control and Prevention says antidepressants are the most commonly prescribed medication in the country. But it’s not always the right people taking them. Some who probably have very little to gain from their use are on SSRIs; others who stand to benefit are not.

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SSRIs work by increasing levels of the neurotransmitter serotonin in the brain and can effect miraculous -- even lifesaving -- improvements in men and women suffering from major depression. But use of these medications is not being restricted to individuals with clear-cut depression; they’re also being widely used to treat far milder complaints, such as loneliness or low energy.

“A lot of people are struggling with very difficult situations,” says Dr. Andrew Leuchter, professor in the department of psychiatry and biobehavioral sciences at UCLA. Financial problems, marital strife or the death of a loved one can send even the most stalwart into a tailspin.

But emotionally struggling or sad is not the same thing as depressed. Depression is not about feeling a bit blue; it’s a devastating disease that undermines one’s sense of self-worth and interferes with the ability to perform even routine activities.

To better understand the way in which antidepressants were being prescribed, researchers at the Rand Corp. in 2002 surveyed close to 700 adults who had received a prescription for an antidepressant. Of those who reported receiving the medication for depression, just 20% tested positive when screened for the disease. Fewer than 30% of those receiving the medication had any depressive symptoms at all.

According to some mental health experts, antidepressants probably aren’t particularly effective in treating mild depressive symptoms.

“They’re not in and of themselves mood elevators,” says Dr. Karen Swartz, director of clinical programs at the Johns Hopkins Mood Disorder Center. “People with basically ‘normal’ mood don’t feel happier when they’re on them.”

Others, however, defend their broader use.

“The evidence regarding who’s going to benefit from these medications and who won’t isn’t so clear-cut,” Leuchter says.

Unfortunately, it’s not easy to tease out which side is right. After starting these medications, people may feel better for reasons that have little to do with their antidepressant action. In some, the drug can produce a placebo effect (these individuals improve simply because they believe the medication is going to help them). In others, it may alleviate problems like anxiety or sleep difficulties, thus making the patient feel better.

Many psychiatrists seem relatively unconcerned about the potential overuse of antidepressants. Though they acknowledge that these drugs carry risks of side effects such as diminished sex drive, nausea and loss of appetite and could cost the patient several hundred dollars a year, they’re quick to point out that the danger of allowing depression to go untreated is far more serious.

Multiple studies have found that roughly half of all people with depression go untreated, and the vast majority in treatment aren’t adequately medicated. These individuals suffer emotionally, and thousands go on to commit suicide every year.

With the terrific medications that are available, that should not be happening. But treating lots of people unnecessarily to ensure that no one who could really benefit from medications is overlooked isn’t the answer.

Primary-care doctors, who dispense 80% of all antidepressant prescriptions, need better guidelines to help differentiate when treatment is indicated. Patients need to understand that antidepressants aren’t a cure-all. They won’t eliminate life’s ups and downs.

The drugs also won’t fundamentally change a person’s character. They can’t cure a pessimistic outlook or a bad attitude and won’t fill someone’s perpetually half-empty glass. To remedy things like that, people have to look well beyond the medicine cabinet.

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Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. The M.D. appears once a month.

themd@att.net

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Doctors’ dilemma

Better diagnosis is certainly part of the solution to getting the right people on antidepressants and the wrong people off them.

“People need to be adequately evaluated,” says Dr. Karen Swartz, director of clinical programs at the Johns Hopkins Mood Disorder Center. “Unfortunately, I fear we’re not using very rigorous ways to diagnose depression.

“A simple show of emotion in front of a doctor can sometimes lead him or her to prescribe antidepressants.” Crying, for example, significantly increases the chances that a patient will be placed on medication.

But identifying depression isn’t nearly that straightforward or clear-cut. In fact, many people who are depressed are rarely tearful and wouldn’t describe themselves as sad. Depression in teenagers, for example, often manifests itself as irritability. The elderly commonly describe feeling disconnected or devoid of emotions. Often nonspecific physical complaints such as headache or gastrointestinal upset are the only symptoms patients exhibit.

And diagnosis goes beyond simply identifying symptoms. Doctors must understand the context in which the symptoms are occurring. After all, someone who’s feeling blue after the loss of a loved one may be experiencing a normal pattern of grief rather than depression.

Although diagnosing depression can be challenging, sometimes all it takes is asking the right questions.

-- Valerie Ulene


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