One of the commonest topics I get asked about are antidepressants. The topics of the questions are numerous and I will not cover all of them here. However I did want to address some of the commonest recurring questions, comments and misconceptions. I will break this post into several parts and address any reader comments that come up as we go along.
Question I: Why are antidepressants over-prescribed and why don't they work well for many people?
I decided to combine these two questions because they partly answer each other. The first part is why are antidepressants over-prescribed? This is a complex issue because the answer depends on the premise of the question, namely that anti-depressants ARE over-prescribed. My response to this premise is yes anti-depressants are over-prescribed but they are also under-prescribed. That doesn't make any sense, right? Actually it does.
You see the research demonstrates that anti-depressant prescription rates in the developed world having been sky-rocketing over the last decade. This can be partially (but not completely) explained by an increasing recognition of depression especially at the primary care levels of the health care system. In fact, when you consider the amount of people whose depression went unrecognized for many years you begin to realize that for many individuals antidepressants are under-prescribed. After all, these are potentially life-saving medications for people who really need them. And the research clearly shows that many people who need antidepressants do not receive them either due to decreased access to or poor quality of care. So we need to do a better job for this under-prescribed group who need antidepressants.
Herein lies the problem of over-prescription though. How do we recognize those who really need an antidepressant? Well, we make sure the person getting the prescription has depression. Depression the illness, not just the feeling of sadness (more on this in a future post). This brings us back to why antidepressants are over-prescribed. Well there are many reasons. I'm sure some readers of this blog will point all the fingers of blame at Big Pharma stating that they have driven this trend both through patient demand and prescriber practice. And while there may be some kernels of truth to any position in any debate including this one, I think that pinning ALL the blame on Pharma is naive. A large driver of over-prescription is the fact that in a zeal to "capture" all cases of depression practitioners have "cast the net to wide". In other words many people who have mild sadness related to life circumstances or even mild depression that would have responded to talk therapy and behavioural modification alone are instead prescribed an antidepressant and sent on their way. This leads to a poor response to the medication because you are treating something that doesn't exist (at least not in the form that the medication would treat) and you are not addressing the underlying causes.
The evidence of antidepressant response rates from clinical trials is compelling. For example in a recent (non-pharmaceutical funded) large-scale clinical trial of antidepressants only about 25% of patients responded to the first go on an anti-depressant. This is appallingly low! However if that same data is reanalyzed to examine only those patients whose depression was ranked severe then the antidepressant response rates jump to around 80%! What does that mean? Well it means that once we "lock in" on the form of depression which appears to be an almost purely biologically disease entity then the response to a chemical agent (antidepressant) is great. But this data also demonstrates the perennial problem in modern day psychiatry. Getting the diagnosis right is very hard compared to other fields of medicine that have the benefit of biomarkers (diagnostic lab or imaging tests).
So in summary I believe that antidepressants are over-relied upon and often don't work well in "normal" human sadness or even in mild cases of depression. In these cases talk therapy, physical exercise (see previous blog posts) and lifestyle/behavioral modification should be tried first before going for an antidepressant. However antidepressants are life-saving drugs that are unfortunately still under-prescribed in moderate-severe depression. These types of depression often present with manifestations such as inability to function, suicidal thoughts or actions or psychosis (loss of touch with reality). Of course there is no perfect solution or template especially in a field as nascent as mental health. I use the above opinion as a "compass" to guide my thinking and practice but I think we should still treat patients on a case-by-case basis working with them to tailor treatment to their specific needs.
STAY TUNED: In the next part of this series I will address the question - Will I become addicted to or dependent on the antidepressant?
Note as a disclosure of impartiality: I have not mentioned any specific antidepressant neither by proprietary or non-proprietary (generic) name in this post. I do not have and have never had any affiliation with any pharmaceutical company; neither in the form of a "consultant" or being on a "speakers' bureau" or otherwise. I have done research and clinical trials with pharmaceutical agents but have not received any reimbursement for doing this by any pharmaceutical manufacturer. Full disclosure: I have owned a small amount of equity in a pharmaceutical company (sanofi-aventis) but this was as part of an investment fund rather than an outright purchase or being granted stocks.
No comments:
Post a Comment