Wednesday, August 14, 2013

Are Too Many Anti-Depressants Being Prescribed?

Look, our friend Dr. Mojtabai and his study on the use of antidepressants is on the Well Blog in the New York Times!  See a Glut of Antidepressants by Roni Caryn Rabin.  Oh, and do read all 405 comments.  

The study looks at patients diagnosed with depression in primary care setting, and many given that diagnosis do not meet criteria for the disorder, but still get prescribed anti-depressants.  I wondered if some didn't meet criteria for depression because the anti-depressants were doing a good job of treating the symptoms.  Unfortunately, I could find the abstract for the original article, so I will refrain from commenting on it further.  

Ms. Rabin writes: 

The vast majority of individuals diagnosed with depression, rightly or wrongly, were given medication, said the paper’s lead author, Dr. Ramin Mojtabai, an associate professor at the Johns Hopkins Bloomberg School of Public Health.
Most people stay on the drugs, which can have a variety of side effects, for at least two years. Some take them for a decade or more.
“It’s not only that physicians are prescribing more, the population is demanding more,” Dr. Mojtabai said. “Feelings of sadness, the stresses of daily life and relationship problems can all cause feelings of upset or sadness that may be passing and not last long. But Americans have become more and more willing to use medication to address them.”
So let me ask you: is this a bad thing?  We're not talking about forced medication here, or prescribing addictive medications, so if a patient comes and says they feel depressed and they want medication, and they don't "meet criteria" for the disorder, but they insist they are suffering and depressed and are willing to accept the risk of side effects, it's it awful if a doctor gives them a prescription for the medication?  "I'm sorry Mrs. Jones, but your extreme sadness and suicidal ideation are only two symptoms and you need more, are you really sure you're sleeping okay?  You don't have major depression so no prescription and you'll be fine after some yoga."  Or maybe the patient tells the primary care doctor that they're depressed, but they don't have enough symptoms to meet criteria, but in fact they do meet criteria for a diagnosis of dysthymia (chronic, low grade depression), or for an anxiety disorder which might also be helped by an anti-depressant.  On the other hand, should we really have the expectation that everyone's mood will be good/fine/okay all the time?  Yes, the drug companies make money off this, but generic Prozac and Paxil cost about $40/year to be on, and one might hope that if they weren't helping, they'd be discontinued. 

And remember, Dr. Mojtabai's study was done with data from primary care settings, it's not about psychiatrists who are more accurate with psychiatric diagnosis than primary care docs.