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.




13 comments:

Steven Reidbord MD said...

Is it a bad thing? I think so. What's the purpose of prescriptions anyway? I see my role as an expert advisor. If doctors don't make distinctions between reasonable and unreasonable uses of a drug — if we just rubberstamp medication requests — we're useless. In this day and age, patients who know what they want and don't seek a doctor's advice can order meds themselves from foreign countries (although the feds don't approve). I have no strong objection to this: in general, I feel people have the right to make choices, good or bad, for themselves. But once a doctor is involved, we owe it to patients to advise them using our best medical knowledge and experience. While the risk of prescribing common antidepressants pales in comparison to the misery of major depression (or panic disorder, etc), it seems plainly unethical to me to expose patients to those risks when they are unnecessary — even if the patient asks.

Put more simply, in a busy primary care office or clinic it's quick to write a script, and it lets both doctor and patient feel "something" has been done, without regard to whether the benefits outweigh the risks.

I'd like to see data on STOPPING antidepressants in primary care settings. In my experience, once started they are refilled far longer than the research recommends.

Anonymous said...

It is a bad thing, a very bad thing. It's a bad thing for research, it's a bad thing for those who actually do have clinical depression or another mood disorder, and it's a bad thing for those who receive the medication.

1. Just because a person comes in stating they're depressed and want XYZ medication doesn't mean such is actually in their best interests. Would you prescribe somebody who isn't suffering from high blood pressure beta blockers? Oh, oh! How about we irradiate every woman who comes in with a lump on their breast? Harm Schmarm, menstruation-related cyst or cancer it's better to just treat it all the same. Antidepressants come with side effects, some obvious and some that clients don't really acknowledge, and some of them can be pretty serious. Let's just give everyone who feels sad for a while a prolonged QT, might prevent a single suicide somewhere down the line. Or how about that portion of the population who actually become suicidal on antidepressants? No biggie right, they asked for it after all.

2. Misdiagnosis affects the treatment of those who actually have the diagnosis. My mother is on antidepressants, she shouldn't be - she was going through a difficult time at work and what she was experiencing should have been dealt with in a therapy setting. As a result, when I crash into a depressive episode she thinks I'm just being lazy and selfish, tries to prescribe more work as a cure to my ails, etc. I'm left feeling even worse about the state I'm in, yet unable to actually fix myself in order to avoid her judgement. You see, she started the pills, and around the same time things at work improved. As a result, her mood improved, but she relates it to the pills. She now has a skewed perception of what depression actually is, because she didn't feel a loss of energy or motivation, she didn't lose her will to eat or suddenly eat us out of house and home, she cried over work stresses and would boil over from anger and frustration, but there were no other symptoms (not even loss or increase in sleep). So, in her mind, depression is a temporary issue that is the equivalent of feeling angry and crying as a result, and all these other things I claim to experience are just me being lazy and refusing to be an adult.

4. So, are we saying that all depression is is a feeling of sadness that extends beyond a few days, weeks? Is there nothing more to it? Well, that'll certainly make researching and creating new medications for depression easier... the only thing new treatments will even need to touch on is inappropriate crying. Forget sleep, forget energy or motivation, forget irritability or suicidal ideation, none of that is actually depression. We're just in the business of treating sadness here, all that other crud is irrelevant whinging.

5. Think of the fish, Dinah. I think we have enough people peeing Prozac, I'd rather not find out how many dolphins an entire population peeing the stuff would kill.

I'm not saying that a PCP shouldn't be diagnosing depression - sometimes it's necessary, but that doesn't give them any right to ignore all but a single symptom when diagnosing. Yes, telling a client "sorry, can't fix ya here!" is uncomfortable, turning down somebody who's sad and telling them they need therapy isn't so pleasant, but being a doctor isn't about making everyone happy - it's about making them healthy, and sometimes that means making the client do some difficult work instead of relying on the convenience of pills and the placebo effect.

Dinah said...

In a primary care setting, if the patient feels strongly that they need medications, but the primary care doc doesn't agree, they can always go see a psychiatrist. And I ask you: how many primary care docs own a DSM and count symptoms and know the criteria? Oops, and what about the Shrink Rappers? I bought a DSM-iv-tr to write our book, I even turned a few pages. Roy: do you have a dsm-V (I bet he does!), Clink: do you? (I bet she doesn't.) And you know I don't.

You got me with poor prozac-exposed fish swimming around frustrated by their sexual dysfunction, and we were wondering why there was a shortage of seafood? But I do understand that research has shown that the dolphins have been happier and more productive since the advent of ssri's.

Radiation is not the same as exposure to SSRI's. And since hypertension is also defined by consensus, perhaps we should be treating people with systolic BP above 130 rather than 140.

I'm sorry, we're not treating your depression because it's not that bad and we don't want you to lack empathy with those who are really suffering?

Anonymous said...

Great post Dr. Reidbord, Regarding your point about stopping antidepressants, sadly many doctors are clueless about doing this safely.

That is why antidepressants withdrawal boards have way too many "customers" and why prescriptions continue to be filled needlessly. Essentially, the person's withdrawal symptoms are being treated and not their original diagnosis.

By the way, I know of one person who is concerned about the over prescription of antidepressants for kids who is going to various pediatricians in his state to make them aware of drug alternatives. This way, doctors don't feel that they have to prescribe a drug to feel like they are doing something for the patients. Maybe if there was more of an effort to do this, the unnecessary prescriptions would decrease.

The other problems with simply prescribing antidepressants wily nily is it could affect the patient getting effective medical care in the future. The article Dinah you linked to in a previous blog entry wonderfully points this out.

So here is a scenario - patient gets prescribed an AD who really shouldn't have received one. Then in future, has symptoms of a serious illness that is blamed on depression because the physician sees in the medical record the person was prescribed an AD. Person is seriously injured or dies due to this neglect. Sadly, this happens with people legitimately diagnosed so the last thing we need is to be adding to this problem.

AA

Anonymous said...

Dinah,

You said,

""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?""

And what if they have another condition that is masquerading as a psychiatric illness such as sleep apnea since you mentioned the issue of sleep?

And speaking of sleep, since insomnia definitely causes depression, what if it is due to other issues besides apnea such as restless legs syndrome, UARS, diabetes, low blood sugar, thyroid disease, etc? Do you really think in the era of rush rush medicine that the doctor is going to continue to investigate after giving the patient a psych med that for many primary care doctors is given as a hush up pill?

AA

Anonymous said...

> "I'm sorry, we're not treating your depression because it's not that bad and we don't want you to lack empathy with those who are really suffering?"

Who said "we're not treating" depression? If it is depression, you treat the depression. If it is sadness, you treat the sadness, if it is an understandable failure to cope during a stressful period you treat that failure. Treating doesn't mean, however, that you need to label it as something it isn't even if insurance companies try their damnedest to make you do so. Treatment does not always mean taking a pill, treatment can mean therapy, treatment can mean monitoring while the client makes lifestyle changes, and those treatments can be given to anyone regardless of whether it's sadness, stress or depression.

Treatment doesn't mean smacking an incorrect label on somebody until eventually that diagnosis becomes irrelevant to people who actually meet those definitions, whom as a result end up being treated incorrectly in the long run as we adjust treatment guidelines for this new "depression" consisting of a single criteria of "sad".

> "And since hypertension is also defined by consensus, perhaps we should be treating people with systolic BP above 130 rather than 140."

Okay, so you lower the limit at which you throw pills at it, and then what? When people start saying that they have high blood pressure because it sometimes reads as 130, usually after a few bad nights of binging on chinese takeout, but averages at 118... where do you draw the line? Do we reduce the definition of hypertension to accommodate the misinformed client? Do we eventually decide that prehypertension actually starts at 110? I mean, my neighbour has an average blood pressure of 100, but mine is 101 so I must be hypertensive.

Likewise, where do you draw the line with depression? Today we reduce it to sadness, are we going to start throwing SSRIs at general discomfort lasting more than an hour tomorrow? Do we just start treating people from birth with an SSRI to avoid the possibility of that baby growing up to feel something that isn't pleasant?

> "In a primary care setting, if the patient feels strongly that they need medications, but the primary care doc doesn't agree, they can always go see a psychiatrist."

Indeed, they can, so why is it that family doctors are so quick to whip out the prescription pad and ignore the criteria for an illness instead of recommending a psychiatrist or a therapist? It's easy even if it's not right, there's less discomfort and we humans are alllll about avoiding discomfort, and it's "just SSRIs", right? It's basically Tylenol, no harm.

And what do you do when that client comes back dissatisfied with what the psychiatrist had to say or how that psychiatrist wished to treat your issue? As a psychiatrist, what do you do when you have somebody in front of you who wants an antidepressant but whom does not actually have depression? Do you treat everyone with medication regardless of whether or not they are the most beneficial option (e.g. versus therapy or lifestyle changes)? Of course not, so why would we accept any other doctor doing this?

Alison Cummins said...

AA, the scenarios you describe are not the ones I encounter in primary care.

I couldn’t get treatment for my depression in primary care because I didn’t meet criteria. It took me a long time, bottoming out, before I was deemed non-functional enough to be allowed to see a psychiatrist who treated my depression. Turns out I didn’t meet criteria for depression because my depression was due to longstanding bipolar II. I eventually started mood stabilizers.

Not long ago I went to my primary care doctor because I thought my excessive tiredness was due to my meds and I wanted to review them. She did a thorough exam, sent me for a full battery of blood tests and referred me to a sleep clinic to be evaluated for sleep apnea. I’m getting a CPAP next week and if that doesn’t resolve my tiredness we can take a look at my meds then.

So my experience is entirely contrary to yours. I’m really sorry you were seriously injured and died because your primary care physician refused to treat you when they saw that you take an antidepressant, but that doesn’t happen to everyone.

Note that my primary care doctor has lots of time to see me even though I have to make appointments with her a long time in advance. If I have to see someone right away I can get a walk-in appointment with one of her colleagues who also has lots of time to see me.

I see my doctor at a public clinic; she is also a medical school professor.

I live in Canada. We have single-payer health insurance. Patients can’t self-refer to specialists, which has its up and downsides. Doctors don’t need a large staff to manage private insurance, which has only upsides. And in general I get excellent care.

Anonymous said...

Hi Allison,

I am glad your experience was more positive.

As an FYI, I was speaking in general terms as that has happened to many people. In my own situation, I feel I wasted 15 years of my life on psych meds when it turns out I had apnea. But I honestly can't blame anyone for that situation.

Unfortunately, I have been unable to stay asleep on a pap machine for any significant amount of time. I do wonder if being on psych meds has made my system so hypersensitive that I am unable to tolerate the therapy that I need. Another post.

Anyway, my point is that prescribing any med when there isn't a clear need is not benign and can be quite dangerous to someone's health in the short and long term.

AA

Amanda said...

I suffered burn out from the incredible stress from my job, what I really needed was to not work there anymore or at least a RX for leave and someone to talk to, could not talk to family because that would be "weak" yeah a bit dysfunctional. I was put on multiple antidepressants and soon became too apathetic to get myself to therapy to actually do the talking,
I had a few cathartic crying sessions but then became unable to get there or help myself because of them, unable to think, or function normally. I took myself off all but one, Effexor. I missed ONE day and it was terrible and I don't trust my Dr to know how to get me off correctly and I was not given complete informed consent before taking as to the yes, addition of Effexor. I have to now read and learn how to safely take myself off of it.
Talking would have avoided 2 yrs of hell, living like a hermit with no one to help me, no one. I could have stayed active and worked, now its all gone and I can only hope it gets better off the drug, I do have dysthmia (sp?) but it has always been manageable for me, talk would have helped me so much but the multiple drugs made that impossible.
I suggest if someone is going to use them to be on them for no more than 6mns and tapered very slowly off. They are appropriate in some cases short term, and a return of the depression is not another depression episode it is the side effect if coming off the drug ad will pass in a month or so, not a relapse. They should not be used as a CYA by the Dr. or to get you out of the door. but only as appropriate with complete informed consent. Talk therapy us a must.
First post Hi

Joel Hassman, MD said...

"If you want to get better, than take a pill, but if you want to get it right, face the truth."

This culture really doesn't get that statement anymore, eh?

Just today, I am working for an ACT pgm for a bit, and staff comes to me to see a patient I saw last week to change his meds, because he is not doing better. ONE F-----g Week! It sucks enough that patients don't know better, now fellow providers in the profession think this crap too?!

Gimme a break! Who else as a provider is burnt out with this quick fix BS!? Oh yeah, honesty is a weakness these days.

And DSM5, more paper to burn this winter!

PsychPractice said...

I'm gonna support the comment underdog here. That would be Dinah. Let's consider how this could turn out well. Guy goes to his PCP. "Doc, I'm depressed." Doc takes a cursory history to rule out other causes, then writes a rx for an SSRI, and schedules the patient for a f/u appointment. If it turns out the patient improves on the SSRI, and doesn't mind the side effects, great. If he doesn't improve, then the PCP refers him to a shrink for more in depth eval.
Not that different from a PCP taking a first shot at treating hypothyroidism, and then referring to an endocrinologist if things don't improve.
I remember being taught, in med school, that the most quickly accurate way to determine if a patient is depressed, in a primary care setting, is to ask, "Are you depressed?"
And most of the primary care docs I know are pretty good at picking up on psych problems, and pretty appropriate at referring when necessary.

Anonymous said...

Psych Practice, the problem is it may take more than a cursory examination to rule out other causes. Meanwhile, the patient is now being exposed to risks of antidepressants and the illness that is causing all the problems is not being treated.

And once someone has a psych diagnosis, everything is seen through that lens and the chances of getting a correct one are slim and none. Doctors instead of taking a fresh look at the case will simply usually rubber stamp the previous diagnosis.

AA

Anonymous said...

I much prefer the physician who doesn't automatically prescribe something. But, then I hate to take medicine, so there's that.

I appreciate the physician who can recognize that just because I c/o a symptom doesn't mean I want a medication for it. Sometimes, I've just needed reassurance that whatever it is will pass (i.e. a virus). I'm perfectly okay (and mostly relieved) when they suggest something that doesn't involve a medication.

I'm not a doctor. I don't know what I need. I want the physician to tell me what he/she thinks. I don't want a vending machine for a doctor.

Pseudo-Kristen