by John M. Curtis
(310) 204-8700

Copyright Aug 5, 2009
All Rights Reserved.

             U.S. drug makers reaped an unexpected windfall, watching antidepressant sales double between 1996 and 2005.  Antidepressant use went from 6% of the total population to 10% during a 10-year frame, accounting for wider use not necessarily an up-tick in depression.  In 2005, 27 million used antidepressants, largely selective serotonin reuptake inhibitors [SSRIs], designed to block the metabolism of serotonin, increasing the vital neurotransmitter in the brain.  “Significant increases in antidepressant use were evident across all sociodemographic groups examined, except African-Americans,” Dr. Mark Olfson of Columbia University in New York and Dr. Steven Marcus of the University of Pennsylvania in Philadelphia wrote in the Archives of General Psychiatry.  More emphasis on drugs, less on psychotherapy and growing off-label uses of antidepressants contributed to the record increase.

            Widespread use of SSRIs for regulating mood during menstruation and treating male sexual dysfunction no doubt contribute to wider use.  “Not only are more U.S. residents being treated with antidepressants, but also those are being treated and receiving more antidepressant prescriptions,” noted Olfson and Marcus’ report, indicating more clearly that primary care physicians have grown more comfortable prescribing the drugs for a wide variety of problems.  Despite Federal Drug Administration black-box warning labels, SSRIs are routinely prescribed for a host of childhood and adolescent problems, including attention deficit disorder and autism spectrum conditions.  With relatively few side effects, antidepressants are prescribed for a variety of behavioral problems.  Increased aggressive and/or self-destructive behaviors prompted the FDA to implement “black box” warning labels.

            Financial impediments in the mental health care delivery prompted more medications and less psychotherapy.  Most managed insurance plans save money emphasizing drugs over more costly counseling.  Outcome research indicates that medication alone rarely deals with the multiple causes contributing to depression and a host of behavior problems.   While the nature of depression remains poorly understood, boosting serotonin levels improves one closely correlated to brain chemistry.  As with other mental health issues, improved social interaction and better support systems contributes to improved outcomes.  “During this period, individuals treated with antidepressants became more likely to also receive treatment with antipsychotic medications and less like to undergo psychotherapy,” attesting to the cost-savings from drugs over psychotherapy.

            Attributing behavior problems to faulty neurochemistry also has its problems.  Whether prescribing antidepressants or not, patients still have to develop better coping strategies, unrelated to changing brain chemistry.  While there’s some evidence that a combination of drugs and therapy works best, there’s no proof that changing neurochemistry reverse conditions like chronic depression.  Many psychiatric patients are diagnosed with co-morbidity, having more than one diagnosis at a given time.  More emphasis on drugs marks a change in the prevailing psychiatric paradigm that, under pressure from drug industry, conceptualizes behavior problems as neurochemical imbalances.  Drug companies increase sales and make big profits when psychiatric patients get managed by primary care docs, never making their way to a psychotherapist’s couch.

            Independent medical researchers find little efficacy in antidepressant medications.  Many physicians routinely prescribe them to cover their liability in the event of some mishap like a suicide attempt.  Since Eli Lilly’s Prozac [fluoxetine] hit the market in 1972, the Church of Scientology has been warning against suicide attempts.  Anecdotal and clinical reports about antidepressants causing suicide have been routinely dismissed by drug makers.  Mental health practitioners have warned about the effects of mania increasing suicidal risk.  To the extent that antidepressants induce mania, it could increase suicidal risk and a host of other acting out behaviors, including, hypersexuality, pedophilia, gambling, crime, domestic abuse, violence and other destructive behaviors associated with mania.  No one knows the destructive effect of 164 million prescriptions written in 2008.

             With over $9.6 billion in annual sales in 2008, antidepressant medications have become a cash-cow to many drug companies.  Widespread use might very well contribute to an up-tick in violent and/or suicidal behavior.  “There are no data to say that the population is healthier.  Indeed, the suicide rate in the middle years of life has been climbing,” said Dr. Eric Caine of the University of Rochester in Upstate New York.  “Antidepressants are only moderately effective in population level,” disputing drug industry claims of efficacy.  Increased risks of suicide or suicidal thoughts in children and adolescents prompted the FDA in 2005 to issue high-risk “black-box” warning labels on all antidepressants.  Psychiatrists and primary care docs should think twice before prescribing antidepressants or risk increasing suicidal and/or violent behavior in otherwise depressed patients.

 John M. Curtis writes politically neutral commentary analyzing spin in national and global news.  He's editor of OnlineColumnist.com and author of Dodging The Bullet and Operation Charisma.