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Antidepressants: The New Candy?

It should come as no surprise to anyone paying attention to health care (not to mention modern American society) that antidepressants are very heavily prescribed.  They are, in fact, the second most widely prescribed class of medicine in America, with 253 million prescriptions written in 2010 alone.  Whether this means we are suffering from an epidemic of depression is another thing.  In fact, a recent article questions whether we’re suffering from much of anything at all.

In the August issue of Health Affairs, Ramin Mojtabai and Mark Olfson present evidence that doctors are prescribing antidepressants at ever-higher rates.  Over a ten-year period (1996-2007), the percentage of all office visits to non-psychiatrists that included an antidepressant prescription rose from 4.1% to 8.8%.  The rates were even higher for primary care providers: from 6.2% to 11.5%.

But there’s more.  The investigators also found that in the majority of cases, antidepressants were given even in the absence of a psychiatric diagnosis.  In 1996, 59.5% of the antidepressant recipients lacked a psychiatric diagnosis.  In 2007, this number had increased to 72.7%.

In other words, nearly 3 out of 4 patients who visited a nonpsychiatrist and received a prescription for an antidepressant were not given a psychiatric diagnosis by that doctor.  Why might this be the case?  Well, as the authors point out, antidepressants are used off-label for a variety of conditions—fatigue, pain, headaches, PMS, irritability.  None of which have any good data supporting their use, mind you.

It’s possible that nonpsychiatrists might add an antidepressant to someone’s medication regimen because they “seem” depressed or anxious.  It is also true that primary care providers do manage mental illness sometimes, particularly in areas where psychiatrists are in short supply.  But remember, in the majority of cases the doctors did not even give a psychiatric diagnosis, which suggests that even if they did a “psychiatric evaluation,” the evaluation was likely quick and haphazard.

And then, of course, there were probably some cases in which the primary care docs just continued medications that were originally prescribed by a psychiatrist—in which case perhaps they simply didn’t report a diagnosis.

But is any of this okay?  Some, like a psychiatrist quoted in a Wall Street Journal article on this report, argue that antidepressants are safe.  They’re unlikely to be abused, often effective (if only as a placebo), and dirt cheap (well, at least the generic SSRIs and TCAs are).  But others have had very real problems discontinuing them, or have suffered particularly troublesome side effects.

The increasingly indiscriminate use of antidepressants might also open the door to the (ab)use of other, more costly drugs with potentially more devastating side effects.  I continue to be amazed, for example, by the number of primary care docs who prescribe Seroquel (an antipsychotic) for insomnia, when multiple other pharmacologic and nonpharmacologic options are ignored.  In my experience, in the vast majority of these cases, the (well-known) risks of increased appetite and blood sugar were never discussed with the patient.  And then there are other antipsychotics like Abilify and Seroquel XR, which are increasingly being used in primary care as drugs to “augment” antidepressants and will probably be prescribed as freely as the antidepressants themselves.  (Case in point: a senior medical student was shocked when I told her a few days ago that Abilify is an antipsychotic.  “I always thought it was an antidepressant,” she remarked, “after seeing all those TV commercials.”)

For better or for worse, the increased use of antidepressants in primary care may prove to be yet another blow to the foundation of biological psychiatry.  Doctors prescribe—and continue to prescribe—these drugs because they “work.”  It’s probably more accurate, however, to say that doctors and patients think they work.  And this may have nothing to do with biology.  As the saying goes, it’s the thought that counts.

Anyway, if this is true—and you consider the fact that these drugs are prescribed on the basis of a rudimentary workup (remember, no diagnosis was given 72.7% of the time)—then the use of an antidepressant probably has no more justification than the addition of a multivitamin, the admonition to eat less red meat, or the suggestion to “get more fresh air.”

The bottom line: If we’re going to give out antidepressants like candy, then let’s treat them as such.  Too much candy can be a bad thing—something that primary care doctors can certainly understand.  So if our patients ask for candy, then we need to find a substitute—something equally soothing and comforting—or provide them instead with a healthy diet of interventions to address the real issues, rather than masking those problems with a treat to satisfy their sweet tooth and bring them back for more.

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25 Responses to Antidepressants: The New Candy?

  1. Rob Lindeman says:

    Yeah, but I WANT candy!!!

  2. A Non says:

    You know, I was in a lot of trouble in 1994 and 2008, and Zoloft and Celexa got me out of that trouble. But to the point of the article, it was my primary care doc in 2008 who started me on Celexa after taking my history (including pdocs) and current symptoms. Is there an Official Diagnosis noted anywhere anywhere from my 2008 visit? I hope not.

    If I couldn’t get the meds without my PCP making a particular diagnostic call and writing it down, I might have just said “Forget it.”

    Not sure why people are riding this “But there’s no DIAGNOSIS!” hobby horse.

    • stevebMD says:

      A Non,

      It’s not the fact that there’s “no diagnosis,” but what that most likely represents in most cases: a hasty, superficial assessment of the patient’s symptoms and the knee-jerk prescription of something that doctors and patients almost universally consider to be “safe.” Sometimes the medication works (and, as in your case, the patient has a condition that responds to the SSRI or whatever is prescribed), but if it doesn’t, the mentality seems to be, “oh well, no big loss.”

      I’m not criticizing primary care docs. They’ve got an incredibly difficult job to do. Instead, I think this trend says more about antidepressants and what we consider to be “psychiatric” illness: simple and common complaints that become medicalized (although without an actual diagnosis) and the widespread belief—by patients and physicians—that a pill will fix them. The fact that this has become more common means that something about it “works.” What does this say about psychiatry?

      • A Non says:

        What does this say about psychiatry?

        They don’t want to get sued? The pdoc I just dropped kept insisting I get on drug X which was on-label only for bipolars and schizophrenics. I asked him if one of these was his diagnosis and he stayed quiet.

        I vote for fear of tort more than anything else. My $200/hr pdoc wouldn’t give me any diagnosis, and I wouldn’t dream of demanding one from my harried PCP.

        I think you’re looking in the wrong place (i.e., pts who want candy). I suggest looking at pt reluctance to leave a trail, and MD reluctance to make a call.

  3. A Non says:

    And the “I Want Candy” wars continue:

  4. I absolutely agree that antidepressants are way-overprescribed, prescribed for conditions for which they are not effective, and often prescribed completely unnecessarily to people who will not benefit from meds but would from seeing a good therapist. (And don’t get me started on the overuse of antipsychotics. A LOT of people think Abilify is an antidepressant).

    This of course does not main that SSRI’s, SNRI’s, trycyclics and MAOI’s are ineffective or unnecessary for certain clinical syndromes. These two issues are often mixed up without even an acknowledgment that this is being done.

  5. Iatrogenia says:

    I’m sure Dr. Steve is aware of the studies showing very poor follow-up and monitoring by primary care doctors after antidepressant prescription, and a lack of knowledge of adverse effects.

    Primary care doctors often leave patients on antidepressants for many years for no good reason.

    Given that psychiatry is also remiss in monitoring, follow-up, and timely discontinuation of medications, saying primary care doctors are worse is a euphemism for negligent.

    Both primary care doctors and psychiatrists are now overlooking treatable medical conditions because they reflexively throw antidepressant “shut-up pills” at patients instead of conducting thorough medical reviews. The medical conditions deteriorate as doctors strenuously medicate the red herring of a vague “depression.”

    All of this carelessness leads to patient injury. Given that perhaps 100 million people are taking antidepressants worldwide, the number of injured is no doubt in the millions.

    Antidepressant overprescription is not just a little glitch in the medical delivery system, it’s a true public health issue.

  6. […] It should come as no surprise to anyone paying attention to health care (not to mention modern American society) that antidepressants are very heavily prescribed.  They are, in fact, the second most widely prescribed class of medicine in America, with 253 million prescriptions written in 2010 alone.  Whether this means we are suffering from an epidemic of depression is another thing.  In fact, a recent article questions whether we’re suffering fr … Read More […]

  7. Eli Lilly Zyprexa,Risperdal and Seroquel same saga

    The use of powerful antipsychotic drugs has increased in children as young as three years old. Weight gain, increases in triglyceride levels and associated risks for diabetes and cardiovascular disease.
    The average weight gain (adults) over the 12 week study period was the highest for Zyprexa—17 pounds. You’d be hard pressed to gain that kind of weight sport-eating your way through the holidays.
    One in 145 adults died in clinical trials of those taking the antipsychotic drugs Zyprexa. This is Lilly’s # 1 product over $ 4 billion year sales,moreover Lilly also make billions on drugs that treat the diabetes often that has been caused by the zyprexa!

    Daniel Haszard Zyprexa victim activist and patient who got diabetes from it.

  8. Luxus says:

    Anybody pointed out that adding a Psychiatric diagnosis or procedure code means that the Primary Care MD will get a third of his reimbursement rate?

    • stevebMD says:

      Luxus,

      That is an excellent point, and certainly docs can (and do) refrain from giving certain diagnoses because of reimbursement issues or potential stigma to the patient. However, in this particular study (and I’ll admit, I did not describe the methodology in detail in my post), doctors reported data about office visits in an anonymous survey. In other words, data did not come from billing records or patient charts, so there was no reason for the doctor to falsify or omit data.

      On the other hand, the survey only permitted the doctors to list a maximum of three (3) diagnoses and six (6) medications. So if “depression” was indeed on a patient’s list of diagnoses but was #4 (after HTN, DM, and chronic pain, for example), then it would not have been reported. But that just begs the question: if a PMD is treating a complicated patient with three non-psychiatric diagnoses that “trump” the psychiatric diagnosis, then is it even relevant to prescribe the antidepressant? Or is the antidepressant being used for an off-label indication?

      • Luxus says:

        And what do you mean by trump? Do you mean by that to treat 1,2 and 3 but not four?
        Here is a reason they might be prescribing antidepressants:
        http://www.ncbi.nlm.nih.gov/pubmed/10904452

        And here is an other:
        http://ajp.psychiatryonline.org/cgi/content/abstract/150/5/734

        A blow to biological psychiatry? that is a funny comment,almost as funny as the primary care doctors managing mental illness ‘sometimes’ statement;
        one of the reasons the 15 minute med check is prevalent in Psych is that a/ that’s where the money is,b/ there are more patients to be seen than there are psychiatrists to see them and c/we have more medications available to us than I don’t know,50 years ago?

      • stevebMD says:

        Luxus,

        Those references are certainly pertinent. Indeed, latent depressive illness & its manifestation as “somatization” in the primary care setting may compromise patients’ response to medical treatment. However, it seems like an argument ex post facto — i.e., a retrospective justification for the addition of an antidepressant to a patient’s regimen. And that’s what I mean by “trump”: if three concurrent (medical) illnesses are being treated, it’s certainly possible that the patient also has clinical depression, but the typical primary care doc doesn’t have the time (or the expertise) to do a full evaluation to determine whether this is the case; in these cases, the addition of an antidepressant for the reasons you describe unfortunately ends up being a shot in the dark, so to speak.

        Regarding the “blow to biological psychiatry,” I’m referring to the fact that if these drugs are used as widely as they are, for improvement (however slight) of a wide variety of conditions for which they were never intended, this just strengthens the argument that they’re nothing more than placebos. Personally, I think these can be extraordinarily effective medications, but their profligate use (as explained by Iatrogenia below) weakens the role of the astute diagnostician, rewards drug manufacturers, and makes patients potentially susceptible to many unnecessary side effects.

  9. Carol Levy says:

    I wonder if some of that is for chronic pain. In doing a fast google search there are many articles giving credence to the use of these meds for those with chronic intractable pain
    http://www.aafp.org/afp/2005/0201/p483.html
    http://www.mayoclinic.com/health/pain-medications/PN00044
    That being said the use of these psych drugs for non psych (or no psych) reasons is not uncommon. You merely have to think back to the 50’s and 60’s when they gave out valium like candy.

  10. Iatrogenia says:

    Luxus, the definition of depression is so vague, psychiatrists don’t even understand what it is. Who knows what primary care doctors are seeing as “depression” or “anxiety.” A shortage of psychiatrists — that makes me laugh.

    Psychiatric drugs are currently prescribed to at least 10% of the US population over the age of 6. 90% of those drugs are antidepressants, and 2/3 of those who receive them are female.

    If the medications were prescribed to the truly severe cases — which is what the original indications were for, truly severe illness — they’d be prescribed a tenth as often. Which would mean a huge decline in business for psychiatry (oh, too bad) and PCPs could go back to treating medical conditions, which so badly need to be addressed.

    (Psychiatric drugs also make their own gravy in side effects etc. that PCPs can’t handle and send to psychiatrists, who are also clueless but fake it, often with polypharmacy, and then you have life-long customers — errr — patients filling up your appointment book.)

    Carol — Pharma has done its darnedest to expand indications for antidepressants far and wide, focusing on common complaints of women (men avoid the drugs for their sexual side effects). The quality of the research is as suspect as any in psychiatry. Again, who knows what is being diagnosed as fibromyalgia, PMS, etc. and whether the drugs are truly the appropriate treatment or merely first-line shut-up pills flung at women.

    • Luxus says:

      I am a big fan of knowing what we treat…..maybe there should be a moratorium on all Psych meds until we know what Bipolar Disorder,Schizophrenia,Depression,Panic Attacks etc are ( and I mean a complete explanation,with nice blood tests and imagery etc )…that or start everybody in Psychotherapy because that is really the most reliable,consistent and well studied intervention we can be trained to deliver ( that and the fact there is no way Pharma is interested in promoting it )

    • stevebMD says:

      Luxus,

      Just a follow-up. Interesting article from the WSJ about the Health Affairs study, relevant to your comment. (Click here to read.) If you ask me, this is the future of psychiatry– the gray zone between mind and body, the unexplored territory which contains the suffering of so many souls. When (if?) we have the “blood test” or the “MRI scan” to diagnose depression or bipolar or schizophrenia, those disorders will be treated by PMDs or neurologists. And why not? Easy test, easy cure. But there will always be an enormous population whose lesions are not so distinct, and who need the understanding and compassion of people like you and me to understand, explain, and soothe their woes. That‘s what we can offer as psychiatrists.

  11. AA says:

    Steve,

    Actually, the WSJ article addresses this exert from Iatrogenia’s previous post:

    “Both primary care doctors and psychiatrists are now overlooking treatable medical conditions because they reflexively throw antidepressant “shut-up pills” at patients instead of conducting thorough medical reviews. The medical conditions deteriorate as doctors strenuously medicate the red herring of a vague “depression.””

    In my opinion, this is the key point from the article:

    “More than 100 medical disorders can masquerade as psychological conditions, according to Harvard psychiatrist Barbara Schildkrout, who cited these examples among others in “Unmasking Psychological Symptoms,” a book aimed at helping therapists broaden their diagnostic skills.”

    Which leads to my next question to you and any psychiatrist who posts on this blog.

    When you see a patient for an initial psychiatric evaluation, what procedures do you follow to make sure that these disorders that can masquerade as psychological conditions aren’t missed?

  12. Carol Levy says:

    Iatrogeniua, I have been an advocate for women in pain awareness for some time now. Research shows gender bias still existsagainst women with complaints of chornic pain despite our having higher incidences of disorders with chronic pai9n as the main or sole complaint.
    To lump PMS into this category of pain disorders which include rheumatoid arthritis, lupus, MS, trigeminal neuralgia, CRSP etc.is to do a disservice to those who live with chronic intractable pain (CIP). (You may be one of the ‘disbelievers in fibro so I will not address that.)
    The clicks I provided do indicate these meds have a place in the treatment of CIP. Google antidepressants and chronic pain and you will find more articles and research info. I am not necessary a proponent of them, just an advocate for any med that provably has been able to get many of us out into the workplace or even just out of bed or able to tie our shoes in the morning.
    This being said my mother had severe psychiatric problems and these meds were thrown at her by a numberr of psychiatrists, the last one telling her everytime she called with complaints of more and more distress, “Take another elavil, etc.”
    Carol
    (author A PAINED LIFE, a chronic pain journey)

    • Iatrogenia says:

      Carol — I’m not a disbeliever in chronic pain, or a disbeliever in fibro, or any of the mysterious syndromes that women (and men) complain of that haven’t yet been pinned down by medicine.

      Yes, you can Google and find lots of studies recommending antidepressants for this and that. The quality of the studies is in question. Most are done by drug companies or researchers beholden to drug companies. They don’t have credibility beyond any other type of study for antidepressant efficacy.

      I’ve actually read many of them.

      The enormity of it is hard to understand: The entire research base for antidepressants, and I do mean all of it, is questionable, for every application, from depression to fibromyalgia.

      I’m sorry if this means no silver bullet for chronic pain disorders, I know a lot of people have put their hopes into antidepressants.

      And personally, I find the targeting of women for antidepressant sales to be highly suspect and deeply offensive.

      • Iatrogenia says:

        Coincidentally, this patient survey info was just released:

        Patients Say Fibromyalgia Drugs Make Things Worse, Rest is Best http://tinyurl.com/3mlytsl

        Antidepressants Prozac, Effexor, and Cymbalta are down at the bottom among “Popular but less helpful,” with heavily advertised Cymbalta being the least helpful of all treatments.

  13. Carol Levy says:

    I have been tried on cymbalta and lyrica, among others to no avail and personally think they are awfl meds, the side effects so awful I went off them within a day.
    It appears (and I am not a medical person) that a majority of CIP disorders tend to be of autoimmune origin, lupus et al and are not mysterious other than maybe why they start iin the first place.
    I am not surre of you are coming from a place of objectivity or prejudice in your reading of the literature. I guessd for me bottomj line is don;t throw out the baby with the bathwater.(or paint all the meds with one brush)
    If women are specifically targeted that is offensive definitely, that being said for women have higher incidences of many of the physical disorders named previously.
    Interesting though that women are often ignored with their complaints of pain and told thery are depressed or it is psychiatric so you may well have a built in audience for thesemeds if only for the bias of many of thesedocs.

  14. Iatrogenia says:

    Dr. Steve and Luxus — Doesn’t it make sense if a person is feeling physically lousy he or she might be feeling down emotionally? Does this really deserve to be called “depression,” treated with the introduction of yet another powerful medication with side effects and drug-drug interactions that further obscure medical treatment? And does this justify keeping the person on a psychiatric medication long after the medical condition has been resolved?

    Studies showing “heart attacks associated with depression” or “diabetes associated with depression” make me angry. Really, wouldn’t you expect a sick person to feel down? Isn’t that a normal reaction?

    Compartmentalizing physical well-being and emotional well-being, as though medical conditions have nothing to do with how the person views life or feels about his or her competency — that’s inexcusable from a profession that claims to treat the “whole patient.”

    The problem is doctors are encouraged to think of psychiatric drugs as a harmless overlay, like a multivitamin, over medical conditions, instead of a risky complicating factor. The drugs can’t do anything but good, right?

    This puts me in mind of an older friend who was in a nursing home on after a heart attack and a botched angioplasty. The house psychiatrist came in recommending, guess what, an antidepressant on top of the 8 drugs she was already on. He insisted she was depressed. She insisted she was having a normal reaction (angry and sad) to her condition. She was right, of course. But how many people get caught up in “the doctor is always right” when these clueless prescription-mongers walk in?

  15. Tim Harmon says:

    My very active and vibrant 69 yr old mother-in-law was stressed over her daughters mental problems. She went to her doctor for something to help her sleep. The doctor prescribed Lorazapam 3 times a day. Within 2 weeks we all noticed she was having memory problems. We did a search online and found out that lose of memory was one of the side effects of taking that drug. I told her she needed to get weaned off, and that it could be very addicting. Too late – she was already hooked. We printed out the information we found online and presented it to her doctor, he said she hadn’t been on it long enough to “get hooked”. He kept prescribing them to her. When she ran out and couldn’t get more, she would raise hell rocking & screaming until we had to take her to the emergency room, where they would sedate her. The hospital even gave her another prescription for Lorazapam! Now she would take both prescriptions!! We found her laid out unresponsive one day. The ambulance took her back to the hospital and said she was “dehydrated”. Nobody wants to take responsability. We have been in & out of hospitals for the past two years now, and have finally had to put my mother-in-law in a rest home because she has anterograde amnesia, and can’t make any new memory’s. She has been found wandering in the street in freezing temperatures, not knowing where she is or what happened 3 minutes ago. The doctors say dementia. We say the drugs.

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