Feeling Blue? Tense? Anxious?

peoplePills

Do you worry excessively or are you anxious a lot of the time?

Are you often bothered by the following:

• A – Feeling restless, keyed-up, or on edge?
• B – Feeling tense?
• C – Feeling tired, weak, or easily exhausted?
• D – Having difficulty concentrating?
• E – Feeling irritable?
• F – Having difficulty sleeping?

If you answered “yes” to these questions, you need (select one):

• A – To stop reading newspapers.
• B – Two weeks vacation with pay.
• C – A pint of Ben & Jerry’s Chocolate Therapy ice cream with the calorie and fat information carefully covered over with a black marker.
• D – A pill.

According to the makers of Paxil (paroxetine), the correct answer is D – A pill.

Ask and Ye Shall Receive?

Eli Lilly, the maker of Prozac (fluoxetine) offers the Zung Self-Assessment Test to see if you should be taking antidepressants. Lilly isn’t responsible for this test, but they do offer it for the benefit of people who would like to know their emotional state. It includes questions like:

• I feel downhearted, blue, and sad (not often – sometimes – often – all the time)
• My mind is as clear as it used to be (not often – sometimes – often – all the time)
• I feel hopeful about the future (not often – sometimes – often – all the time)
• My life is pretty full (not often – sometimes – often – all the time)

If you go down the list and enter “sometimes” in all the spaces, you’ll be advised to speak to your physician about whether you need an antidepressant.

Beyond the Psychiatrist

In the past, a psychiatrist usually diagnosed depression. This offered two benefits. First, patients had to have a reasonable degree of impairment of some duration before their family physician referred them to a psychiatrist. Second, psychiatrists are able to make a differential diagnosis.

But with the development of newer and safer drugs for the treatment of depression, family physicians and other primary care practitioners, who may lack both the skills and the time to do the same assessment as a psychiatrist, got into the game. In addition, this perceived safety resulted in an increased use of direct-to-consumer advertising.

Just because you can have it, should you have it?

By 1998, 65% of physicians said they had been approached by patients with brand-specific requests for drugs (Contracept Technol Update. 1998 Dec;19(12):153-5.). In April 2005, The Journal of the American Medical Association published the results of a study in which actresses approached physicians, and said that they had seen an ad for Paxil on television. Out of 49 such visits, 27 (or 55%) resulted in a prescription for an antidepressant, most often Paxil. By comparison, patients who did not mention an ad were prescribed antidepressants just 10% of the time.

The results of the study beg the question: Could any of these performers be said to have been properly diagnosed, let alone treated? After all, as long as SSRIs seem to be safe, there is no reason not to indulge the patient. It’s almost fair to ask whether those physicians who refused to prescribe the requested drug did so because it seemed medically inappropriate, or because they resent direct-to-patient drug advertising and were getting even.

There’s evidence that antidepressants are being prescribed when not necessary or appropriate. Pressures, such as from organizations wishing to keep costs down and/or from patients asking for prescriptions for the drug they saw on television, have altered the diagnosis and treatment of all but the most serious cases of depression.

A report in the August 2005 Journal of Affective Disorders makes the point that “treatment-resistant depression” is very likely to be nothing more than misdiagnosed depression. At one time, “treatment-resistant depression” was used exclusively to deal with depression that didn’t respond to changes in activity (Aust N Z J Psychiatry. 1994 Mar;28(1):14-22.), but it is being used increasingly to deal with cases that haven’t responded to a course of SSRIs.

And even if you’re a little bit depressed, antidepressants aren’t always the best treatment. In December 2004, the British National Health Service issued guidelines for treatment of mild depression. Since many cases resolve by themselves, the guidelines recommend beginning with a period of watchful waiting. Moreover, the guidelines specify: “Antidepressants are not recommended for the initial treatment of mild depression, because the risk-benefit ratio is poor.”

Additionally, there is some evidence that the relatively safe SSRIs are of limited effectiveness in an elderly population (Arch Intern Med. 2004 Jun 14;164(11):1197-204 and Am J Psychiatry 2004 161: 2050-2059.) Further, the American Journal of Psychiatry study said the very elderly did not respond to a dose of medication, active or placebo, as much as they did to having somebody visit with them, talk to them, and pay attention to them.

But what’s more interesting, the Zung Self-Assessment Test thinks that eating less, and steady weight loss, are symptoms of depression. According to Consumers Reports, in 2002, Americans paid $76 million for three of more than a dozen weight loss supplements (figures for the other products weren’t available). Based on this, I’d wager that for a lot of people, losing 10 pounds would do more to relieve depression than a year’s supply of Prozac.

Depending on Drugs

According to an NDCHealth audit, in 2004 there were 22,597,383 prescriptions written for Lexapro and 21,752,487 for Prozac. Other antidepressants routinely generated over 10 million prescriptions each. The total number of prescriptions written in 2004 for the most commonly used antidepressants came to 71,206,795 in the United States alone.

Depression is a growing problem. It should be. Anybody who doesn’t have occasional episodes of depression probably isn’t paying attention to what’s going on around them. Antidepressant therapy can be helpful, in properly selected cases. But it seems as if, in the interests of speed, we’ve replaced “get a life” with “take a pill.”

In Aldous Huxley’s classic, Brave New World, people enjoy the benefits of the happy pill Soma (a fictional drug, unrelated to the muscle relaxant carisoprodol, which is marketed under that name). In the novel, there’s a song lyric:

Hug me till you drug me, honey;
Kiss me till I’m in a coma;
Hug me, honey, snuggly bunny;
Love’s as good as soma.

Maybe we should try love first. After all, it seems to work with the elderly.

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