Antidepressants: Who Needs Them?

A woman who had been depressed for 20 years with frequent thoughts of suicide started Prozac, and, 10 days later, said "it felt like a switch was flipped. I felt normal for the first time."

Another woman had sunk into depression after the birth of a child, and had begun to think she was a bad mother, as she could not enjoy her baby. She started the antidepressant Remeron, and within two weeks was feeling cheerful and spirited again.

Antidepressants are truly miracle drugs for some patients.

Last week, a number of major media outlets highlighted a 2004 report from the Centers for Disease Control (CDC). The report showed that antidepressants were the most prescribed medication class, surpassing nonsteroidal anti-inflammatory drugs and anti-asthmatics.

Should this surprise us? Are antidepressants being overused?

A Brief History of Antidepressants

Fifty years ago, there were no antidepressant medications. In 1957, Roland Kuhn in Switzerland reported that the chemical N-(gamma-dimethlaminopropyl)-iminodibenzylhydrochloride, which came to be called imipramine, had a striking effect on patients with depression.

"They again become interested in things, are able to enjoy themselves, despondency gives way to a desire to undertake something, despair gives place to renewed hope in the future," he wrote.

In the same year, iproniazid, a tuberculosis (TB) drug was reported to lift the moods of some TB patients who were depressed. These two medications were the first of the tricyclic and monoamine oxidase inhibitor (MAOI) antidepressants, which were widely prescribed for the next 30 years.

But these medications have important side effects that made physicians cautious about their use. The MAOI antidepressants can cause dangerous, even lethal, changes in blood pressure in patients who consume foods such as aged cheeses, drinks such as red wine, or medications such as other antidepressants that interact with the MAOIs.

Similarly, the tricyclic antidepressants can be lethal if used in excessive amounts as happens when patients intentionally take an overdose, which depressed patients sometimes do.

By the 1980s, scientists had some idea about how antidepressants work. Brain chemicals called neurotransmitters seemed to play a role.

Two of them in particular, norepinephrine and serotonin, were decreased in the brain in depression, and increased in response to antidepressants. Scientists at Eli Lilly and Company developed a drug that could specifically increase serotonin levels in the brain, and Prozac, the first serotonin selective reuptake inhibitor, or SSRI, was born.

Prozac was free of the dangerous side effects of the MAOI and tricyclic antidepressants, and thus it could be prescribed more liberally by physicians, including those without psychiatric expertise, such as internists, obstetrician/gynecologists, and family practitioners.

The use of antidepressant medications has risen dramatically since that time. One study showed that the use of SSRIs and other newer antidepressants increased by 26 percent every year between 1989 and 2000 in primary care.

Whereas antidepressants were prescribed in 6.3 million visits in 1989, they were prescribed in 20.5 million visits in 2000.

Why Americans Need Antidepressants

Thus, answering the questions posed above requires us to understand the true problem of depression, and how these medicines can help.

First, it is important to understand that major depression (or clinical depression) is a very common illness, affecting 7 percent of Americans in any given year.

Second, antidepressants are effective not only for depression, but also for anxiety disorders, which are common as well, and for other problems such as insomnia, chronic pain and migraine headaches.

Some people have argued that using antidepressants in the setting of depression is not a good idea because these only paper over the "real" problems in people's lives. In fact, depression is a "real" disease and needs to be treated directly.

Certainly, people with depression do often have issues that need to be dealt with, such as problems in their marriage, or difficulties in the workplace.

But trying to fix these without first treating the depression with medication is like trying to fill the empty bathtub without first replacing the faulty drain stopper. One's efforts are likely to be energy down the drain. Once the depression is treated, life's challenges can be tackled with more confidence and competence.

Antidepressant Fears: a Growing Problem?

In the last three years, the number of antidepressant prescriptions written for children and adolescents has significantly decreased.

This has occurred largely in light of concerns from the Food and Drug Administration about potential suicidal behavior induced by antidepressants, particularly of the SSRI type.

A "black box" warning was placed on all antidepressants in 2004 to alert patients below age 18 to these concerns, and this past May an order was issued to extend the warning to include patients age 18-24.

Additional reductions in prescriptions could follow. This would be unfortunate, because although there might be a transient increase in suicidal risk associated with emerging from deep depression and becoming energized enough to act on suicidal thoughts, the far greater risk lies in remaining untreated.

While no treatment in medicine is without its risks and drawbacks, we use those that are likely to do more good than ill. With antidepressants, we sometimes get miracles, and often get substantial improvement.

Treatment is like brilliant sun for someone who has been under a dark cloud. Beautiful and warm -- but watch out for sunburn.

Dr. James Potash is an Associate Professor of Psychiatry and Co-Director of the Mood Disorders Program (http://www.hopkinsmedicine.org/moods) at the Johns Hopkins School of Medicine in Baltimore, Maryland. He has no financial relationships with any pharmaceutical companies. If you have questions or comments, please email at moods@jhu.edu. To participate in our studies, call 1-877-MOODS-JH.

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