a couple of points. The OP makes their case by stating that x percent of those people they see (as a medical care provider) are on prescriptions. And no one yet has pointed out the basic :
Ummmm. dude. You see folks who have made a complaint to their doctors in the first place - that’s not really a good random sampling.
That part over, another point that I think is appropriate is that you’re also seeing them at one specific moment in time. I was on an anti depressant (for about a month - took I think a total of 3? pills). But if I’d come by your scope, I’d have been one of em. And was in fact one of whatever number of scripts in a given year. Point being that acute depression can also be a temporary condition.
I am quite prepared to believe that there’s been a huge increase in the number and percentage of scripts for depression. That’s not to say either that A) there’s more depression now than before or even B) we’re over medicating now.
I believe that we were seriously undermedicating before. (warning anecdote alert) in 1954 my mom saw her eldest child die of a genetically linked disease. She was 3 mo pregnant w/me at the time. They moved to a new house - with mom attempting to work through her grief and watch a 2 year old, deal with a summer pregnancy etc. Then I was born and the hospital gave her the wrong baby at first, told her not to be silly, that was her child, then realized their error, and also pooh-poohed her frantic fears when I displayed certain symptoms that her first child had also had at birth (‘don’t be silly, lots of babies are croupy’). I think some anti depressants would have been a good thing. She was told to ‘tough it out’
Do some doctors over prescribe? you bet. Do some folks seem to have a lower tolerance for life’s foibles? also a truth. Are we therefore overmedicating as a generality? Don’t know.
One of my basic problems with concepts such as the OP, is that we’re attempting to make generalizations about what is individually better. I get the same heebie geebies when folks talk about ‘do we do too many cesarian sections?’ as if there exists some magic number of correct ones that we can know about in advance.
When you establish a concept of ‘we’re over medicating’ or doing this that or the other medical treatment too much, then we run the risk of forcing individual physcians to make a medical decision for an individual patient not simply based on “what is best for this exact person at this time” but to keep this ‘are we overmedicating’ concept in mind as well.
I totally agree, and admitted that in the OP. But I didn’t think I would be off by 60%!!!
I don’t think that’s a risk at all. I think physicians SHOULD have that in mind, considering the power of these drugs and the tendency of many [I believe] to overprescribe the meds based soley on patients asking for them or based on some small amount of data gathered on the patient in the course of one visit.
Maybe I’m paranoid, but I work in a medical office and I’ve seen the way the drug reps push certain drugs. I’ve seen the small amount of information that physicians are fed from the drug companies in their handouts. Not the prescribing info, but pamphlets put out by the drug companies. I’ve also seen many of my family and friends using the drugs and I wasn’t so sure that they were the answer. Then again, IANAMD so…
Perhaps the answer would be to put the drugs in the hands of people trained to use them. Maybe give them to psychiatrists(or psychologists, can never remember which one is the MD), or something, instead of any old Joe MD being able to prescribe them. Heh, that would make some of these guys just a tad bit angry, what with all the God-Complexes running rampant in doctor’s offices and hospitals.
I don’t know the answer, but some people have expressed some of my fears in this thread. I hate to see people give control over to a drug if it’s not neccesary when they could have got better some other way, or especially if they are just experiencing “normal depression”.
Well, actually, I think it’s entirely possible given the select sampling to be off that much. As an example - I work w/exoffenders, should I start speculating about what percentage of folks are using/abusing drugs based on my clients? nope.
I do understand your concern re: the drug reps et al (after all baby brother of mine sells hospital surgical supplies for a living - suddenly everyone should have mirogel for sinus surgery). Except that if the dr. is doing what I suggest (look at exactly what is best for that specific patient right then) then that’s what it should be. I stand behind my concern that the doctor should NOT in fact look at statistical averages over the population as a whole, At least partially because they aren’t seeing anywhere near a good random sampling.
So, to take your example, if Doctor feelgud reads in his most recent JAM that 40% of the population could be considered clinically depressed, should the good Doctor make the leap that in their practice 40% will be, too? I would say not on your life - their practice may range anywhere from 20% up to 80% depending on the luck of the draw. And, if, for example, the good Dr. does a family practice where many members of the same large extended family are also seen, can’t you see that might skew their particular demographics quite a bit?
While generalizations about large populations have their place and can be good things, you really need to be careful when taking that large generalization and attempting to insure that same level is true for a much smaller group. (another, better example is demographics - the City of Detroit, for example has a much, much, much larger percentage of minority residents than the state of MI as a whole, despite it being the largest city in the state - see what I mean?)
This is something I’ve thought about a lot. I am the only member of my family (parents, sister, aunts, uncles, first cousins) who has never taken an antidepressant. Out of the bunch, the only one who I would define (completely absolutely, 100% IMHO) as severely depressed, longterm, is my father. I believe at this time that my sister is off of them and my mother is taking St. John’s wort when she remembers. 3 out of 4 of my best friends are on them now.
I have very mixed feelings about the subject. I think that we are, as a nation, overmedicated wimps. Sprain your ankle? Take two Tylenol and walk on it anyway. Have the sniffles? Take an antibiotic - no, it probably won’t help, and it will give you a yeast infection if you’re female, and it might breed a resistant strain of something that you really don’t want, but WTF, ya never know?
I think that in some cases, extreme, never-get-out-of-bed-or-leave-the-house depression is a luxury. Or, at least some of the stuff that comes with it is. Most depressed people I know still manage to get out of bed and do what they need to do to pay rent. For my father that was working an hour a day, four days a week, 8 months a year, as a tenured professor. For my friend Elisabeth it means putting in a 50 hour work-week. I think that if my dad had chosen a path that required him to be at work 40 hours a week, he would have been. As it is, for 20 years he went to work when he had to, came home and went to bed, and got up for dinner, watched TV for an hour, and went back to bed. He has been suicidal for almost my entire life. Maybe not having much to do contributed to his depression, I don’t know.
My mom’s theory is that depression is contagious. I think that on some level she’s right. At various times in my life, including right now, my father’s depression has directly influenced my mood. It is difficult to spend time with a truly depressed person and not get pulled down too. I think that maybe those people, the pulled-down-by-association, are the ones that could benefit from a talking therapy over drugs.
That’s the route I chose when I got depressed. I always kept the idea of pills on the back burner, but I was terrified of the side effects (specifically hand tremors, which both my father and sister developed). It took a couple of years, but I’ve been stable and happy for a while now, and have the tools to take care of myself moving forward. I also still have my therapists number, just in case.
Two years ago we finally found the real physical, and emotional roots of my father’s depression. He went to a sleep clinic as a last resort. Originally he was supposed to stay for a night. I think they kept him for a week. He had such a severe apnea that he never got more than 10 minutes of REM sleep in a night. According to the doctors he should have been dead years ago, or completely insane. The apnea is caused in part by massive scar tissue, due to his nose being broken at least 6 times before he was two years old. Unfortunately it has been going on too long, fixing the physical problem hasn’t been enough. We’re all still dealing with the emotional realities of that kind of abuse, and he’s built up insane tolerances to all of the available drugs. Nothing works for him anymore and we are now looking into a new device which electrically stimulates the vagus nerve that is currently in trials in Texas. If it doesn’t work, I am positive we will lose him to apathy or suicide within the next few years.
Sorry for the completely personal digression, but sometimes it helps to put a story with a debate.
Yup, Cyn is correct. His father abused him physically for most of his childhood, and emotionally until he finally died a few months ago.
My father had never dealt with the physical aspects of the abuse, just sort of swept it under the rug, until the sleep clinic proved to him that the abuse provided a physical root to all of his problems.
I just reread what I wrote last night, and would like to add a couple of things for clarity. When I was talking about us being overmedicated wimps, I never finished the thought. I think that for most people, physical or emotional pain is a signal, your body/mind has had enough and you need to give it a rest. Stay in bed, wallow for a few days, really feel it and move on. I think that we are wimps because we’d rather drug it and not feel it at all.
For people like my dad, the drugs did help for a time. It was amazing. For about a year he made some friends, talked to me and my sister, had a life, and then they stopped working. I know for many people like him, they do continue to help, and are absolutely a positive thing.
I believe that most people have never seen a truly, deeply depressed person. I also see learned behavior in my own bouts with it. For example, my first bad one was 7th grade. I went to school, came home, covered my bedroom windows with tin-foil, and sat in bed with the lights off until dinner time. I ate dinner and went back to bed. It never occured to me until a year ago where I learned that behavior.
I question the efficacy of drugs in short-term or event driven depressions. I think in many cases people tend to bottom out (although that bottom may get shallower and shallower as people rely more and more on drugs), call the shrink and do something about it. Then they start to feel better. I think the act of doing something about it, whether it’s getting drugs, entering therapy, getting a job you like, kicking out the horrible roommate, whatever, is the turning point for a lot of people and begins the upswing. People who take Prozac attribute the better feelings to the drug and may go back to it again, but I think the sense of control from taking charge is the real cure.
Consider that the much more effective conventional psychiatric one-on-one conversational therapy also costs ten to one hundred times as much as mother’s little helpers and you will quickly see why HMO’s are content to sign off on what is, for the most part, totally inneffectual and superfluous over-medication.
No one is being done any favors by this and no one should fool themselves into thinking that this recent spate of unnecessary drug based psuedo-therapy won’t pose some serious problems for our population in the near future.
I’d love to dive into this debate, and perhaps I will once things slow down.
I did want to respond to this, though. The studies I have read have said that for people with moderate to severe depression, SSRIs alone are much more effective than therapy alone. The drugs plus the therapy are just a little better than the drugs alone.
I have a long post brewing on this issue, and I might get it posted tonight if it’s a slow call night at the VA.
I believe the Irvin and Lynn (1999) article is the best at getting at the effectiveness rates of SSRI’s and placebos. There are a number of others, which I would have to look up, but would be happy to do so if you would like.
Regarding the 2-4% effect size, there is a movement in psychology to place less emphasis on "statistical significance" and more emphasis on "effect size"...the reason being is that it is very easy to manipulate statistics in such a way as to obtain "statistical significance" for virtually anything. "Effect size" is somewhat (though not impossibly) harder to manipulate and thus sometimes a better measure of the importance of a finding. 2-4% effect size is nearly 0% effect size. Of course we should not ignore any findings which are significant, however the point I was trying to make is that while there may be some relatively tiny influence of biology on depression (and perhaps even that relegated to hypothytoidism, vitamin deficiencies, or poor exposure to sunlight and excersize, rather than a "chemical imbalance") depression is unlikely to be, in most cases, the "medical disease" some folks assume that it is.
Why do HMO's cover the prescriptions for SSRIs? Well many HMO's cover Viagra as well, despite a host of research that, once again, suggests most cases (though certainly not all) of impotence are not due to medical problems. My answer would be that some bean counter somewhere decided that it would be more costly for the company to discontinue covering SSRIs (in terms of lost consumers) than to continue covering SSRIs. I suspect it was economics, not research, which dictates such decisions. Is there anyone here that actually believes HMOs are primarily concerned with following clearly established and researched medical procedures whatever the cost?
Even with “Effect size”, one must place it in context using the mean, standard deviation, etc. for it to make any sense. You cannot say that “2-4% effect size is nearly 0%”, unless perhaps you know the standard deviation to be 2%.
For the sake of argument, if I measure the width of widgets and the mean is 1.000 inch with a standard deviation of .001 and population of 1000, then a widget found to be 4% out (1.040 inches in this example) is clearly a significant finding.
It gets a bit heady, but page down in the Effect size page to see an example that actually uses SSRI data collected by Van Etten & Taylor, and once again the conclusion is that there is a significant effect.
[oh, please no smile at the end of a discussion, it reminds me of Seethruart shudder]
A view from a non-Capitalist healthcare system so take the following with a pinch…
Isn’t the disconnect to do with, on the one hand, the drugs being prescribed by a qualified practitioner in receipt of all the facts (and who may or may not be under the ‘influence’ of a pharm company) but who, also, will be exposed to potential litigation for his / her actions / inactions and, on 'tother, the information / evidence available re the need for an ambulance ?
From afar, the healthcare system appears to be driven by profit and. potential litigation – wouldn’t a combination of those two factors be the root of most decisions ?
Before I question some of the statements I’ve read here, let me say that yes, I think SSRI:s and other anti-depressants are overprescribed.
I’m at home, so unfortunately I don’t have the statistics handy, but IIRC the prevalence of Major depression is about 5-6%, the incidence a bit higher. Of patients with the diagnosis Major depression, about 10% will develop Chronic depression (lasting +2 years). The prevalance of mild to moderate depression is much higher, about 10-15%.
(Prevalence = percent of a population who has the disorder at a given time, usually 1 year
Incidence = percent of a population who will develop the disorder during their life time)
Regarding what is anti-depressants and not of the medicines you list, please se below. I’m especially unpleasantly surprised to hear you have many patients on clozapine, since the risk of very severe, even lethal side-effects (risk of agranulocytos is 1-2%) is rather high. Where I live, clozapine has only one indication, and that is therapy-refractory schizophrenia.
The link between serotonin and depression has been firmly established the last decade. I’m not sure what you mean by “theoretical”? The serotonin hypothesis for depression started back in the 1960’s and has since been investigated both with in vitro methods such as autoradiography and postmortem spinal taps, but also in living people with methods such as cerebrospinal fluid measurements (starting in the 1970’s), platelet studies (yes, platelets have serotonin receptors! studies started in the 1960’s) and more recently, micro-dialysis and positron emission tomography receptor studies.
If you however doubt the link, I have 100:s of references, but if you’re interested in the area, the easiest is just to perform a search on Pubmed/Medline with the terms “serotonin” and “depression”. Authors like Asberg, Artigas, Delgado and Stahl provide good basic references. A nice book with an extensive chapter covering serotinin, is:
Feldman, R. S., Meyer, J. S., Quentzer, L. F. (1996). “Principles of Neuropsychopharmacology”.
For interested laymen, I recommend review articles since those are less technical, and also, there’s a really good book around with wonderful pictures: SM Stahl (1996) “Essential psychopharmacology”.
So, I don’t really understand what you mean when you say the link between serotonin and depression is not well documented. However, a link between A and B is not the same thing as A causes B.
What effect size are you referring to here? Effect size of efficacy of SSRI:s compared to placebo, or effect size of differences in measurements of serotonin turn-over rate between depressed patents and healthy controls?
Why should we assume this? Since the link between serotonin and depression (and anxiety) is well established, a study demonstrating this is not so, would indeed be very hot stuff to publish.
I’m sure there are some studies around that show low effectiveness of SSRI:s, but there are 100’s of randomized, double blind placebo controlled studies around that show an efficacy of about 60% and significantly better than placebo. (Which is the same efficacy as the older TCA:s had, but with less side-effects).
I actually looked for the Irvin & Lynn article, but I couldn’t find it. Could you please post a link where to find it, or at least the abstract?
What studies are these? Are they controlled clinical trials? What was the inclusion criteria? Do you have any references?
About studies funded by drug companies - yes, the drug industry certainly want to make their medicine look as good as possible. But it’s actually very easy to check whether a study was funded by a drug company or not - all sources of fundation must be published together with the paper.
Also, I don’t want to be picky, but most of the medicines on your list above are actually not SSRI:s. Just for clarification:
Efexor (venlafaxine) is an SNRI (Serotonin Norephinedrine Reuptake Inhibitor), it affects the norephinedrine (NE) system as well as the serotinin (5-HT) system. It also has some effect on dopamine (DA).
Elavil (amitriptyline) is a TCA (tricyclic antidepressant), ie the older type of antidepressants that are largely replaced by SSRI. TCA:s has a different mechanism of action from SSRI:s and SNRI:s, although they also affect 5-HT and NE.
Wellbutrin (bupropion) only has a minimal effect on the 5-HT system. Instead, it inhibits reuptake of DA and NE.
Prozac (fluoxetine) is an SSRI
Paxil (paroxetine) is an SSRI
Other SSRI:s are: Citalopram, sertraline, fluvoxamine maybe something more I don’t remember on top of my head.
Finally, I just want to say I agree with this, but I think the problem is more complicated than people just wanting a “quick-fix”. There’s also a finacial aspect. Like you, I’ve seen studies demonstrating Cognitive behavioural therapy as being an equally efficient treatment for depression as pharmacotherapy (even more, since recurrency rate is lower), but it’s a lot more expensive.
PS: Have you checked out APA:s “treatment of choice” standard?
