Think Twice Before You Dump Antidepressants
Placebos may work as well in many, but that might not include you
By JoNel Aleccia
There's little question antidepressants are overprescribed and that many people who take the most popular drugs in America might do just as well with therapy or even a trip to the gym.
But that doesn't mean patients should toss out that bottle of Prozac or Paxil without careful consideration, warned psychology experts and scientists responding to a study that concluded placebos are as effective as medication in all but the most depressed.
And it certainly doesn't mean that severe depression — including the mood disorders that affect nearly 21 million adults in the U.S. — should be regarded as anything but the debilitating disease that it is.
"This is about very sick people; there's something wrong with their brains," said Dr. Helen Mayberg, a professor of psychiatry neurology at the Emory University School of Medicine. Mayberg and others worried that a study released Tuesday by Irving Kirsch of the University of Hull in England might lead depressed patients to abruptly stop their drugs without medical guidance. Kirsch and his researchers analyzed results of published and unpublished studies from the federal Food and Drug Administration to find that four of the most common new-generation antidepressants appear to help only the most severely depressed.
The drugs, which include those commonly known as Prozac, Effexor, Paxil and Serzone, worked no better than placebos in less severely depressed people, the researchers concluded. They suggested the drugs shouldn't be prescribed unless other therapies, including counseling and lifestyle changes such as exercise, have been tried.
Don't Stop Abruptly
About 118 million antidepressant prescriptions are issued in the U.S. each year, but starting or stopping the drugs should be done very carefully and under medical guidance.
"If you are currently taking an antidepressant drug and it's working for you, by no means stop," Mayberg said. Instead, patients should consider the new information and decide if it's time to evaluate their medication, added Deborah Serani, a psychologist in private practice in New York. Stopping the drugs abruptly can have dangerous results. "It can cause a backlash of severe depressive symptoms," said Serani, who herself has taken antidepressants for 15 years, including the generic version of Prozac.
The experts said the new study provided valuable insight, but that it was based on a limited number of short-term studies in a field in which long-term results are the point. Because no one knows what causes depression, and because treatment must be individualized, each case must be evaluated on its own merits, they added.
Serani has seen severely depressed patients fail to respond to antidepressants, and she's seen mild to moderately depressed patients respond very well. Other research has shown that patients respond better to a combination of medication and psychotherapy than to either treatment on its own, Mayberg said.
The power of the placebo effect on depression has long been recognized, said David Barlow, founder and director emeritus for the Center for Anxiety and Related Disorders at Boston University. Antidepressants likely are overprescribed, partly because of the hurried nature of care in the U.S. health system, Barlow noted. In busy primary care practices, there's considerable pressure to do something, anything, for patients suffering from mild to severe depression. "A placebo can make people feel better as well," he said.
Doctors must be more judicious in prescribing anti-depressants and patients must be more careful about requesting and using them, said Elinore McCance-Katz, a professor of psychiatry at the University of California at San Francisco. That can be complicated, especially in a country where antidepressants are advertised in magazines and on television. "What really bothers me is that big Pharma allows marketing directly to consumers," she said. Patients generally have little opportunity to verify the drug companies' claims, she added.
Depression Must Be Taken Seriously
The worst thing patients, their families and their doctors can do is decide that depression should not be treated seriously and carefully, Mayberg said. "Is this can we dump on the mentally ill once again?" she said. "Their families tell them to 'snap out of it' and to 'get a grip.'"
The entire field of neuro-psychiatry needs to work harder to find the cause of the depression and to discern effective ways to treat it so that people won't be tempted by simplistic solutions. "If that's all it took, working a little harder at the gym, we'd be done already," Mayberg said.
MSNBCET Feb. 26, 2008
Primary care diagnosis of depression suboptimal
2 Mar 2008
In a BMJ clinical review on the presentation, assessment and management of depression in primary care, Finnish researchers report that despite increased awareness, rates of diagnosis remain suboptimal.
According to the World Health Organisation, depression is the greatest non-fatal, global burden of disease. Despite increasing understanding and awareness of the condition, diagnosis and treatment of depression in primary care is not always optimal. The review revealed that between 50% and 70% of patients with depression remain undetected by primary care. More specifically, they identified somatisation as one of the single-most important problems associated with a missed diagnosis.
“Given that about two thirds of depressed patients present mainly with somatic symptoms, detecting depression in connection with somatisation should be a core professional skill of doctors,” the authors stated.
They pointed out that patients at high risk of depression can be screened, primarily, using two simple questions: During the past month have you often been bothered by feeling down, depressed, or hopeless? During the past month have you often been bothered by having little interest or pleasure in doing things? Answering ‘yes’ to either question warrants further screening.
They also highlighted the significance of the patient–doctor relationship. A management plan needs to be created and negotiated together factoring in patient preferences, concomitant disorders and medications, the severity and type of symptoms, suicidal risk and availability of treatment options.
They noted that multifaceted interventions have been shown to be more effective than single component interventions, and stressed the importance of the collaborative care modelling. “The collaborative care model seems promising for enhancing treatment outcomes and bridging the gap between primary and secondary care, given that it allows patients to be managed by case managers or primary care providers under specialist supervision without the need for treatment elsewhere,” they claimed.
In the acute phase, the primary goal is the remission of symptoms, noting that remission of symptoms is associated with a better prognosis than the improvement of depressive symptoms without remission. Their review also outlined the types and appropriateness of psychological treatments, pharmacological treatments, and a combination of both.
An important aspect of management is evaluating treatment efficacy; the authors recommended careful monitoring irrespective of the treatment modality used as well as the use of structured measures of symptom severity and functional status.
The review stressed that where pharmacological therapy is the chosen treatment modality, should patients show insufficient response to therapy within 2–4 weeks, steps need to be taken to optimise the current treatment. This usually entails increasing the dose to the upper level of the standard dose. Should there be no improvement after 4 weeks of pharmacological treatment or less than moderate improvement within 4–8 weeks of psychological treatment, they recommended assessment of compliance to treatment and reassessment of the original diagnosis. Furthermore, owing to the strong tendency for depression to recur, they recommended that patients at high risk of recurrence be maintained on prophylactic treatment.
Research is ongoing and there are new generation antidepressants, such as melatonergic agomelatine, in development as well as computerised cognitive behaviour psychotherapy, the researchers concluded.
Furthermore, they added, transcranial magnetic stimulation and therapeutic brain stimulation are showing promise as potential future treatment modalities.
Reference
Timonen, M. & Liukkonen, T. 2008, ‘Management of depression in adults’ British Medical Journal; 336: 435–439.
Antidepressant therapy linked to diabeteshttps://www.omnus.com.au//Psychiatry/ArticleDetails.aspx?articleId={19f4153f-b904-4a44-9fca-f43a6a6c740a
Data from the large Diabetes Prevention Program in the United States have suggested that antidepressant therapy increases the risk of type 2 diabetes two- to three-fold, but the risk is effectively eliminated in patients prescribed metformin.
The data included 3,187 participants who were overweight and had impaired fasting glucose or impaired glucose tolerance and were therefore considered at high risk of diabetes. They were randomised to intensive lifestyle interventions, metformin, or placebo, and followed for an average of 3.2 years.
At baseline about 10% had symptoms consistent with depression (usually mild) and 6% were taking antidepressants. The proportion with symptoms declined to 8% and the proportion taking antidepressants increased to 9% while the study was in progress.
There was no association between depression symptoms at baseline and the subsequent likelihood of developing diabetes. However, use of antidepressants at baseline increased the risk of diabetes by a factor of 2.25 in the placebo arm and 3.48 in the lifestyle intervention arm. Continuous antidepressant use during the study was associated with higher diabetes risk in both these arms, as was intermittent use in the lifestyle arm. The risks were calculated after controlling for potential confounders including BMI, fasting glucose levels and physical activity.
There were no links between antidepressants and diabetes onset in participants taking metformin.
It was well known that people with diabetes had higher rates of depression than the general population, which in turn interfered with management of both disorders, but there had been very few studies on depression as a possible causative factor. Tricyclic antidepressants were known to cause weight gain and hyperglycaemia, but SSRIs (taken by about 80% of those being treated) were previously thought to be benign or even reduce weight and improve insulin sensitivity.
The findings needed to be replicated and confirmed before the clinical implications could be defined. There were very large numbers of people at high risk of diabetes, and if 10% of them were also being treated with antidepressants then the public health consequences could be substantial.
Reference
Rubin, R. Ma, Y. et al. 2008, 'Elevated depression symptoms, antidepressant medicine use, and risk of developing diabetes during the Diabetes Prevention Program.' Diabetes Care vol. 31, pp. 420-426
