Sunday, March 4, 2012

Antidepressants are Overprescribed

Depression is a feeling of impending doom or hopelessness.  When multiple symptoms are found to persist for long periods of time, one may be diagnosed with major depressive disorder. Other forms of depression may be mild or temporary. Dr. J. Michael Bostwick, M.D., an expert in Psychiatry at Cambridge Hospital, points out that mild depression occurs throughout the normal course of life when, for example, someone experiences a death of a family member, has trouble adjusting to a new environment, or suffers from dysthymia (538). Antidepressants are usually the first line of defense used to treat depression and are sometimes found to be necessary, but they have become far too accessible. Antidepressants should not be considered the cure-all solution for all forms of depression because there are many more beneficial alternative forms of treatment with less unwanted side-effects.
Antidepressants are medications used to reduce the effects of depression. Dr. Morgan Sammons, PhD, who is currently the dean for the California School of Professional Psychology at Alliant International University, observes that the rate of suicides has decreased since antidepressant use has become widespread (327). In many cases of major depressive disorder, changing the chemistry of the brain through the use of medicine appears to be the best solution. George Sims, a journalist from Countryside Magazine, swears that antidepressants were the only solutions to his problems (101). Dr. Jeffrey C. Danco, PsyD, a clinical psychologist, found that in 1998, over 60 million prescriptions were written for Prozac, Zoloft and Paxil (10). More recent statistics show that antidepressants have become the most popular pharmaceutical, with 118 million prescriptions in 2005 (Danco 10). There is undoubtedly great benefit found in the use of antidepressants for the treatment of some forms of depression.
There are, however, many side-effects to using antidepressants including drowsiness, dry mouth, nervousness, anxiety, insomnia, decreased appetite, nausea, headaches, long-term weight gain, cognitive impairment and decreased ability to function sexually (Bostwick 543). These side-effects fall into two basic categories: short-term and long-term. Short-term effects can be felt during the first few weeks of use and before the antidepressant starts to relieve the depression, while long-term effects are felt later and once the depression starts to subside.
With most antidepressants, people may experience nausea or a dull headache during the first few weeks (Bostwick 543). Bupropion can cause jitteriness and fluoxetine can cause nervousness, anxiety, agitation, insomnia, low energy, and fatigue (Bostwick 543). These early side-effects sometimes discourage the continued use of antidepressants. Sleep may also become a problem and the patient may be prescribed a benzodiazepine to assist, which can be very addictive (Bostwick 544).
As the antidepressant effects start to be felt, patients can lose control of their sexual functioning; thus upsetting the patient and sometimes discouraging the continued use of the antidepressant (Bostwick 453). Weight gain can later show up as eating or exercise patterns change (Bostwick 453). Since the loss of sexual function and weight gain can sometimes be the causes of depression itself, these effects ironically act against the antidepressant. This may be part of the reason that stopping the medication can become more difficult in the future. Tiffany Kary, a journalist for Psychology Today, explains how withdrawal from antidepressants is sometimes nearly impossible, causing confusion, vomiting, and suicidal impulses (15).
Also, one has to question the placebo effect of antidepressants in treating depression. People suffering from depression usually feel that they are out of control of their own life and that drugs will sometimes give them the sense of control they are lacking (Danco 11). Sometimes people will start to feel better before the first antidepressant has even been swallowed just because they think they will feel better (Danco 13). Because the side-effects of antidepressants are so great, patients can not doubt the power of the medication and that power is sometimes mistaken to be treating the depression (Danco 13).
With all the adverse effects of antidepressants, one would assume that prescribing antidepressants would be handled with great care; however, caregivers will often reflexively prescribe them at the first sign of any mild depression. Instead, they should more accurately diagnose patients to be sure they are in need of antidepressants. They should first consider alternative forms of treatment including watchful waiting and psychotherapy. They should prescribe antidepressants when they are absolutely sure that other forms of treatment will not work.
Watchful waiting simply involves frequent visits with face-to-face contact to assess whether depression symptoms have resolved or more aggressive treatment is needed (Bostwick 539). According to the article, “Watchful waiting just as effective, less costly than newer antipsychotics for AD”, watchful waiting has been used effectively as a method of treatment for other illnesses such as Alzheimer’s disease and certain types of cancer (5). Watchful waiting is a very good solution if there is a diagnosis of mild or temporary depression or if the diagnosis is unclear. The patient should be carefully observed over a period of "4-to-8 weeks" (Bostwick 539). If, however, the condition of the patient does not improve or worsens, other forms of treatment should be considered.
Psychotherapy should be considered as one of the first forms of treatment for depression. During psychotherapy, a person suffering from depression will discuss the factors that may be causing the depression with a trained mental health care professional. The goal of psychotherapy is to uncover the root of the depression and discuss it openly. If behaviors and emotions contributing to depression are better understood, the chance for behavior modification or problem solving is much greater. Therapy techniques include cognitive behavior therapy, behavioral activation treatment, psychodynamic approaches, problem-solving therapy, interpersonal psychotherapy, and social skills training. Patients will learn, through therapy, to eventually cope with their depression and in some cases remove the factors causing it.
One study, conducted by Christopher F. Sharpley, PhD, shows that psychotherapy can biologically rewire the brain (603). The reward section of the limbic system is usually affected the most from depression (Sharpley 604). Some brain structure differences tend to be common in patients suffering from depression (Sharpley 604). The amygdala, for example, usually appears to be larger in volume while the hippocampus appears to be smaller. Psychotherapy has been found to reestablish limbic circuitry balance and cause the same measurements seen in those not suffering from depression (Sharpley 607).
However, psychotherapy takes extra effort by both the patient and the caregiver. For it to be of any benefit, the depressive patient must have an ability to work in a relationship absent serious regression or withdrawal (Ahola et al. 357). Unfortunately, depression is known for affective blunting that can seriously hamper the development of a workable treatment relationship (Ahola et al. 357). By starting with psychotherapy, patients are avoiding the unwanted side-effects of antidepressants while the caregiver can monitor the depression. The mental health professional can accurately diagnose the patient over time to determine if other forms of treatment are required, including antidepressants.
Proper diagnosis is extremely important in determining whether someone is in need of antidepressants. In a sample of 100 patients, 10 patients with depression will be correctly identified, 10 will be missed, and 15 patients who are not depressed will be falsely given the diagnosis (Bostwick 540). One of the main problems with diagnosis of depression is that primary care physicians are responsible for more than 75% of them (Bostwick 540). Given that depression is a mental illness, better diagnoses would come from referring depressed patients to mental health professionals.
To be diagnosed with major depressive disorder, a patient must exhibit a depressed mood or depressed pleasure as well as a substantial social or occupational impairment (Bostwick 539). Also, the patient must have four of the following symptoms: weight loss or weight gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or reduced energy, preoccupation with feelings of worthlessness or guilt, poor concentration or indecisiveness, or morbid or suicidal thoughts. These symptoms must last for at least two weeks (Bostwick 539). Patients experiencing symptoms less than these may be diagnosed with a mild depression and should not reflexively be prescribed an antidepressant.
With the right mix of medication, watchful waiting, and psychotherapy, people suffering from depression can become psychologically stable and live fulfilled lives. There are many side-effects from antidepressants and there are times when antidepressants can be the only solution. Watchful waiting is sometimes a way to monitor a patient while trying to diagnose accurately and waiting for the problem to go away. Psychotherapy can provide biological benefits as well as teaching the patient to better cope with depression. Psychotherapy takes effort by both the patient and the caregiver and is not as easy as the prescription of medication.  We cannot abandon antidepressants entirely as they do have their use and can be considered a good solution in many cases; however, with a little extra effort on part of the caregiver and the patient, other forms of treatment can be far more beneficial.

Works Cited

Ahola, Pasi, et al. “The Patient-Therapist Interaction and the Recognition of Affects during the Process of Psychodynamic Psychotherapy for Depression.” American Journal of Psychotherapy 65.4 (2011): 355-379. Print
Bostwick, J. Michael. “A Generalist’s Guide to Treating Patients with Depression With an Emphasis on Using Side Effects to Tailor Antidepressant Therapy.” Mayo Clinic Proceedings 85.6 (2010): 538-550. Print
Danco, Jeffrey C. “Why Psychiatric Drugs Work: The Attribution of Positive Effects Due to Psychological Factors.” Ethical Human Psychology and Psychiatry 10.1 (2008): 11-15. Print
Kary, Tiffany. “Are Antidepressants Addictive?” Psychology Today 36.4 (2003): 15. Print
Sammons, Morgan T. “Writing a Wrong: Factors Influencing the Overprescription of Antidepressants to Youth.” Professional Psychology: Research and Practice 40.4 (2009): 327-329. Print
Sharpley, Christopher F. “A review of the neurobiological effects of psychotherapy for depression.” Theory, Research & Practice 47.4 (2010): 603-615. Print
Sims, George. “Depression: a leaf with no color.” Countryside & Small Stock Journal 95.5 (2011): 98-101. Print
“Watchful waiting just as effective, less costly than newer antipsychotics for AD.” Brown University Geriatric Psychopharmacology Update 12.2 (2008): 1-6. Print

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