DSM5 in Distress

The DSM's impact on mental health practice and research

Antidepressant Use Skyrockets

Bad news from the center for disease control.

A new CDC study based on a large survey of the general population reveals the following alarming results:

1) Rates of antidepressant use continue to escalate—a remarkable 11 percent of the general population now takes an antidepressant. Antidepressants are now the third most prescribed class of medications in the US—and are first in the 18-44 age group. Rates of antidepressant use have increased an astounding 400 percent in just 15 years.

2) Far too often, the wrong people are on antidepressants, and the right people aren't taking them. Just one-third of severely depressed people who really need the medication are taking it, while more than two thirds on antidepressants are not currently depressed.

3) Since the placebo response rate for mild depression approaches 50 percent, it seems obvious that many people are using antidepressants as placebos—incurring their side effects and costs without any real benefit from the active ingredient in the pill.

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4) Many people probably stay on antidepressants for too long. More than 60 percent have been taking them for more than two years and 14 percent for more than 10 years. Of course, people with chronic or severe depressive illness require long-term maintenance care. But the sharp escalation of antidepressant use in those with mild or nonexistent disorder suggests that much of the prolonged use is unnecessary and placebo driven.

5) Antidepressants are often prescribed loosely. Fewer than one-third of antidepressant users have consulted a mental health professional in the past year. Most of the prescriptions are written by primary care doctors, with little training in psychiatric diagnosis and treatment, after very brief visits and under the influence of drug salesmanship.

How did we get into this mess? There is no mystery. The massive overuse of antidepressants (and also antipsychotics) began about 15 years ago when drug companies in the US were given a precious and unprecedented privilege—one that is appropriately denied them in the rest of the world. They were suddenly free to advertise directly to their potential customers on TV, in magazines, and on the Internet. The companies also aggressively built up their marketing to doctors, especially primary care physicians who were "educated" into the notion that depression was being frequently missed in their practices and that it is a simple "chemical imbalance" easily corrected by a pill. The consequent casual medicalization of normality mislabeled as sick many people with nothing more than the expectable symptoms of everyday life.

The results were entirely predictable. Unneeded pills are prescribed mostly by untrained primary care physicians to patients who are misled into wanting medication by a campaign of false advertising that suggests pills are necessary to deal with life problems that really aren't depression or a chemical imbalance after all and then the placebo effect turns many into long-term true believers who loyal customers for life.

What are the clear implications for the future? We need to do a much better job of getting antidepressants to the people who really need them and to reduce their wild misuse in those who really don't. Direct to consumer advertising should be outlawed—just as it is in the rest of the world. Primary care doctors need to be re-educated and refocused toward spotting severe depression and away from their loose prescription habits. The public must be re-educated away from the notion that all of life's inevitable sadnesses require medication and toward the realization that most of a pill's magic for mild depression is placebo effect.

What are the implications for patients? Most important, if you are clearly and persistently depressed and are not taking medication, you should consult a mental health professional, the sooner the better. Medicine and psychotherapy can be a big help and it makes no sense to continue suffering on your own. On the other hand, if you have been taking antidepressants for a mild depression or for a depression that is now better, this is a good time to re-evaluate whether you need to continue. But don't do this on your own. You may run into problems of recurrence or medication withdrawal effects. So consult a mental health clinician to discuss whether medication is still necessary and if not how best to gradually discontinue it.

The prescription of antidepressants is increasingly out of control. The pushback can come only from government regulation that better controls misleading marketing and reeducating physicians and the public to help unlearn the lessons previously taught.

DSM 5 is a step in just the wrong direction. It is proposing several changes that will further increase inappropriate antidepressant use. These include: Medicalizing grief, reducing the threshold for generalized anxiety disorder, and introducing new and highly questionable disorders for mixed anxiety/depression and binge eating. It is time to roll back, not expand, the reach of psychiatric diagnosis where it doesn't belong and to refocus our efforts where they are really needed and can do the most good.

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

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