In Practice

A practicing doctor's views on psychiatry and contemporary culture.

Prozac for the Long Term?

What does it mean to be on an antidepressant for years?

The New York Times science section today features an essay on the long-term use of antidepressants. The lead refers to the sort of question I introduced in Listening to Prozac: how do these medications shape identity? But most of the piece concerns the biological effects of taking the drugs for years.

The author, Richard A. Friedman, quite properly says that we do not know about the effects of extended use and calls for better post-marketing studies. This point cannot be emphasized enough. Since we have vast numbers of people on antidepressants chronically, it is irresponsible for us as a society not to examine the medications through multi-year studies. This kind of research is hard to motivate; few young scientists in need of publications choose to undertake work whose results will emerge far down the road. The Food and Drug Administration, which has taken baby steps in this direction, should be mandating the relevant investigations; the National Institute of Mental Health should be supervising them.

Because his patient, now 31, was an adolescent when she first took Prozac, Friedman mentions research about suicidality, pro and con — but presumably he knows whether his patient is at risk. She was suicidal before taking medication but not since. Likewise, he refers to the studies I have discussed here and elsewhere repeatedly that show a bias in the publication of short-term drug trials; positive, but not negative or equivocal, outcomes tend to find their way into print. Again, this concern has little to do with Friedman’s patient. Whatever the odds for the average person, Friedman’s actual patient responded to medication. For her, the widely publicized concerns about new-onset suicidality and overall efficacy are red herrings.

Friedman’s case presents the most usual scenario. On medication, a patient gets better. She experiences few side effects, or only ones that are tolerable in the short run. Then, the disease recurs, and the patient requires longer intervals of treatment. Side effects like loss of sex drive become troublesome. Now, issues of the unknown enter in: What does it mean, psychologically and physiologically, to be on a medication for years?

If I were allocating resources for research on the medications we have to hand, I would put a fair proportion here, into investigating what it means for any patient, adolescent or adult, to take antidepressants for much of a lifetime.

Note added 4/22: For thoughts concerning possible beneficial effects of long-term antidepressant use, see my more recent posting on medication and resilience in the brain.

Peter D. Kramer is a psychiatrist and author. His books include Against Depression and Listening to Prozac.

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