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Overprescribing Antidepressants

Surprising new data on the misuse of antidepressants.

An article in today's Los Angeles Times reports some eye-popping facts about the misuse or overuse of SSRI antidepressants (the class of drugs that includes Prozac, Zoloft, Paxil, Effexor, Luvox, and Lexapro). Among the most startling revelations:

"Researchers at the Rand Corp. in 2002 surveyed close to 700 adults who had received a prescription for an antidepressant. Of those who reported receiving the medication for depression, just 20% tested positive when screened for the disease. Fewer than 30% of those receiving the medication had any depressive symptoms at all."

Put another way, more than 70% of patients in the survey presented no medical need for antidepressant treatment, and a further 10% fell into a significant gray area, with an insufficient number of symptoms to warrant a DSM diagnosis.

This begs the question (extrapolating from an admittedly small survey): If only one-in-five patients given SSRI antidepressants manifests any real need for them, why were all of them prescribed the same type of medication?

The answers, I think, appear just a fraction later in the article:

1) "Many psychiatrists seem relatively unconcerned about the potential overuse of antidepressants."

2) Psychiatrists are "quick to point out that the danger of allowing depression to go untreated is far more serious" than the litany of side effects patients routinely suffer from the drugs.

The article lists only the most-common side effects from SSRI medication—diminished sex drive, nausea, and loss of appetite. It omits any mention of the key reason the FDA decided in 2004 to add a black-box warning to this class of drugs: a marked increase in suicide ideation among especially teens. Alas predictably, the article also says nothing about either more serious side effects or the well-documented problem of withdrawal symptoms from SSRI antidepressants, especially anticholinergic ones such as Paxil, which influence the cholinergic system and thus the production (or temporary suppression) of adrenaline.

Even so, I think the article unwittingly makes a valuable point: many psychiatrists and clinicians, concerned about factor #1 (overuse of antidepressants), nonetheless invoke factor #2 (concern about undertreated populations) to eclipse or downplay their unease about side effects from this type of medication.

We often hear concern voiced about "undertreated populations," even though the same psychiatrists know that 5,000 Americans recently began a new course of Paxil every day. But how credible is such concern, and is it truly warranted or a convenient way of changing the subject about overdiagnosis? The International Review of Psychiatry reported in June 2005 that more than 67.5 million Americans—almost one-in-four of us—have taken a course of antidepressant medication. Which begs another question: When do we reach a number or percentage so sizeable that concern about undertreatment tips appropriately into unease about overmedication?

The data reported by the article make clear that the outcome we're facing as a country is extremely troubling. If 4-out-of-5 Americans are being put on antidepressants out of concern about undertreatment, then 70-80% of SSRI patients are risking mild-to-serious side effects for symptoms they have not produced, for an illness they do not have. That makes no sense at all; it doesn't begin to add up.

Christopher Lane, the Pearce Miller Research Professor at Northwestern University, is the author most recently of Shyness: How Normal Behavior Became a Sickness. Follow him on Twitter @christophlane

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