Consumer Reports, the consumer magazine that reviews common products like refrigerators and vacuum cleaners and rates them, also dabbles in trying to educate consumers in other areas, like health. Earlier this week, they published a review article on the effectiveness of the commonly-prescribed class of medications for depression, antidepressants.
The impetus for this article was apparently the Olfson (2009) Archives of General Psychiatry study that examined data from household surveys. You know, the one we reported on back in August, noting that antidepressant use was up 75 percent. A day later, I wrote this blog entry discussing the new study, and perhaps the more important data point the study found — psychotherapy use was down 35 percent in the same time period (1996-2005).
The Consumer Reports article starts with a bit of a scary tone:
But for some people, [antidepressants] may also have dangerous or troubling side effects — drowsiness, feelings of panic, nervousness, sexual problems, thoughts of suicide or weight gain — and should be taken only by people who really need them.
True that. But who makes the determination of who are the people who really need them? Why, hopefully your doctor of course. While many people think you can just stroll into your doctor’s office and ask for and prescribed any medication you want, few doctors will cooperate without asking a whole lot of questions first. (If your doctor doesn’t ask you any questions and instead just whips out his prescribing pad, it’s time to find a new doctor.)
It might help to look at some data at this point. One such study is Kravitz et al. (2005), who did a randomized controlled trial of visits to a doctor’s office by “model” patients complaining of either major depression or an adjustment disorder with depressed mood. The diagnosis, “Adjustment disorder with depressed mood,” isn’t something that ordinarily should be treated with medications, because it doesn’t rise to the severity level of a significant clinical disorder (by definition). So let’s look at the prescription practices of the doctors after the model patient went into the office with one of those two diagnoses and asked either for a specific brand of medication, any kind of medication, or no medication at all:
Brand-specific drug request | General drug request | No drug request | |
Major depression | 53% | 76% | 31% |
Adjustment disorder | 55% | 39% | 10% |
Acceptable care for major depression | 90% | 98% | 56% |
What you see is that the people asking for a specific brand of medication (e.g., because, perhaps, they saw an ad online or on TV) were prescribed a medication about half the time, regardless of concern. Remember, in most cases, an antidepressant is going to be overkill for an adjustment disorder and is not considered the standard of care.
What’s even more enlightening is that just the simple request of asking for a medication more than doubles the chance you will get one (and for an adjustment disorder, it nearly quadruples your chances!). Is this all that surprising, though? Doctors don’t want to say “No” to their patients when they make a reasonable request, and asking for an antidepressant medication when depressed would be perceived by most doctors as a reasonable and expected request.
All of this demonstrates that patient requests have a significant impact on physician prescribing and treatment behavior — but not always in the way you think. If a patient with major depression goes into the office and asks for a specific brand of medication, this study found that the patient was less likely to be prescribed medication than if they just went in asking for an antidepressant in general. The opposite was true if the patient had a more minor concern, which suggests that — despite the fact that antidepressants shouldn’t even be generally prescribed for adjustment disorders — doctors are more willing to do so when a specific brand is mentioned. *
So let’s get back to the Consumer Reports article. They highly recommend psychotherapy as an adjunct or even as an alternative to antidepressant medications. I wrote about this issue originally back in 1992 and have been beating the same drum since. For most people, antidepressants alone are a poor choice. If you want to feel less depressed, sooner, your best bet is the combination of psychotherapy with antidepressants.
The article then goes on to recommend people try generics — a generally good recommendation — before they try the name brand antidepressants:
- Generic bupropion
- Generic citalopram
- Generic fluoxetine
- Generic paroxetine
- Generic sertraline
“All of the generics are as effective as the more expensive brand-name drugs.”
Well, that’s true in general, but it may not be true for you. We don’t have any test or way of determining which drug is going to work best for you with the least amount of side effects. So what doctors do is they prescribe the antidepressant they are most comfortable with and most commonly prescribe. This is great for them, but your mileage may vary in terms of whether it helps you. Absolutely, try generics first, but don’t be afraid of also trying a name-brand drug if generics aren’t working for you.
Consumer Reports also leaves out the unfortunate fact that some generics — notably the generic form of Wellbutrin (bupropion — the first generic recommended on their list!) — have found not to be equivalent to their name-brand counterparts. I’m a big fan of generics, don’t get me wrong, but with poorer quality control, generics’ bioequivalence isn’t always the same as the name-brand in production environments. This is something that I hope the FDA does a better job of policing in the future.
Little has changed in the field of antidepressants in the past decade, except that more generics have become available as name-brand drugs lose their patent protection. Antidepressants remain a powerful class of medications used to treat serious, sometimes life-threatening mental disorders. They should be used wisely, not as some panacea to any problem with living. And when treating major depression, they should nearly always be used in conjunction with psychotherapy — not instead of. It’s good to try generics first, but don’t be put off if your doctor offers you a name-brand drug (especially if it’s covered by your insurance plan’s drug coverage).
Read the full article: Consumer Reports: Antidepressants can be helpful but risky
References:
Kravitz RL, Epstein RM, Feldman MD, Franz CE, Azari R, Wilkes MS, Hinton L, Franks P. (2005). Influence of patients’ requests for direct-to-consumer advertised antidepressants: a randomized controlled trial. JAMA, 293(16), 1995-2002.
Olfson, M. & Marcus, S.C. (2009). National Patterns in Antidepressant Medication Treatment. Arch Gen Psychiatry, 66(8) , 848-856.
A disturbing side-note this study also found was that if you didn’t ask for medication and had major depression, the chances you would receive the minimal acceptable care from your doctor are nearly cut in half! Yikes. So apparently doctors — whether they realize it or not — are making decisions about the severity of your condition based upon whether you ask for medication or not.
4 comments
Hear, hear.
I have some concerns about the subject matter.
1. First, unlike most of the products Consumer Reports evaluates, medications vary drastically in their effectiveness depending on each person’s individual body chemistry, which is one reason there are so many options and also one reason it sometimes takes some trial and error to get the choice of meds and doses right for each person. It’s not like a Toyota, say, which is going to have the same strengths and weaknesses no matter who drives it.
2. Second, as noted by Dr. Grohol, a prescription of an antidepressant without psychotherapy is a bad idea – not least because the effectiveness of an antidepressant often starts dropping off after several months, leaving the patient who has not learned cognitive coping skills back at square one.
3. I’d go further, also, and say that an MD or DO without experience in psychiatry should refer patients who appear to have mood disorders to a psychiatrist; too often the general practitioner quickly prescribes psych meds and doesn’t involve the appropriate specialist; one major reason is that the general practitioner is unlikely to have the skills at differential diagnosis needed, and that can be dangerous. In one of the most common situations, a person who is depressed at the moment, but actually has bipolar disorder rather than major depressive disorder or dysthymia, can’t safely take an antidepressant without pairing it with a mood stabilizer. The antidepressant taken alone is likely to trigger severe mania which can have disastrous consequences.
4. Finally, this doesn’t mention the benefits of other strategies including moderate exercise, sleep hygiene, dietary improvements, and some supplements such as fish oil or other sources of omega-3 fatty acids. There are also plenty of books for people suffering from depression, along with support groups like the 12-step program Emotions Anonymous.
For someone who has suffered from depression for over forty years (like me) therapy seems pointless. I been to four therapists over the years with little success. Their advice would just scratch the surface while my depression has embedded itself inside of me and it’s going to take something more aggressive to get relief. I’ve taken many different antidepressants and now on cymbalta. It’s fairly effective but seems to be pooping out. I would love to exercise but with depression I have absolutely no energy to do anything. I will always keep looking for the right treatment though hope for a “normal” life seem very distant.
Hi doc.,
I have pondered the question “how do we get AD’s to the people who really need them and restrain from having them prescribed to people who either won’t benefit from their use, or are undiagnosed bipolar and the prescription might be a dangerous if not deadly course of action.”
Despite what the mental health community believes, SSRI’s and SNRI’s are being doled out like Halloween candy by GP’s. I believe I had a front row seat to a manic episode incited by Prozac. It caused me much distress and the impending divorce saw me fall into a fit of depression. I went to my GP after loosing a lot of weight very fast. I spent 20 min. explaining how I believed AD’s had ruined my marriage. At the beginning of the description he even interrupted and said, “It sounds like (my wife) might be bipolar”. So he was aware of the risks. At the end of the appointment, do you know he tried to prescribe me an AD? I said, “Doc, how do you know that I am not bipolar? Are you planning one monitoring my behavioral changes over the next couple of month or keep in contact with my family as the FDA protocol requires?”
His answer was that “the new SSRI’s are better and more mild then the old.”
The solution to the problem seems simple. I can’t get cancer treated by a GP, so why can i get depression treated by one? The reality is when the patient walks out the doctor’s office, who is going to come back and tell this GP about a manic episode?
Only budeprion was found to be not as effective as brandname Wellbutrin for some people because the administration of the medication is slightly different. Bupropion is fine. Furthermore, Wellbutrin is very expensive (insurance usually won’t cover a brandname if a generic is available) and often not stocked anymore. And if you’ve only ever been on a generic version of the med then it doesn’t really matter does it? The issue is when a patient is switched from generic to generic or brand to generic because which may have slightly different amounts of medication. But again, this is not likely to cause a problem.
There was a great NY times article about this.
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