Nervousness

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:

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.

Footnote

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.