Antidepressants Lift Clouds, But Lose ‘Miracle Drug’ Label: “The euphoria that accompanied the first antidepressant drugs has faded, forcing drug manufacturers to strive to create a new class of drugs.” The article explores the premise that, while millions are helped by these medications, often to the point of complete symptom relief, millions of others are not helped enough or “sexual dysfunction, emotional numbing, insomnia, weight gain, restlessness and memory lapses make the drugs unusable — or simply not worth the trouble.” But the author doesn’t grasp the central significance of that fact, leaving the reader with the impression that it it simply a scientific problem calling for the discovery of new and better drugs. The reality is much more complicated, and is much more a problem with the attitudes and assumptions toward antidepressants among the prescribers, the manufacturers and the consumers.

The greatest factor in the blush being off the rose is that the newer antidepressants have been applied to a broader and broader segment of the population, many of whose conditions are not really suitable to such medication treatment and therefore will not succeed, and many of whose conditions do not trouble them to an extent that they’d be willing to put up with inconvenient side effects.  This is occurring for several interlocking reasons, about which I often talk here on FmH —

  • because the newer drugs have been easier and less dangerous to use;
  • because doctors (especially non-psychiatrists) have been subjected to an unprecedented onslaught of marketing pressure to prescribe them broadly;
  • because psychiatrists are unconsciously under pressure to expand their notion of the size of their potential clientele, to compensate for losing market share to nonprescribing competitive mental health professions;
  • because of discoveries, or mythology, suggesting that antidepressants are applicable to a much broader range of mental health problems all mediated by the same neurochemicals;
  • and because managed care has relentlessly pressed mental health practitioners to find rapidly expedient alternatives to interminable courses of therapy

So both the intolerance and ineffectiveness of many of these drugs comes first and foremost from the broadening definition of the depressive conditions for which they are considered applicable, far beyond the major depressive episodes of the greatest severity which were the major target of antidepressants before Prozac. Paradoxically, complete symptom remission happens most often in the more severe conditions, as compared with the smouldering, chronic, low-level depressive syndromes that appear to be more a part of sufferers’ personality or constitution which have been the last decade’s greatest area of market expansion in antidepressant use.  The market is fairly tapped out because just about everybody who might be benefit from an antidepressant has already received them, and then some.

Peter Kramer’s seminal Listening to Prozac broke some of this ground, asking us to consider the social impact of using antidepressants in this way. He called it “cosmetic psychopharmacology,” a term that is precise and economical in summarizing what’s wrong in the seduction of modern American psychiatry into this largely pharmaceutical-industry-manufactured dream. From an ethical as well as a macroeconomic viewpoint, even if SSRIs and newer agents can help a given temperament problem, should  they be used in that way? And selling medication by creating demand through advertising to the public compounds the problem by fostering massive misconceptions. The smiling faces of recovered patients in the ads are false promises that these are ‘happy pills’ that can take away our troubles. Instead, as I explain to my patients, what the medications do is more akin to Freud’s famous dictum about the goal of psychoanalysis being to turn neurotic unhappiness into ordinary, everyday unhappiness. If someone has something to be distressed about, they’ll usually still be distressed about it after antidepressant therapy. In fact, they may be more distressed about it, i.e. more able to feel  their distress, and certainly more able to function in the face of such distress. I often analogize medication to a bicycle — it’ll get you where you need to get faster and more efficiently than walking, but you still need to do the peddling.

Prozac arrived on the scene just as psychiatry and neuroscience were getting sophisticated about the biological underpinnings of major mental illnesses such as depression, and the SSRI antidepressants became inextricably woven into the fabric of the discoveries of the Decade of the Brain, as the ’90’s were called by the American Psychiatric Association. While, as a neuropsychiatrist and psychopharmacologist, I’ll be among the first to support that paradigm, I’m also among the first to say we have overdone it, both because of the above-mentioned catalogue of pharmaceutical industry- and managed care industry-driven pressures, and because of an intellectual laziness among overworked overextended workaholic psychiatrists that takes the form of biological reductionism. This will be neatly illustrated by a single unpalatable statistic I recently encountered — that the recent average per-patient cost for medication for all patients hospitalized at my 85-bed psychiatric hospital is nearly $15 per day. Not only are medications given without proper regard to diagnostic precision and likelihood of benefit, but multiple medications are usually given together, making it impossible to tell which — if any — are the effective agent if the patient does respond. Each medication is thrown at a different target symptom without regard for the notion that a single medication-responsive disease process going on within the patient’s CNS might cause several or many symptoms which might co-correct with the prescription of a single proper, judiciously chosen medication.

The article goes on to explore in more detail some of the pitfalls of taking Prozac and similar medications. Emotional flatness and apathy are indeed side effects — these medications mute the intensity of acute and intrusive emootion. That is how they work in severe distress, turning down the volume knob, so to speak, to allow the symptoms to be livable. And that is why the medications are often not as suitable to “cosmetic psychopharmacology” as patients would wish. There is one dramatic exception. Even when they are not effective with depressed mood, some patients to whom I have prescribe SSRIs do not want to come off them because of how effective they are against irritability and temper outbursts. In fact, I sometimes think they may be far better against this target symptom than as antidepressants. You can see how this would be a benefit of ‘turning down the volume knob.’ The loss of libido and impaired orgasmic ability often caused by SSRIs may be a form of turning down the volume as well, and some people — sexual abuse victims and men with premature ejaculation problems — sometimes welcome this side effect.

Other reported side effects (some of which have led to lawsuits about which you’ve read my vituperations here) are either entirely specious — the reported link between antidepressant treatment and propensity to violence — or exaggerated — the complaints of a withdrawal syndrome when SSRIs are stopped too suddenly (which they should not be…)

While several novel trends in drug design or mechanism of action are in the works, the quest for the Golden Calf in an antidepressant psychopharmacology industry dying to recapitulate the phenomenal success of Prozac has largely taken the form of new formulations of the same drugs — timed-release versions that can supposedly be taken less frequently (claiming better response, convenience, compliance and tolerability); the condemnably deceptive practice of marketing the same substance under a different brand name for a new indication (Serafem Prozac; Zyban Wellbutrin); and purifying out the active subingredient, such as one stereoisomer out of the two, in a current antidepressant. (If only one of the two stereoisomers is active, you can get the same benefit from half the number of milligrams of only the active moiety, but of course they’ll be able to price the drug at twice the cost of its mixed counterpart.) These are of negligible if any pharmaceutical advantage and should be seen as attempts by the manufacturer to extend their proprietary rights beyond the expiration of their patent.

Responsible psychopharmacology demands collaborative responsibility among the consumer, the prescriber and the manufacturer, with prominent failings in each domain. Since most of you are in the former camp, potentially at least, I’ll finish with a caveat emptor. If you’re prescribed the newest, best (most expensive) agent, you should grill your physician about the basis for their choice. Even if you have a prescription drug plan so it doesn’t end up costing you more than the older alternatives, the trend is driving up health care costs for all of us, and justifying the ever-deeper penetration [that’s right; they’re screwing us all…] of managed care bean counters into the practice of medicine..