
- Vol 31 No 9
- Volume 31
- Issue 9
Are Antidepressants Really “Over-Prescribed” in the US?
The “story behind the story” is not the over-prescription of antidepressants-though it happens-but the under-availability of optimal treatment.
COMMENTARY
As psychiatrists, we often hear the claim that antidepressants are “over-prescribed,” or that there is an “epidemic” of antidepressant use in this country. Typically, this claim comes from psychiatry’s
By and large, I don’t think so. In many respects, the claim that “too many Americans are taking antidepressants” is a myth. A myth, of course, is not a lie or falsehood-it is a narrative that often contains a kernel of truth, but which is wrong in important respects. The claim that “George Washington threw a silver dollar over the Potomac” is a myth not because young George couldn’t have done it, but because there were no silver dollars in his youth.
To be sure: in some primary care settings, antidepressants are prescribed too casually; after too little evaluation time; and for instances of normal stress or everyday sadness, rather than for MDD. And, in my experience, antidepressants are vastly over-prescribed for patients with bipolar disorder, where these drugs often do more harm than good: mood stabilizers, such as lithium, are safer and more effective in bipolar disorder.3 But these kernels of truth are concealed within a very large pile of chaff.
For example, the media often report that antidepressant use in the United States has “gone up by 400%” in recent years-and that’s probably true. Specifically, the National Center for Health Statistics (NCHS) reported that from 1988-1994 through 2005-2008, the rate of antidepressant use in the United States among persons of all ages increased by nearly 400%.4 But the
There is also good evidence that some minority populations are being underserved and undertreated for clinically serious depression. For example, the NCHS report found that whereas 14% of non-Hispanic white individuals were taking antidepressant medications, only 4% of non- Hispanic black and 3% of Mexican American persons were doing so.5 While these disparities could reflect different underlying rates of major depression, they may also reflect biased prescribing practices or lack of access to appropriate care, among some ethnic groups. Indeed, Dr Hector M. González and colleagues6 found that-compared with non-Latino white populations-Mexican American and African American individuals meeting 12-month major depression criteria had lower odds for receiving any evidence-based depression therapy at all.
Of course, it’s easy to get fixated on numbers, and to neglect more basic questions relating to the use of antidepressants. Specifically:
• Do antidepressants do what they are supposed to do (ie, are they effective in the treatment of MDD)?
• Are the people most in need of medication-those with more serious, incapacitating forms of depression-the ones who are receiving antidepressants?
There has been a good deal of misinformation in the general media regarding the efficacy of antidepressants. The best available evidence supports the conclusion that compared with placebo, antidepressants are effective in the acute treatment of moderate to severe major depression.7 Their efficacy probably decreases (vs placebo) as we move toward milder cases of MDD-and, to be clear, antidepressants are neither necessary nor appropriate for instances of ordinary grief or every-day sadness.8 We also know that for some patients, antidepressants have potentially serious adverse effects and should be prescribed only with the patient’s fully informed consent.
But wait-aren’t these medications being handed out, willy-nilly, to patients with very mild depression, and to persons with no psychiatric disorder at all? Bearing in mind that most antidepressants are prescribed by primary care doctors-not psychiatrists-it’s true that between the early 1990s and early 2000s,
Moreover, there is a fundamental problem with claims that antidepressants are “over-prescribed.” Psychiatrists are routinely cautioned against reaching medical conclusions without actually examining the patient. But by the same token, without knowing the specific reasons why Dr Jones prescribed an antidepressant for a specific patient, it is presumptuous to assume that the doctor’s decision was wrong. For example, many depressed patients seen in general practice may not meet the full, formal DSM-5 criteria for MDD. But such “sub-threshold” individuals may still experience substantial distress and impairment10 and find antidepressant medication helpful. Of course, psychotherapy alone may be preferable in many such cases, but access to “talk therapy” in the US is often very limited or beyond the financial resources of the patient.
Indeed, the “story behind the story” is the poor access to specialized mental health treatment for depression in the US.5,11 As Dr González observed in an interview with The Wall Street Journal, “Few Americans with depression actually get any kind of care, and even fewer get care consistent with the [best practice] standards of care.”11 And there-in lies the real failing of American mental health care: not the over- prescription of antidepressants-though it happens-but the under-availability of optimal treatment.12
For further reading
• Pies R. Devil or angel?
This article was originally posted on August 5, 2014 and has since been updated.
References:
1. Levine B.
2. Frances A. Antidepressant use has gone crazy: bad news from the CDC.
3. Ghaemi N. This Month’s Expert: Nassir Ghaemi, MD. On antidepressants in bipolar disorder.
4. National Center for Health Statistics. Health, United States, 2010: with special feature on death and dying. Table 95. Hyattsville, MD. 2011.
5. Pratt LA, Brody DJ, Gu Q. Antidepressant use in persons aged 12 and over: United States, 2005-2008.
6. González HM, Vega WA, Williams DR, et al. Depression care in the United States: too little for too few. Arch Gen Psychiatry. 2010;67:37-46.
7. Pies R. Are antidepressants effective in the acute and long-term treatment of depression? Sic et Non. Innov Clin Neurosci. 2012;9:31-40.
8. Zisook S, Pies R, Iglewicz A. Grief, depression, and the DSM-5. J Psychiatr Pract. 2013;19:386-396.
9. Mojtabai R, Olfson M. Proportion of antidepressants prescribed without a psychiatric diagnosis is growing.
10. Lewinsohn PM, Solomon A, Seeley JR, Zeiss A. Clinical implications of “subthreshold” depressive symptoms. J Abnorm Psychol. 2000;109:345-351.
11. Wang SS. Studies: mental ills are often overtreated, undertreated.
12. Pies R. Antidepressants work, sort of-our system of care does not. J Clin Psychopharmacol. 2010;30:101-104.
Articles in this issue
about 11 years ago
Factors That Predispose Patients to Treatment-Resistant Depressionabout 11 years ago
Management of Treatment-Refractory Schizophreniaabout 11 years ago
Ketamine for Treatment-Resistant Unipolar Depression: Current Evidenceabout 11 years ago
Psychiatry’s Underground Economyabout 11 years ago
How I Got Schooled in Ancient Psychiatryabout 11 years ago
My Anniversaryabout 11 years ago
Sexualized Transference in Older Adultsabout 11 years ago
The Association Between Major Mental Disorders and Geniusesabout 11 years ago
Patient Resistance in Eating Disordersabout 11 years ago
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