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The “story behind the story” is not the over-prescription of antidepressants-though it happens-but the under-availability of optimal treatment.
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 vociferous critics1-but in many cases, it is voiced by psychiatrists themselves.2 So . . . have we really become a kind of Prozac Nation, to reference the title of Elizabeth Wurtzel’s 1994 memoir?
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 actual percentage of Americans 12 years or older taking antidepressants is about 11%-a large proportion of the population, for sure, but not exactly Prozac Nation.5 Furthermore, recent increases in antidepressant prescribing probably reflect new but legitimate uses of these medications for non-depressive conditions, such as neuropathic pain, PTSD, and panic disorder-for which several antidepressants have FDA-approved indications.
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. GonzÃ¡lez 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, antidepressant use seemed to be concentrated among people with less severe, and poorly defined, mental health conditions.9 However, more recent NCHS survey data (from 2005-2008) found that rates of antidepressant use rose as self- reported severity of depressive symptoms increased.5 This is what we would expect if clinicians were prescribing antidepressants appropriately-for major depression, rather than for everyday stress, sadness, and sorrow.
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 GonzÃ¡lez 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? The role of psychotropics put in perspective. Accessed July 30, 2014.
This article was originally posted on August 5, 2014 and has since been updated.
1. Levine B. The antidepressant epidemic. February 16, 2013. http://www.infowars.com/dr-bruce-levine-the-antidepressant-epidemic. Accessed July 30, 2014.
2. Frances A. Antidepressant use has gone crazy: bad news from the CDC. Psychiatr Times. October 28, 2011. Accessed July 30, 2014.
3. Ghaemi N. This Month’s Expert: Nassir Ghaemi, MD. On antidepressants in bipolar disorder. Psychcentral Professional. Accessed July 30, 2014.
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. NCHS data brief, No. 76. Hyattsville, MD: National Center for Health Statistcs; 2011. Accessed July 30, 2014.
6. GonzÃ¡lez 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. Health Aff (Millwood). 2011;30:1434-1442.
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. Wall Street Journal. January 5, 2010. Accessed July 30, 2014.
12. Pies R. Antidepressants work, sort of-our system of care does not. J Clin Psychopharmacol. 2010;30:101-104.