With ever-increasing regularity, and regardless of the referral source, people with garden variety psychosocial problems are presenting to my office seeking antidepressants. I would never demean the perceived acuity of an external stressor, but these are issues I’ve seen and heard hundreds of times before – relationship dissatisfaction, a boorish boss and wayward children – to mention just a few.
The common denominator among these folks is that uniformly, they are not depressed. Some are mildly dysphoric, but most are merely frustrated by their current plight. When I make the point that their issues are possibly solvable if we were to develop an action plan together, many of them balk. They want pills. And they want pills without any clear expectations for what they hope to accomplish by taking them.
A new study commissioned by the Centers for Disease Control and Prevention yielded these results: Rates of antidepressant use continue to rise, and as such, 11 percent of the general population now takes these medications. Antidepressants are now the 3rd most prescribed class of medications in the United States and are in 1st place within the 18-44 age range.
Antidepressants are quite readily available. Stressed, overworked primary care physicians faced with strangling time constraints are increasingly capitulating to patient demands for these agents. This is not to say these drugs are being prescribed like candy, but they are being prescribed for the wrong people, or more specifically, for the wrong set of symptoms. Psychosocial stress – accompanied by mild dysphoria – is not an indication for use.
So what are the implications for the future? The best case scenario would be that primary care physicians would be re-educated toward better spotting moderate to severe depression and thus reserve their prescribing habits for these presentations. After all, this physician subset generates 80 percent of the prescriptions for antidepressant drugs. This would be a massive undertaking, begging the question who would orchestrate the re-education and under what circumstances. The NIMH? The APA? The AMA? These are enormous, unwieldy bureaucracies. And how would “buy-in” be accomplished? Mandatory CME?
Another step would be to ban direct-to-consumer advertising to help at least ameliorate the growing volume of inappropriate consumer requests for these medications. These ads are enormously powerful, and play directly to the consumer’s perceived vulnerabilities.
Neither of these is likely to happen. Physicians don’t like their judgment questioned and the drug company lobbyists would fight the relinquishment of direct advertising tooth and nail.
A more realistic approach would be for the CDC – in partnership with the National Institute of Mental Health (NIMH) – to take this issue directly to consumers through television, radio and internet campaigns. These agencies should make it clear to people that antidepressants are indicated for those with persistent, moderate-to-severe depressive symptoms that are unremitting for at least a couple of weeks. These ad campaigns should emphasize the importance of consulting a mental health professional and the role that competent psychotherapy can play in long term symptom remission.
When it comes to drug selection, clear rationale for each choice is a must. Physicians should be more discriminating about prescribing antidepressants; and consumers need to better understand that these medications, in and of themselves, are not the singular solution to their depression woes.
————————————————————
Joe Wegmann is a licensed clinical social worker and a clinical pharmacist with over 30 years of experience in counseling and medication treatment of depression and anxiety. Joe’s new book, www.pesi.com. To learn more about Joe’s programs or to contribute a question for Joe to answer in a future article, visit his website at www.thepharmatherapist.com, or e-mail him at joe@thepharmatherapist.com.