Taking Antidepressants But Still Sad

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Taking Antidepressants
But Still Sad

Antidepressants aren't the magic that millions hoped. For the first time, prescriptions fall.

(March 27, 2006) -- The nation's heady romance with antidepressant medication appears to be over.

First came the warning of a possible link between selective serotonin reuptake inhibitors and suicidal thoughts among children and adolescents. Then came a drop in sales — 14% last year compared with the year before. Now research has found that a single medicine typically does not effectively treat depression for most people and that those with depression often stop taking the medicines altogether.

"The problem is not that the drugs don't work. They do. The challenge is we can't predict who will get well with what medicine," says Dr. Andrew Leuchter, vice chairman of the department of psychiatry at the David Geffen School of Medicine at UCLA.

With that increased understanding — of both the illness and the treatment — has come an attempt to craft more balanced, realistic therapies.

As Dr. David Kupfer, chairman of the University of Pittsburgh School of Medicine's psychiatry department, points out: "The problem of not treating is much more dangerous than all the problems we get into by treating the illness."

Clearly, a one-size-fits-all approach will not suffice. Patients who complained to their internists about feeling blue have not been well-served by simply a prescription for an SSRI — and few warnings about side effects or the very real possibility that the drug might not work.

"Depression is no different from epilepsy or diabetes or hypertension: No one treatment is sufficient for a majority of patients in all medical diseases," says Dr. Madhukar Trivedi, the head of a recent study on antidepressants and a psychiatry professor at the University of Texas Southwestern Medical Center in Dallas.

His study, published in the January issue of the American Journal of Psychiatry, found that a single SSRI medication works only for about 30% of chronically depressed patients. For most of the 2,876 outpatients participating in the study, real progress came only with subsequent drugs or with a combination of drugs.

A second study from the same group, published Thursday in the New England Journal of Medicine, looked at the remaining patients who did not respond to the single medication the first time. More than half of this group switched medications completely, and about a quarter of them became symptom-free within 14 weeks. An additional 565 augmented the initial antidepressant with a second medication, and within 14 weeks of treatment, one-third became symptom free.

But many patients have been too shy or too discouraged — and many primary care physicians not up to speed on sophisticated approaches — to pursue this more complex treatment.

Between 70% and 80% of people with depression receive their treatment not from a psychiatrist but from a primary care doctor. And these doctors typically prescribe one medication in the hope that it will work. As these studies reveal, most of the time it doesn't.

"Most depression is treated in primary care. And while they do a good job with a lot of things, they often don't follow up as well as psychiatrists do," says Dr. Thomas Schwartz, a professor of psychiatry at SUNY Upstate Medical University in Syracuse, N.Y. "Part of our job is to come up with alternatives for our patients. Often we end up adding medications so they work together."

Lindsey, a 28-year-old Palm Desert resident, knows this firsthand. Since she was 17, she's been through an alphabet soup of medications, each with various side effects.

Effexor "sucks in terms of your sex life." Zoloft "just didn't work." Wellbutrin triggered urinary incontinence. And the lithium that she was given when her depression was thought to be bipolar disorder caused her to develop jerky movements and gain 50 pounds.

After suicide attempts and dismal reactions to the medication, and a descent into substance abuse that finally led her to the Betty Ford Center, she has found a psychiatrist she trusts — one who has tweaked her Effexor with a low dose of Wellbutrin. After all, repeated research has shown that the most effective treatment for depression is medications along with psychotherapy. With that approach, she is losing weight and has managed to get, and hold down, a job.

"Of course, if I knew then what I know now, so much pain could have been avoided," says Lindsey, who, like the other antidepressant users quoted in this story, did not want her last name used. "I was feeling really hopeless in trying out all these different drugs and not having them work."

As many patients learn, the key to effective treatment for depression — as with most illnesses — is giving the medications time to work and knowing when they aren't.

"What we should be doing is starting from the get-go and telling patients and families, you may not respond to this treatment alone," says University of Pittsburgh's Kupfer. "We think we are allowed to use one drug, one bullet. If we were treating cardiovascular disease or asthma, we would be talking about a treatment strategy over a lifetime."

The newer, more measured view of antidepressants should not have been entirely unexpected, points out Fred Goodwin, the former head of the National Institute of Mental Health and professor of psychiatry at George Washington University. Every drug has a life cycle, he says.

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First, it's called a magic bullet that will save the world. Prozac's history can attest to that. As the first SSRI, the green pill was featured on the cover of Newsweek in 1989, and the 1993 book "Listening to Prozac" spent months on the bestseller list.

Then comes the backlash. For antidepressants, that stage reached its peak during the Food and Drug Administration hearings in February 2004 where the message was: These drugs are killing our children.

Finally, it levels off somewhere in between, assuming its more reasonable place in public perception.

Antidepressants now find themselves in that place.

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Last updated: 3/06

Taking AntidepressantsBut Still Sad

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