Antidepressants: Hype or Help?

Journal editorial suggests the newer antidepressant drugs are overprescribed

There's no doubt the newer generation of antidepressants, which include Prozac and , have revolutionized the way depression is treated.

Was that change for the better?

No, says Dr. Giovanni Fava, a professor of clinical psychology at the University of Bologna in Italy and the department of psychiatry at the State University of New York at Buffalo.

In an editorial in the current issue of the journal Psychotherapy and Psychosomatics, Fava argues that drug company propaganda, rather than need or clinical evidence, is responsible for the soaring popularity of these newer antidepressant medications.

Other doctors and, not surprisingly, the pharmaceutical industry disagree with Fava's position.

Almost 10 percent of the U.S. population suffers from depression, according to the National Institute for Mental Health, though most don't seek treatment for the condition.

During the 1990s, Fava says, doctors started prescribing antidepressants for long-term use because several studies suggested a depression relapse was likely if an antidepressant drug was discontinued.

However, in his editorial, Fava says the evidence for long-term antidepressant use really isn't clear and other research has shown the duration of treatment -- whether three months or three years -- doesn't really matter because the drugs are most effective in the acute phase of depression. He says that despite the lack of evidence, these medications were touted in journal articles, symposia and practice guidelines.

He also contends the effectiveness of these antidepressant drugs has been overemphasized, and they're no more effective than older tricyclic medications; they just have fewer side effects. And, he adds, research has shown antidepressants don't actually change the course of depression; they just speed the recovery.

Fava also says that because the drugs have fewer side effects and are more tolerable, more patients with mild depression are being put on medications they may not need.

Fava says the effects of withdrawal from these antidepressant drugs are downplayed, and non-drug options such as cognitive behavioral therapy get short shrift in research literature.

Fava does, however, believe that antidepressants have a place in treatment. For patients who need them, he advocates a careful assessment after three months of antidepressant therapy, and then tapering the drug therapy down until the patient is off the medication. At the same time, he recommends cognitive behavioral therapy, lifestyle changes and more traditional well-being therapy.

After a patient has been off antidepressants for a month, Fava advises another assessment to make sure the depressive symptoms haven't returned.

Dr. Norman Sussman, a psychiatrist at New York University Medical School who has also studied the effects of antidepressants, says Fava raises several issues in his editorial that have been debated for years. The bottom line, he says, is that antidepressants work.

"The literature indicates they're effective, and I have seen them work," Sussman says.

He adds some of the clinical trials Fava uses to make his point were more rigidly constructed than a real-life treatment plan would be. Sussman says there's always an element of trial-and-error to antidepressant therapy to find what works best with the least side effects. In clinical trials, he says, researchers can't switch medications mid-trial, but in the real world doctors can adjust the amount of medication given.

There have been several studies where some patients were switched to placebo drugs after three months of antidepressant therapy, and that patients who stayed on the drugs were less likely to relapse into depression, Sussman says.

He acknowledges the newer medications probably aren't any more effective than the older medications in most cases. "The real breakthrough was in the tolerability," he says.

Before the newer drugs were introduced, antidepressants had a lot of unpleasant side effects. Patients had to be started on a low dose, which was gradually increased over a month or two before they were getting the full dose to minimize the unpleasant side effects, Sussman says.

Sussman does agree with Fava that pharmaceutical companies only present their best data and may sometimes overstate their products' efficacy. However, he says, that doesn't change the fact that antidepressants work.

Jeff Trewhitt, the national spokesman for the Pharmaceutical Research and Manufacturers of America, says he doesn't believe drug companies are guilty of propaganda, and explains that the industry is introducing new guidelines to ensure that firms avoid any appearance of impropriety.

"In the vast majority of cases, the relationship between sales representatives and physicians is appropriate and helpful," Trewhitt says. He adds the new guidelines forbid gifts of theater or sporting event tickets, and travel to information seminars can only be reimbursed if a physician is speaking at the conference.

As to whether the newer antidepressants are being prescribed appropriately, Trewhitt says, "Based on the anecdotal evidence, it seems clear to us in the vast majority of cases that physicians are using these antidepressant medications because they are effective, and in many cases have fewer side effects than many of the older drugs."

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