March 30, 2004
Learning From Prozac: Will New Caution Shift Old Views?
fter the federal advisory issued last week, the most popular antidepressant drugs may soon carry boldface warnings that patients who take them may become suicidal in the first weeks of therapy.
Although the science behind the move is murky, the effects of the warning may be beneficial.
The Food and Drug Administration asked drug companies to add the warnings to their labels. But agency officials conceded that no studies had clearly established a link between antidepressants and suicide.
The F.D.A. acted on the basis of unpublished studies that suggested that suicidal thinking and behavior occurred more often among depressed children and adolescents who were given newer antidepressants like Paxil and Effexor.
Yet suicidal impulses are also symptoms of depression, making the data difficult to interpret. One estimate suggests that one person in six with severe depression eventually commits suicide. Antidepressants typically take three weeks or longer to begin working. Patients who think about suicide or make suicidal gestures in those first weeks may have done so because they were depressed, not because the medications caused the suicidal impulses.
Moreover, it is a psychiatric commonplace that profoundly depressed patients may be at higher risk for suicide when antidepressants begin to take effect, simply because the medication gives them the energy to carry out plans that they were previously too depressed to enact.
It is also difficult, as F.D.A. officials have observed, to determine the reliability of the reports of suicidal thinking or behavior in the studies. In one study, a girl was reportedly described as suicidal because she had slapped herself.
Yet even if it turns out that the antidepressants do increase suicidal thoughts or actions in some people, that pales as a public health problem beside the challenge of treating depression in the general population.
Most people with serious depression — an illness that affects one of 10 Americans at some point — never seek treatment.
Antidepressants, whatever their side effects, work for many people and have undoubtedly prevented countless suicides. Still, most experts agree that the drugs do not work well enough. Many people improve but do not recover completely. About a third of depressed patients do not respond to any medication at all.
In this sense, the drug agency's action may have salutary consequences. Studies have made it increasingly clear that the best treatment for most psychiatric difficulties is a combination of medication and psychotherapy, or at least continuing contact with a mental health professional.
That is true for schizophrenia, for borderline personality disorder, for anorexia, for trauma. It is true in spades for depression.
Some studies have found psychotherapy alone to be as effective for mild to moderate depression as medication. Used in tandem, the two forms of treatment are more effective than either alone.
A pragmatic effect of the federal advisory may be that prescriptions for antidepressants are more frequently accompanied by psychotherapy or, at least, by regular visits to doctors. The agency recommended that patients be closely monitored when they started on antidepressants and when the doses were altered.
Prozac and its successors changed the way Americans thought about psychiatry and psychiatric illness. When they first entered the market, the drugs seemed to offer a risk-free solution to everything from serious mental illness to everyday blues. They appeared not only to alleviate depression, but also to make people more alert and more focused, less shy, more assertive and more self-confident. "Better than well," as Dr. Peter D. Kramer put it in "Listening to Prozac."
Even better, the newer drugs seemed free of the unpleasant side effects of older antidepressants, which caused, among other problems, constipation, weight gain and cardiac difficulties. And they were safer. Unlike older drugs, the newer generation was almost never fatal in overdose. Prozac became one of the most widely prescribed medications of all time.
Yet the honeymoon has been ending for a while. Over the last decade, it has become clear that Prozac and its cousins have side effects of their own, not least, sexual problems that many people find unacceptable. Some people report feeling emotionally deadened on the antidepressants. Others gain weight.
Stopping the drugs is, in some cases, also a problem. With the exception of Prozac, they must be slowly tapered off to avoid withdrawal effects.
The F.D.A. advisory is likely to temper the public's view of the drugs even further. Perhaps they will eventually be viewed simply as useful tools rather than magic bullets, and they will be less likely to be dispensed irresponsibly or with tolerant shrugs.
Since the ascendancy of the biological approach to psychiatry in the 1980's, Americans have tended to view psychiatric illness as something that should always be treated with drugs and to believe that medication is the only intervention needed. But the real story of 20th-century psychiatry is how complex mental illness is and how difficult it is to treat.
If there is are lessons to be learned from this controversy, they are that antidepressants should not be dispensed like candy, that depression is a serious problem and treating it a serious enterprise, that therapy should always be considered as an option and that, at the least, patients who are given medication should be carefully followed by people who ask them how they feel.
Tanya Luhrmann is a professor at the University of Chicago and the author of "Of Two Minds: An Anthropologist Looks at Modern Psychiatry."