The Antidepressants Controversy: A Depressive's Perspective

First, Department of Duh: I can't imagine that anyone who has had any firsthand experience with antidepressant medication was the least bit surprised by these so-called 'new' warnings. When the "antidepressants may cause kids to kill themselves" story first came out, back in mid-October, I wrote the following letter to the NYTimes about it. Like all my many letters to the Times, it was not published:

Antidepressants can save lives. They have saved mine, several times.

However, it should not need stating by the FDA that whenever anybody, adult or child, is put on a drug to treat depression, they should be closely monitored and receive compassionate, knowledgeable care from a mental health specialist until they recover. GPs and pediatricians should not be prescribing such drugs and sending people along on their merry way.

There are no antidepressants on the market today (and perhaps none are possible) that take less than several weeks to have an antidepressant effect Anyone who has ever been through it could tell you that those weeks of waiting and wondering if the drug will work, if any drug will work, or if you are just to be left to rot inside you own personal mental hell, are excruciating. It doesn't matter how much doctors explain that it takes a few weeks, a depressed person responds by feeling immediately hopeful (wow, there is something actually wrong with me; there are drugs that can help) and then, when everything isn't instantly okay, more hopeless than before. When each minute is torture to live through, several weeks is too long, and the thought that the drugs might not work at all makes suicide a tempting option.

Whether there might be some actual biological effect of the drugs that causes increased risk of suicide, I cannot say. But it is in the very nature of the illness that the period of initial treatment is dangerous. The furor over the drugs themselves is a distraction from the fact that people are still not getting the mental health care that they need.

Last time I started taking the antidepressant Zoloft, to treat my depression, my psychiatrist checked in with me daily by phone, and I saw her in her office several times a week until I recovered. Her constant support and contact were critical to my getting through that dangerous time safely. Not everyone is lucky enough to get this kind of care, but everyone should.

If the FDA warning results in more careful care for those suffering from depression, it will save lives. However, such care is expensive and badly reimbursed by insurers, who continue to discriminate against mental illness. I suspect the warning will therefore simply prevent people from getting the help they need. They will get neither counseling nor medication, and some of them will kill themselves. It will be small comfort to their families that they won't have a drug to blame.

Now, two months later, here's Medscape, reporting on one of the studies that prompted the warning:

For each of the drugs, both in children and adults of all ages, suicidal behavior was more common within a few days to a month of starting the antidepressant than later on. The authors thought the most likely explanation of this finding is that antidepressant treatment is not immediately effective and that the medication may be prescribed just when the patient's symptoms and suicide risk are greatest.

And later in the article:

One problem related to the prescription of newer antidepressants is inadequate monitoring of patients by physicians. It is possible that partial or early response to medication might result in some patients' energy levels increasing before their suicidal ideation clears, leaving them able to think about or enact a suicide plan, whereas before they were too incapacitated to do much of anything. Undiagnosed bipolar illness may also be a culprit. Prescribing antidepressants for bipolar patients, if they are not concurrently taking mood stabilizers (eg, lithium, valproate), can induce mania or cycle acceleration and otherwise increase symptoms.[6,7]

And:

[A]ntidepressants are not trivial medicines and their use has to be carefully monitored by the prescriber and other clinicians. The National Committee for Quality Assurance has focused on this issue for several years, but only for patients older than 18 years. The Health Plan Employer Data and Information Set requires that participating health plans report the percentage of time that a clinical guideline—3 or more follow-up practitioner visits within 12 weeks of an initial antidepressant prescription for major depression—is met.[12] National HMO/POS plans currently show that patients follow their medication regimen, on average, only approximately 20% of the time.[13] That statistic is obviously not very good and may indicate that practitioners do not understand that patients with depression must be monitored carefully and frequently, especially if the depression is severe enough to warrant treatment with antidepressant medication. Hopefully, a benefit of the new concern about the safety of antidepressants will be increased vigilance and monitoring for all newly treated patients.

So basically, these studies have concluded something that many, many patients (and no doubt, psychiatrists) already knew: treating depression is damn serious business.

I worry now, as I did two months ago, that all this new public anxiety about antidepressants will not result in better care for those who are suffering from the disease. What it does seem to be resulting in is an increase in stigma for those who take the drugs. Recently I wrote a second (also unpublished) letter to NYT, in response to a December 14th op-ed:
entitled "This is Your Country on Drugs", in which being on antidepressants is compared with taking steroids:

Unless and until you have experienced the unbearable suffering of severe depression, please do not equate antidepressants with sports-performance-enhancing steroids. As my psychiatrist said to me a couple of weeks ago, as she added another med to my mix, "look, a hundred years ago there wouldn't have been anything more I could do for you." Yes, I also get great psychotherapy, and try to practice good self-care and have a good social support network, but a hundred years ago I would have been in the same position a diabetic was: likely to die young after horrible suffering.

I know a lot of people are probably on antidepressants because they complained vaguely to their GP, who threw some Zoloft samples at them to get them to go away. Maybe they don't even know why they're on them, or if, as the new UK practice guidelines suggest, they'd feel better if they just exercised a little more. But I'm not one of them. I take antidepressants because otherwise I couldn't live, and I resent being lumped together with people who take steroids so they can play a better ballgame.

I have many concerns about the drugs that I take. I am not about to mount a vigorous defense of pharmaceutical companies. I think there are legitimate questions to be asked about how to deal with the increasing number of diagnoses of depression, in both adults and children -- what social factors contribute to the problem? What can be done about it? Is it over-diagnosed? Is it under-diagnosed? How can we possibly pay for decent, compassionate care for those who suffer from depression?

I am not an epidemiologist or a public health expert, so I really don't know what the answers are. If the 'new' information about the safety problems associated with antidepressants results in genuine, and compassionate, research and debate about these issues, that will be good. So far, from where I sit, it has only fueled hysteria and served as a pretext to score points about the overmedication of the American public.

Me, I'll take overmedicated to dead, any day of the week.