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Monday, August 12 2013
August 12, 2013, 2:53 pm

A Glut of Antidepressants

Over the past two decades, the use of antidepressants has skyrocketed. One in 10 Americans now takes an antidepressant medication; among women in their 40s and 50s, the figure is one in four.

Experts have offered numerous reasons. Depression is common, and economic struggles have added to our stress and anxiety. Television ads promote antidepressants, and insurance plans usually cover them, even while limiting talk therapy. But a recent study suggests another explanation: that the condition is being overdiagnosed on a remarkable scale.

The study, published in April in the journal Psychotherapy and Psychosomatics, found that nearly two-thirds of a sample of more than 5,000 patients who had been given a diagnosis of depression within the previous 12 months did not meet the criteria for major depressive episode as described by the psychiatrists’ bible, the Diagnostic and Statistical Manual of Mental Disorders (or D.S.M.).

The study is not the first to find that patients frequently get “false positive” diagnoses for depression. Several earlier review studies have reported that diagnostic accuracy is low in general practice offices, in large part because serious depression is so rare in that setting.

Elderly patients were most likely to be misdiagnosed, the latest study found. Six out of seven patients age 65 and older who had been given a diagnosis of depression did not fit the criteria. More educated patients and those in poor health were less likely to receive an inaccurate diagnosis.

The vast majority of individuals diagnosed with depression, rightly or wrongly, were given medication, said the paper’s lead author, Dr. Ramin Mojtabai, an associate professor at the Johns Hopkins Bloomberg School of Public Health.

Most people stay on the drugs, which can have a variety of side effects, for at least two years. Some take them for a decade or more.

“It’s not only that physicians are prescribing more, the population is demanding more,” Dr. Mojtabai said. “Feelings of sadness, the stresses of daily life and relationship problems can all cause feelings of upset or sadness that may be passing and not last long. But Americans have become more and more willing to use medication to address them.”

By contrast, the Dutch College of General Practitioners last year urged its members to prescribe antidepressants only in severe cases, and instead to offer psychological treatment and other support with daily life. Officials noted that depressive symptoms may be a normal, transient reaction to disappointment or loss.

Ironically, while many patients in the United States are inappropriately diagnosed with depression, many who actually have it suffer without treatment. Dr. Mark Olfson, a professor of clinical psychiatry at Columbia University Medical Center, noted that from the time they develop major depression, it takes Americans eight years on average to seek care.

Diagnosing depression is an inherently subjective task, said Dr. Jeffrey Lieberman, the president of the American Psychiatric Association.

“It would be great if we could do a blood test or a lab test or do an EKG,” Dr. Lieberman said, noting that similar claims of overtreatment have been made about syndromes like attention deficit hyperactivity disorder. “A diagnosis is made by symptoms and history and observation.”

The new study drew 5,639 individuals who had been diagnosed with depression from among a nationally representative sample of over 75,000 adults who took part in the National Survey of Drug Use and Health in 2009 and 2010. The subjects were then interviewed in person with questions based on the D.S.M.-4 criteria.

Only 38.4 percent of the participants met these criteria for depression during the previous year, Dr. Mojtabai said.

It’s possible some of the participants did not appear to be depressed because they had already been successfully treated, said Dr. Jeffrey Cain, the president of the Academy of Family Physicians. Their improved mood may also have colored the way they responded to questions about the past.

“If I’m checking people who are being treated for high blood pressure and taking medication, I would expect it to be better when I’m checking them,” Dr. Cain said.

According to the D.S.M., a diagnosis of major depressive episode is appropriate if the patient has been in a depressed mood and felt no interest in activities for at least two weeks, and also has at least five symptoms that impair functioning almost every day. These include unintentional weight gain or loss, problems sleeping, agitation or slowed reactions noticed by others, fatigue and low energy, feelings of excessive guilt or worthlessness, difficulty concentrating and recurrent thoughts of death.

“We’re not just talking about somebody who’s having a bad day or got into an argument with their spouse,” Dr. Lieberman said. “We’re talking about something that is severe, meaning it’s disabling and distressing and is not transient.”

Many doctors have long prescribed antidepressants soon after the death of a family member, even though the D.S.M. urges clinicians to differentiate between normal grief and pathological bereavement.

One 50-year-old New York City woman said her doctor prescribed an antidepressant a few weeks after her husband died, even though she thought her feelings of shock and sadness were appropriate.

“He told me, ‘You have to function, you have to keep your job, you have a daughter to raise,’ ” said the woman, who asked that her name be withheld because few friends or family members knew she was taking antidepressants.

Most of the study participants were not receiving specialty mental health care, but Dr. Cain pointed out that it was not clear who was making the misdiagnoses: a psychiatrist, non-psychiatrist physician or other provider, like a nurse practitioner.

But while a psychiatrist may spend up to 90 minutes with a patient before making a diagnosis, patients often are more comfortable with their primary care doctors, who rarely have that kind of time.

Dr. Lieberman suggested watchful waiting may be appropriate in some cases, and more integrated forms of health care may soon make it easier to send patients to a mental health provider “down the hall.”

Doctors need to improve their diagnostic skills, Dr. Mojtabai said, and must resist the temptation “to take out the prescription pad and write down an antidepressant and hand it to the patient.”

Posted by: Dr. Dan L. Boen AT 04:04 pm   |  Permalink   |  Email
Wednesday, August 07 2013

This Month’s Expert: Michael Posternak, M.D., on Choosing Antidepressants

By Michael Posternak, M.D.

This Month's Expert: Michael Posternak, M.D., on Choosing AntidepressantsTCR: Dr. Posternak, thank you for agreeing to speak with us and I also want to thank you for having collaborated on a series of research articles that have been extremely useful to clinicians. I’d like to start with your article about factors that we use when we are selecting antidepressants (Zimmerman, Posternak, et. al., Am J Psychiatry 161:1285-1289, July 2004). How did that study come about?

Dr. Posternak: Most psychiatrists pretty much agree that all antidepressants are more or less equally effective. So if you start with that premise and you have 10-15 antidepressants out there, why are you picking one versus another? And what algorithm are we all using? Dr. Zimmerman developed a questionnaire for psychiatrists to fill out immediately after they wrote antidepressant prescriptions. We asked, “What influenced you to choose that medication?”

TCR: And what were your findings?

Dr. Posternak: We found that there were three compelling factors: The first was avoiding specific side effects, the second was the presence of comorbid psychiatric disorders, and the third was the presence of specific clinical symptoms. For example, many people wanted to avoid sexual side effects or weight gain and would choose meds based on this. And if a patient had depression plus panic disorder, for example, we would lean toward the SSRIs. And if someone’s clinical profile included both insomnia and poor appetite, we might choose Remeron (mirtazapine). As you can see, there was nothing terribly earth shattering about any of these findings, but they give us insight into what factors people are actually considering when they prescribe an antidepressant.

TCR: Do you find that there is much research support for the validity of these factors?

Dr. Posternak: No, because there isn’t much research to begin with. For example, if you look for papers on antidepressant efficacy for patients with comorbidity (and comorbidity is the norm rather than the exception) there is almost nothing out there. Most treatment trials assessing depression exclude patients with comorbid disorders or do not assess for them. A prototypical example would be the common practice of avoiding bupropion in patients with depression and significant anxiety. And yet John Rush and colleagues have published three papers showing no difference between Wellbutrin and sertaline in efficacy for anxiety in depressed patients (see, for example, J Clin Psychiatry 2001; 62:776-781).

TCR: You and Dr. Zimmerman have also written about the concept of “remission,” which has become the gold standard for antidepressant trials lately. How do you suggest we decide when a patient has responded well enough to an antidepressant?

Dr. Posternak: I think that is a terrific question. Even from a research standpoint, there is something problematic about using “remission” as the endpoint of a study. The problem is that, both in clinical trials and in our practices, patients start off with different degrees of depression. So let’s say you define your endpoint as a HAM-D score of 7 or less. A patient who starts at a HAM-D of 26 and has a 50% improvement will not meet criteria for remission, but will nonetheless feel much better than when they started the medication. Many patients may not reach the formally-defined point of remission, and may have residual symptoms and yet you and your patient may decide that you are satisfied with that response and you don’t want to keep pushing the dose or switching medications.

TCR: What research instruments would you suggest for use in our practices?

Dr. Posternak: Over the years, I have come to conclude that the CGI (Clinical Global Impression) is a pretty good judge. I ask patients, “Do you think your depression is partially improved or much improved since starting medication?” Usually if they are “much improved,” this corresponds with a greater than 50 percent improvement on the HAM-D, and most of us are not going to switch medications at that point. You might still try to tweak the regimen to help them sleep or improve their energy, but generally we would say that we have found something that seems to be worth sticking to.

TCR: And what are your favorite medication manipulations for tweaking the regiment to enhance response?

Dr. Posternak: The two that I use the most, and that I think are the simplest and most effective are: 1) Ensuring that patients get adequate sleep, and 2) Enhancing energy.

TCR: Tell me a bit about sleep. Why is this so important in resolving depression?

Dr. Posternak: When people don’t sleep it affects many other things like energy, concentration and mood, often leading to irritability. So one of the simplest interventions that I can do for my patients is to help them get a good night’s sleep. Some people are reluctant to take a sleep medicine and if so, I say to them, “This is important for your depressive illness, because if you don’t sleep well the research studies have demonstrated that you are going to be at higher risk for relapse.”

TCR: What are your “go-to” agents for insomnia?

Dr. Posternak: Well I often start with trazodone, because it is safe, it generally doesn’t lead to tolerance, and people like the fact that it has no addictive potential. I usually start at 25 mg because I don’t want them to get turned off from being groggy in the morning. If it doesn’t work at that dose, I will titrate the dose fairly aggressively until they are either sleeping well or they have limiting side effects. You can safely go up to 600 mg, which is an antidepressant dosage.

TCR: What do you do if trazodone doesn’t work?

Dr. Posternak: I like Remeron, but very often this is not an option because people are concerned about weight gain, so then I will move to benzodiazepines.

TCR: What about the non-benzo’s, like Ambien or Sonata?

Dr. Posternak: I rarely go to these next for a very simple reason, which is cost. I generally stick with the generics. I think that they are at least as effective and they are a fraction of the cost. My sense is that the non-benzos are marketed based on their lower risk of dependence or addiction, and yet I find in my clinical practice that people do not get addicted to sleeping pills. It just doesn’t happen, so why should we spend so much money on these other medications? I explain that to patients.

TCR: What benzos do you usually use?

Dr. Posternak: I simply use Valium (diazepam), 5-10 mg.

TCR: Why Valium and not Ativan (lorazepam) or Restoril (temazepam), or the others?

Dr. Posternak: Lorazepam is short-acting, so I find it less effective. Xanax (alprazolam) is the same thing; it is a very short-acting medication. It may help them fall asleep. It may even help the first few nights, but I find if I am treating more long-term insomnia that tolerance builds up. Restoril should be as effective as Valium in theory based on half-life, but in clinical practice I haven’t found that to be the case.

TCR: What about Klonopin?

Dr. Posternak: Klonopin I find is less sedating, which is useful for a daytime anxiolytic but I find that it is just not as effective as a hypnotic.

TCR: You also mentioned enhancing energy?

Dr. Posternak: Yes, and what I use for this, and what I feel is underutilized, is psychostimulants. A lot of times people are depressed, are not as happy as they would like, because they are not as focused or their energy isn’t as good. Like sleeping pills, stimulants have an immediate effect, which is nice and it is quite dramatic.

TCR: And then which specific medication do you like to use?

Dr. Posternak: Well, being boring and simple, I start with plain old generic Ritalin (methylphenidate) and I dose it 5 to 10 mg twice a day, early morning and early afternoon.

TCR: And what do you tell patients when you give it to them about potential side effects?

Dr. Posternak: I tell them that it is very well-tolerated, that its purpose is to increase their energy and help their concentration, and that we can increase the dose if it doesn’t work. As far as side effects, I’ll say, “You might get a tremor, it could increase your anxiety, it could cause insomnia, it could increase your heart rate, but in general people tolerate it very well.”

TCR: Do you see problems with stimulant abuse?

Dr. Posternak: A small minority of my patients report that they tended to get euphoric on stimulants and then crash afterwards. But this is rare.

TCR: How do you deal with prescribing stimulants long term?

Dr. Posternak: Once they are stable and I want to see them every three months I give them two post-dated prescriptions.

TCR: Is there anything else that you have been doing lately for antidepressant augmentation?

Dr. Posternak: Yes, we just completed a randomized trial of T3 (triidothyronine, trade name “Cytomel”) augmentation, and we found that it accelerated antidepressant response in comparison to placebo augmentation.

TCR: What dose did you use?

Dr. Posternak: 25 mcg QD.

TCR: Many psychiatrists are tempted to use Cytomel but are concerned about causing medical problems by adding thyroid hormone to our patients’ systems. What are your thoughts about that?

Dr. Posternak: I don’t think that they have to be concerned about that. If someone has an arrhythmia, I wouldn’t use it, but otherwise 25 mcg. is a very low dose; it is quite safe and you really don’t have to be concerned about that from a clinical standpoint.

TCR: And before you start, do you recommend that we get any particular labs?

Dr. Posternak: No, it is not necessary. If you use T3 and it works, then you will want to get a TSH at some point just to make sure you are not affecting the thyroid gland. But if it doesn’t work, you’ll just stop the medication and you’ll save your patient a blood draw.

This article originally appeared in:
The Carlat Psychiatry Report
Click on the image to learn more or subscribe today!

This article was published in print 1/2006 in Volume:Issue 4:1.

APA Reference
The Carlat Psychiatry Report. (2013). This Month’s Expert: Michael Posternak, M.D., on Choosing Antidepressants. Psych Central. Retrieved on August 7, 2013, from

Last reviewed: By John M. Grohol, Psy.D. on 30 Jul 2013
Posted by: Dr. Dan L. Boen AT 08:39 am   |  Permalink   |  Email
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