Antidepressants: Too Much of a Good Thing?Experts debate whether they are being prescribed too quickly, too often< November 5, 2002 > Now that some of the stigma of mental illness has been stripped away, more Americans than ever before are reaching out for help with depression. The heart of the argument: Are antidepressants being over-prescribed or under-prescribed for those struggling with depression? The answer is not as simple as you may think. In a study published recently in the Journal of the American Medical Association (JAMA), Columbia University psychiatrist Dr. Mark Olfson and his colleagues examined national trends in the outpatient treatment of depression between 1987 and 1997. Olfson found the percentage of Americans being treated for depression more than doubled during the 10-year period. And the total number of people receiving treatment rose from 1.7 million to 6.3 million. The researchers also found that patients were almost five times more likely to be treated with antidepressants than they were in 1987. A number of factors account for the dramatic rise in the use of antidepressants. Proponents say they are the fastest, most reliable method of delivering much needed relief to victims of a debilitating disease. "The most robust and rapid response to treatment is obtained from antidepressant medications," says Dr. Barnett Meyers, a professor of psychiatry and clinical epidemiology at Cornell University's Weill Medical College in White Plains, N.Y. And the newer generations of antidepressants—called selective serotonin reuptake inhibitors and marketed under such brand names as Prozac, Zoloft, and Paxil—produce less troublesome side effects than older medications. Further fueling the rise in the use of antidepressants: The proportion of pharmacy costs borne by health insurers increased over the 10-year period of Olfson's study, reducing out-of-pocket costs for consumers. Depressed patients were also more likely to consult initially with their family physician or a psychiatrist, who would tend to prescribe medication, as opposed to psychologists or social workers who would be more likely to provide psychotherapy, the study found. That helps to explain, in part, the sharp decrease in the percentage of people receiving psychotherapy for depression. The researchers found that 60.2 percent of those treated for depression in 1997 received psychotherapy, down from 71.1 percent in 1987. And the average number of psychotherapy visits per patient, per year, also declined from 12.6 to 8.7 over the 10-year span. The trend toward antidepressants as the treatment of choice is viewed with concern by some mental health experts. "The idea that depression is simply some sort of biological error that can be easily fixed by an antidepressant fundamentally shortchanges people," says Dr. James S. Gordon, a psychiatrist who directs the Center for Mind-Body Medicine in Washington, D.C. "What's happening now appears to be more economical," Gordon adds. "There's a tremendous amount of advertising [by the drug companies]. Doctors are immediately reaching for the prescription pad without thinking of the complexity of the human being sitting in front of them." Many experts also attribute the shift in treatment options to the rapid growth of managed care plans and aggressive efforts to reduce healthcare costs. "The Olfson data, indicating that there has been a 50 percent reduction in the use of psychotherapy alone over the 10-year period, probably results from obstacles that insurance companies place as a barrier to obtaining this treatment," says Meyers. He adds that depression is often best treated using a combination of medication and psychotherapy. "These economically driven barriers can be expected to decrease the number of mental health practitioners with psychotherapy training, which will further limit access of patients to this treatment," Meyers says. "Research data demonstrating that mild clinical depression may respond robustly to psychotherapy, and that psychotherapy augments the benefits of antidepressants argue that this trend should be reversed." Major depression affects more than 19 million Americans at any point in time. Current research suggests a combination of antidepressants and cognitive behavioral psychotherapy is the most effective treatment regimen for most forms of major depression. In cases of mild depression, some studies show that psychotherapy can be as effective as medication. Although depression is a very treatable disease, the majority of depressed Americans receive no treatment at all, according to a 1999 US Surgeon General's study titled, "Report on Mental Health." And a 2001 report by the National Institute of Mental Health concurred, stating that only 25 percent to 50 percent of individuals with anxiety and depressive disorders receive appropriate treatment. Meyers says that studies from around the world show that when mistreated or left untreated, depression can have devastating consequences. For instance, major depression accounts for 20 percent to 35 percent of all suicides, according to the Surgeon General's report. "Depression is one of the major public health problems of our country," Gordon says. "We need to look at what's making people depressed and address it in a comprehensive, holistic, and individualized way." "In that mode, drugs certainly have a part, but that's a smaller part than they are playing now," he adds. Always consult your physician for more information. In Other Mental Health News:
Reading Fashion Magazines Can Give Women the Blues
Women, you know that crummy feeling you get after leafing through a fashion magazine chock full of models who, let's face it, look way better than you?
Researchers found that women who looked at advertisements featuring stereotypically thin and beautiful women showed more signs of depression and were more dissatisfied with their bodies after only one to three minutes of viewing the pictures.
The women who registered the biggest drop in self-image after viewing the pictures were those who already felt bad about themselves to begin with, said Laurie Mintz, lead author of the study and an associate professor of educational and counseling psychology at University of Missouri-Columbia.
"It's like a vicious cycle for a lot of women," Mintz said. "Basically, women who already feel ashamed of themselves are the people who are going to be most impacted by those images."
Researchers divided 91 Caucasian women ages 18 to 31 into two groups. The first group was shown advertisements for underwear, nail polish, jewelry, lotion, gum, and liquor that featured rail-thin, seemingly flawless women. The other group of women was shown ads for the same types of products without people in them.
Mintz and graduate student Emily Borchers then used three well-accepted tests to measure psychological changes after viewing the images, including depression, self esteem, and body satisfaction.
The body satisfaction test, called the Objectified Body Consciousness Scale, is designed to assess to what degree women see themselves as an object, how ashamed they are that their body does not measure up to cultural ideas, and how much they believe they are responsible for their body not meeting the cultural standards.
One portion of the questionnaire asks women to rate, on a scale of one to five, their happiness with 35 body parts, including their nose, lips, waist, thighs, overall weight, and body hair.
Researchers found that after looking at the pictures of the beautiful models for one to three minutes, the women's body dissatisfaction increased significantly. Depression levels registered a slight uptick, while self-esteem was unchanged.
"What is really, really striking to me is that it took such a short time," Mintz said.
The study has not yet been published.
Joan Chrisler, a professor of psychology at Connecticut College, said she's not surprised by the findings. "There have been several studies that have shown after women look at fashion magazine their body satisfaction and their feelings about themselves decrease," Chrisler said. So what is a woman to do?
Avoid reading fashion or celebrity-gossip type magazines, Chrisler said. Of course, it is hard to avoid billboards, television, and all the other places these images are shown.
So try to remember images are not realistic.
Forget airbrushing. Models in today's ads can have portions of their bodies digitally altered to erase even the most minute mole, bulge, or asymmetry. Some "models" depicted in ads are not real people at all, but composites, Chrisler said.
Today's mass media is blurring the lines between fantasy and reality, making it seem as if "perfection" is attainable with the right diet, the right beauty products, the right plastic surgeon, Mintz said. For the vast majority of women, this of course is not the case.
"Within current mass media messages, the distinction between reality and a fictionalized ideal are often unclear," Mintz said. "Unlike art, literature, and music, which are usually in the context of something unattainable, the images that that individuals are constantly exposed to through the mass media are perceived as realistic, and thus, seem to set cultural standards."
In the study, Mintz cited previous research that asked adolescent girls what the ideal woman looked like. The girls said she is 5 feet 7 inches tall, weighs 100 pounds, is a size 5, and is blond and blue-eyed.
"What we need is for young women to stand up and say, 'I've had it. Enough!'" Chrisler said.
Define your standards for beauty, Chrisler suggested. "It's only the ideal if you accept it as the ideal, and you don't have to. You can ask yourself: 'What does beauty mean to me?' You can decide beauty is a range or something internal or a sparkle in the eye."
Online Resources(Our Organization is not responsible for the content of Internet sites.) American Journal of Psychiatry American Psychiatric Association Journal of the American Medical Association (JAMA) |
For more information on depression, please visit the Mental Health Disorders information module on this Web site. Study Explains Why Depression Can Strike AgainFinds 'trait marker' in people recovering from disease Physicians and patients have long known that people who have a major depressive episode have a greater risk for suffering another. These people, although ostensibly recovered, also remain unusually sensitive to emotional stress. Now researchers reporting in the November issue of the American Journal of Psychiatry have identified what may be a "depression trait marker" in the brain that explains why patients who have recovered nevertheless remain vulnerable to another depressive episode. And in a second study recently released, another research team says it has identified the first gene that leaves women vulnerable to clinical depression. "Depression is not a single event for many people and each episode, if you're lucky, can be treated and you can be well, but depressed patients know that they are at risk for more episodes," says Dr. Helen Mayberg, lead author of the "trait marker" study and a professor of psychiatry and neurology at the University of Toronto. "The question is what about your brain seems to be the area of vulnerability." Previous research has already demonstrated that the brains of depressed people work in different ways than healthy people. This study takes the concept further. It "goes to a new level because it talks about people who have recovered from depression or who have been treated. Their brains are functioning differently, and it's a question of why they're functioning differently," says Dr. Kenneth Skodnek, chairman of the department of psychiatry and psychology at Nassau University Medical Center in East Meadow, N.Y. "This is special because I believe this is the first time that there has been evidence even when someone recovers that the brain is still not functioning normally." In this study, researchers asked 25 adults to remember an extremely sad experience in their life, then scanned their brains with positron emission tomography (PET) while they recalled the event. The participants belonged to one of three categories: 10 women who had recovered from a major depression (nine were on medication and one was not); seven women who were at that time in the throes of a major depressive episode (only one was on medication); and eight healthy women who had no personal or family history of depression. The scans, which measure blood flow, showed that the brains of the recovered patients and currently depressed women experienced different changes than the brains of the healthy participants. "We saw that recovered patients looked for all intents and purposes like acutely depressed patients and that there were some very specific areas of the brain that changed uniquely in depressed patients that we don't see in healthy subjects and vice versa," Mayberg says. "Under that emotional stressor, the recovered depressed patients looked like the worst depressed patients. When we stressed healthy subjects' brains, we didn't see any decrease in brain activity." Specifically, the subgenual cingulate and the medial frontal cortex areas of the brain were involved. The subgenual cingulate has already been identified as being involved in the experience of intense sadness even in healthy individuals. It is also a target of antidepressant medication. "These people are different even when they're treated," Skodnek says. "It's almost like someone comes in with congestive heart failure, you treat them" and the heart appears to be doing OK. "But if you know what's going on with the heart, it's not OK." Whether the differences in brain function are a cause or effect of a previous depressive episode remains unknown. Nevertheless, this research and future studies it spawns will have important implications for identifying people at risk for depression and in identifying new targets for drug therapy. Although this appears to be a trait marker for depression, Mayberg is careful not to overstate the case. "I wouldn't want anyone to think we've got the glucose tolerance test for depression," she says. Meanwhile, researchers at the University of Pittsburgh say they have found evidence that a gene in chromosome 2q33-35 leaves women at a higher risk for depression. However, they found no such correlation in men, suggesting that vulnerability to the disease is at least in part influenced by one's gender. Always consult your physician for more information. Depression and Heart Bypass SurgeryFrame of mind can signal later health problems, a new study says People who suffer from depression a month after they have had coronary artery bypass surgery are more likely to have angina and other cardiac problems five years later. Interestingly, this is true of men, but not women, according to a new study in the November-December issue of the journal Psychosomatics. The study included 172 people. They were given questionnaires that assessed their level of depression before they had coronary artery bypass grafting. They were interviewed again at one month, one year, and five years after their surgery. At the end of the five years, the researchers were able to analyze data for 117 of the original 172 people. They found that 32 percent of the people were depressed before they had surgery, 28 percent were depressed a month after surgery, 21 percent were depressed a year after surgery, and 16 percent were depressed five years after surgery. However, the researchers say that strong association was found in men only, not in women. The study found that five years after surgery, both depressed and non-depressed women had about the same, relatively high, level of chest pain. The researchers say their findings suggest a way to improve long-term results for people who have coronary artery bypass surgery. These patients could be evaluated for depression a month after their surgery and given treatment if they are suffering from depression. Always consult your physician for more information. |