Are they prematurely whipping out those prescription pads?
A few years ago, Sharon Mesmer hit a rough spell. Within the span of 24 months, the Brooklyn-based poet and creative writing instructor lost her sister to a drug overdose; slammed her head on a Moscow hotel bathtub on the first day of her eagerly anticipated six-month teaching assignment and had to rush home; and fractured a tooth, which promptly got infected. Although she’d never had psychological issues before, Mesmer found herself overcome with symptoms of anxiety and depression: crying, pacing, losing her appetite (and 20 pounds), and shunning people and activities she’d previously adored.
She saw a psychotherapist for talk therapy, but two months later when she went to her gynecologist (who served as her primary care doctor) for an annual exam, the doctor was eager to prescribe an antidepressant. Mesmer declined. “I knew I needed to learn from what was going on in my life,” she says. “I didn’t want to be numbed by antidepressants.”
In declining the pills, Mesmer bucked a trend that’s been growing for years, and continues to show no signs of abating. Prescriptions for antidepressants are skyrocketing in the US, making it the third most commonly prescribed class of drugs. Doctors appear to readily hand out the pills without concern that it’s a serious and sometimes dangerous medication. And women are the biggest recipients.
A recent study found nearly one in six American women, some 16 percent, are currently on an antidepressant. And a 2011 government query of Americans’ health shows millennial women are three times more likely than their male peers to be taking an antidepressant—some 9 percent vs. 3 percent. Among older women the disparity is even greater: 23 percent of women 40 to 59, and 19 percent of those over 60, compared to 8.5 and 9 percent of men, respectively.
Most striking is the fact that antidepressants are being prescribed even to people who don’t meet the official psychiatric criteria for depression. When Johns Hopkins researchers looked at symptoms in patients on the drugs who had been diagnosed with depression in the prior year, they found 62 percent didn’t reach the standards laid out in the Diagnostic and Statistical Manual of Mental Disorder, the industry bible.
The unchecked growth of antidepressant prescriptions has begun to cause alarm among some psychiatrists. “So many of my female patients come to me over-diagnosed, misdiagnosed or mistreated,” says Kelly Brogan, a psychiatrist in private practice in New York and author of the book, A Mind of Your Own. While Brogan has long touted natural treatments over drugs for her patients, when researching her book even she was surprised to discover that what she’d learned about depression in her traditional medical training wasn’t accurate. “We’re told a tale about depression—that it’s a chemical imbalance. We’re told it’s a disease like diabetes,” she says. “But in six decades of research there’s actually no science to support that. It’s more akin to a fever—a symptom that tells you the body is struggling with something, but not what that is or what you should do about it.”
“The brain is the last frontier. We still have such a rudimentary understanding of how it works,” says Matt Rudorfer, a psychiatrist and program chief of the division of services and intervention research of the National Institute of Mental Health. “When we have a treatment that shows effect, we infer what it’s doing in the brain, but we really don’t know.” Rudorfer hopes that will change with two national research initiatives currently underway, where diagnostic equipment like PET scans and fMRI record actual activity inside the head when various medications are administered.
Depression is usually described as a malfunction of brain chemistry that regulates mood and pleasure, especially the neurotransmitters serotonin and norepinephrine. Yet as far back as the 1970s, researchers were already casting doubt on low serotonin as a prime cause.
“Serotonin and norepinephrine [the two brain chemicals targeted by most antidepressants] are just one part of the puzzle. In the last decade, we’ve started to uncover how complex that puzzle is,” says Alex Korb, a neuroscientist at the University of California, Los Angeles, and author of The Upward Spiral. It’s now believed that at least a hundred neurotransmitters and hormones are involved in the delicate symphony of regulating mood. These suspects include cortisol, oxytocin, GABA, melatonin, glutamate, and endocannabinoids (compounds that activate the same receptors as marijuana).
Even the hormones in oral contraceptives may cause shifts in the brain. A recent Danish study of a million women ages 15 to 34 found that, compared to non-users, women on the pill are nearly a quarter more likely to be given antidepressants. Researchers aren’t certain whether the altered hormones from the pill leads to the blues, but they call it a “potential adverse” effect. Psychiatrists do believe at least some of the gender disparity is called for. Hormones likely play some role in depression, Rudorfer says, noting that the gap first rears its head in puberty.
But this doesn’t explain all of it. Some part of the disparity in antidepressant prescriptions may simply be that women see their family physicians more than men do. A few years ago, the American Academy of Family Physicians launched a brief assessment known as the patient health questionnaire (PHQ) to help their member physicians quickly determine who needs an antidepressant. This was thought to be helpful because there aren’t enough psychiatrists to go around. But it means a diagnosis of depression and the drugs that follow now typically happen in a 15-minute office visit, rather than the hour and a half that psychiatrists typically allow. In addition, the symptoms (mentioned in the questionnaire) attributed to depression skew towards the way women deal with problems such as feeling tired, sleepy, or withdrawn. Men have been conditioned to react more with anger and even alcoholism.
If researchers don’t yet understand what happens in a brain exhibiting symptoms of depression, it’s not surprising that the drugs currently available are not even especially effective. In the well-publicized NIMH STAR*D study, which followed nearly 3,000 antidepressant users, a paltry one-third went into remission after several months. Many of the rest moved on to a different drug, but in total, after trying as many as four separate medications and combinations, fully 33 percent remained symptomatic.
Equally damning is a largely overlooked 2008 report in the journal PLOS Medicine, where British and American scientists studied all the data on four antidepressants that had been submitted by their manufacturers to the FDA, rather than only published reports. For people with moderate depression, they found, the drugs worked no better than a placebo. Only the most extreme sufferers got more benefit than their placebo counterparts.
And antidepressants can have rare but significant side effects, including brain bleeds, the risk for which is small but elevated, especially in the first 30 days of use. The side-effects list for selective serotonin reuptake inhibitors (SSRIs, such as Paxil or Prozac) also includes nausea and reduced sexual desire, while serotonin and norepinephrine reuptake inhibitors (SNRIs, like Cymbalta and Pristiq) can cause constipation and difficult urination. Norepinephrine and dopamine reuptake inhibitors (NDRIs, e.g., Welbutrin) can cause insomnia and hyperventilation. Meanwhile, antipsychotic drugs (such as Abilify), which are approved as add-ons if other drugs aren’t working alone, bring on seizures in rare cases and, according to the most recent warning from the FDA, the uncontrollable urge to binge eat, gamble, and have sex.
Of course, some women do have serious depression, which typically recurs periodically between adolescence and early adulthood, and may be helped by meds. But for others, depression may be a temporary reaction to life’s difficulties. Last year, Canadian researchers published a paper outlining the logical explanations for symptoms of depression in response to today’s highly stressful environment. Depression may let the body conserve energy during trying times, they suggest, or be a way to reduce risky behavior (because you’re less likely to do any activity) during adverse situations.
Julie Holland, a psychiatrist in private practice in New York, believes doctors shouldn’t be so quick to label a woman’s volatile moods as abnormal. Holland especially fears that antidepressants blunt women’s full emotional range. “You lose the low end on these medications, but you also lose the high end: There’s less joy, creativity, empathy, and surprise,” she says.
Psychotherapy, an alternative to medication, is currently underused, many experts say. When asked their preference, patients seeking psychological help are three times more likely to pick talking over taking drugs, a Harvard Medical School study found. Access is a challenge, says Lynn Bufka, associate executive director of practice research and policy at the American Psychological Association: “You have to find someone who is trained, who takes your insurance, and has an opening for new patients,” something that can be tough in a city and downright impossible in rural communities. Fortunately, even short-term methods like cognitive behavioral therapy (CBT) have been deemed effective, as are therapy sessions online.
There’s also the often debated option of herbal treatments. Sarah Lisovich, a 23-year-old marketer in Chicago, finally agreed to take an antidepressant last year after the mild depression she’d always felt ratcheted up when she graduated from college and started her first real job. The meds made her extra anxious and, most disconcerting to her, blunted her desire to make art. Determined to get off the pills, she saw a new psychiatrist who suggested she try St. John’s Wort. Neither her therapist or family doctor (who’d prescribed the SSRI) ever mentioned this herbal medicine, which some studies have found to be effective for mild to moderate depression, and which greatly helped her.
Experts say lifestyle approaches can help many women with depression—but doctors and therapists don’t always convey this. Taking even small steps to elevate yourself can start your healing, Korb explains. Some of the daily habits he suggests include getting more sun (vitamin D a key ingredient for brain neurotransmitters), exercising as much as you can (even if it’s a short walk), getting sufficient sleep, and cultivating a mindfulness practice that works for you. Diet is crucial too—Brogan suggests cutting sugar and processed foods from your diet.
If you do decide to go on antidepressants, or if you’re on them now and don’t have a history of chronic, severe depression, Holland suggests talking to your doctor about tapering off after six months. “When you break your leg, you don’t keep the cast on forever,” she says. Yet the Institute for Safe Medication Practices study found 80 percent of users reported being on their antidepressants long-term.
Ann Rea, an artist in San Francisco, wishes she’d gotten that advice decades ago, when she bounced from one antidepressant to another starting in her late 20s. With each drug change, she’d feel marginally better for a short while. Her psychiatrist warned that she’d never be able to stop the drugs, but after a decade of feeling numbed, she’d had enough. Rea cleaned up her diet, started walking for exercise, and set manageable goals, like selling her first painting by a set time. Within a year she was off all pills.
She now wonders what part of her depression and anxiety was just a healthy, human response to the emotionally abusive environment she was reared in. “The drugs don’t help you evaluate and get out of the problem you’re in, like if you’re living with a jerk or your boss is a terror,” she says. Rea has never experienced depression again—although she is proud to say she sometimes feels appropriately sad.