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COMPASS POLLY DREW Anti-Depressants Need Close Look

Posted on: Sunday, 24 October 2004, 14:00 CDT

Anti-depressants need close look

"So doctor," I ask my friend, child psychiatrist Donna Brehm, "what are your thoughts on the Food and Drug Administration (FDA) issuing a 'black box warning' for the popular SSRI anti- depressants?"

"It's not a big surprise," she says. "These are powerful medications and should not be taken, or prescribed, lightly."

These "first line" anti-depressant medications, SSRIs (selective serotonin reuptake inhibitors), were first introduced in the mid- 1980s. Prozac was the first, and then came Zoloft, Paxil, Luvox, Celexa, Lexapro, Effexor and others. These medicines are enormously popular with psychiatrists, primary care doctors and the depressed patients they treat. That's because of their minimal side effects and relatively quick relief from symptoms that impair daily living. And, it's nearly impossible to overdose and cause suicide with these medications.

People with severe clinical depression and other mental illnesses sometimes try and kill themselves with their own medication. Some medicines kill (not SSRIs) especially in combination with other substances (such as alcohol).

Last August, the Journal of the American Medical Association published a study funded by the National Institute of Mental Health (NIMH) that researched 439 depressed adolescents over a three-year period. It found most improved were those who were given Prozac (the only anti-depressant approved for use in teens by the FDA) and talk- therapy. Of that group, 29% reported feeling suicidal at the beginning of treatment but "improved significantly" with the combination therapy.

With this fresh, respected NIMH study just out, why would the FDA strongly request that drug companies give their little darlings of psychiatric medicine a "black box warning?"

For those who don't know, a "black box warning" is just that: a lined warning that tops the inserts that accompany medicines that need caution. A "black box" is the equivalent of an arm shake. It says to the doctor: "Hey! This is serious! Educate your patients about bad side effects! Follow-up! Document! And for God's sake, if you are unsure, consult with a specialist before you prescribe this drug!"

Other medicines that carry these ominous warnings are taken very seriously.

Prescribing psychiatric medicine requires expertise in the art of the interview. Most primary care doctors spend less than 15 minutes with patients, a fourth of the time a psychiatrist spends making an initial assessment and diagnosis.

Not all SSRIs are the same. They are more like cousins than twins. Each touches a certain symptom differently. And no two people react the same way to one medication.

It's a complex decision to decide which medicine to start a depressed patient on. That's why those who are highly trained and savvy know that even though a person may "present with classic depression," the doctor may have missed something important. Or the patient innocently, or because of embarrassment, omitted some piece that's critical to the entire diagnostic picture.

Overnight, that seemingly harmless first drug of choice becomes a ticket into the pathos of hell. Psychiatrists know this, predict it and educate. They insist on follow-up "med checks" to follow all the nuances in the use of anti-depressant medication.

It's true that certain mental illnesses can be "activated" by anti-depressants. Psychiatrists understand this better than anyone.

If all of this sounds like an infomercial for psychiatry, good, they need it. The profession is so stigmatized that even health insurance won't cover mental illness the way it covers every other medical condition. County programs are underfunded and understaffed.

People who need help also feel the stigma. My husband, a family practice doctor, says that if he refers patients to heart specialists, they go. But when he refers to psychiatry, patients resist.

Primary care doctors who choose to treat mental illness need to tread lightly. Most know that they need a lot more training then a visit from a pharmaceutical rep. They need to read current literature, attend meetings and get up to speed on how mysterious and powerful these medicines are. Most people suffering from mental illness just don't have the extra chutzpah to advocate for themselves.

But that only takes care of the small picture. Psychiatry and psychotherapy are in desperate need of fresh, national policy changes.

"My profession is in a crisis (in part) because we need (mental health) parity," said Brehm.

People would be mortified if their expensive health insurance paid just $2,000, or nothing at all, for other potentially life- threatening, chronic illnesses such as asthma or stomach ulcers.

For Brehm, it's hard to work under these wage conditions after all those years of medical school and training. And, with the new black box warnings, her liability just got higher. So will her malpractice premiums.

SSRIs don't kill people. But, being cavalier with psychotropic medicine could.

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Polly Drew is a marriage and family therapist. E-mail her at pollydrew@earthlink.net.

Source: Milwaukee Journal Sentinel

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