Are Doctors Overprescribing Antidepressants?
Many people not diagnosed with depression take them
More doctors who are not psychiatrists are offering antidepressants to patients, often for vague complaints of fatigue, headaches or gloominess.
Indeed, the practice of prescribing these drugs without a diagnosis of depression is escalating and more common in men and women over age 50.
Nearly four of every five prescriptions are written by primary care doctors and specialists untrained in psychiatry who are dispensing powerful drugs that may have either no impact or harmful effects.
Antidepressants are now the third most commonly prescribed class of drugs in the United States, according to a study in the August issue of Health Affairs. (Prescription painkillers and cholesterol-lowering drugs were the first and second most prescribed drugs, the study reports.) Antidepressants also are one of the most costly medications to the health care system, with annual sales of approximately $11 billion.
The drugs are effective for a limited number of conditions, including clinical depression, chronic depression and some anxiety disorders.
“My sense is that we now have a large group of people taking them for unclear reasons,” says coauthor Mark Olfson, M.D., a professor of clinical psychiatry at Columbia University. “And when you treat less severe problems, it becomes harder to demonstrate that they’re helpful at all.”
The study looked at information from surveys conducted by the Centers for Disease Control and Prevention that considered more than 230,000 visits by adults to offices of primary care doctors and specialists who were not psychiatrists.
Researchers found that 73 percent of prescriptions for antidepressants were written for patients with no formal diagnosis of depression in 2007, compared with 60 percent in 1996.
The share of doctors who prescribed antidepressants without such a diagnosis increased from 30 percent to 55 percent in the same period. The typical patient who received antidepressants without a formal diagnosis was a white woman over 50 who had high blood pressure, diabetes or several medical problems.
Psychiatrist Dilip Jeste, M.D., of the University of California in San Diego calls the study’s conclusions important.
Jeste, president-elect of the American Psychiatric Association, says that recommending medications for reasons not approved by the Food and Drug Administration, a practice called off-label prescribing, “is not illegal, nor is it rare in clinical practice.” However, “antidepressants are powerful drugs and can have a variety of adverse effects, which are more common in older adults with multiple medical problems,” so “the study’s findings are worrisome.”
Depending on the specific drug, side effects can include dizziness, sleep problems, changes in blood pressure and weight gain.
Olfson says that people should recognize the difference between the sadness and grief that becomes more common with age and the persistent and distressing pattern of depression that interferes with sleep, appetite and concentration. He advises people to talk over these feelings with a doctor.
“Find out if your doctor feels your symptoms fit the definition of clinical depression, and why, and whether medication will help,” Olfson says. “And because antidepressants don’t work immediately, ask how long it will take before you can expect to see a difference.”
You should be able to take time to talk about these matters with your doctor and not try to rush through the conversation in the course of one hurried 15-minute visit.
“This discussion will help you understand your own treatment better so you can recognize if it is or is not working,” counsels Jeste.
Source: AARP.org
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Are My Meds Making Me Depressed?
Q: I’m 72 and being treated for hypertension, hypothyroidism and swelling in my ankles. Shortly after I went on metoprolol for my hypertension, I started having strange dreams and difficulty sleeping all night. The doctor prescribed ramelteon to help me sleep, but it hasn’t seemed to help. Then I started having leg cramps almost every night. The doctor prescribed a muscle relaxant, cyclobenzaprine, but I didn’t like the way it made me feel, so I stopped taking it after the second dose. I also takelevothyroxene for my thyroid condition and furosemide for the swelling.
Through all this I have become more and more depressed. My doctor said he didn’t think the medications were causing me to feel this way and I would just have to learn to live with it. Is he right? Is it just that I am getting older? Or is it possible that the medications are causing my depression?
A: The problems you’re having are almost certainly related to the metoprolol, which is in a class of blood pressure medications called beta-blockers. Many doctors do not know that beta-blockers should not be prescribed to people over 60 with uncomplicated hypertension (high blood pressure without angina or heart failure), especially because they are associated with a higher risk of stroke and other adverse events, including new-onset diabetes and even death.
The nightmares, insomnia, muscle cramps and depression that you’re experiencing are all telltale side effects of beta-blocker use in your age group.
I would recommend that you ask your doctor about changing to a benzothiazepine calcium channel blocker — another form of blood-pressure medication. This would need to be done over five to 10 days to avoid problems related to sudden withdrawal of a beta-blocker. I’m confident that, with this change, you will no longer need the sleeping pill and the muscle relaxant, as they were dealing with problems caused by the metoprolol.
Source: AARP.org
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10 Types of Medications That Can Make You Feel Depressed
Researchers have long known that many drugs can make us feel down or even depressed and that, as we age, our changing body chemistries put us at a greater risk for this side effect. But few doctors think to review the medications list when their patients have the telltale symptoms of depression: lack of energy, listlessness, feeling rundown, excessive fatigue, changes in appetite and sleeping patterns, sadness, despair. As a result, they often layer on top of the drugs causing those symptoms a new drug, such as an antidepressant, for treating them, which may in turn trigger additional side effects.
Are you feeling depressed? One of the drugs you’re on could be the cause. Read below for the major classes of drugs that can cause depression. If you suspect that your depression symptoms are linked to a prescription drug you’re taking, talk to your doctor or health care provider right away. It’s important that youdo not discontinue them on your own.
1. Beta-blockers
Why they’re prescribed:Beta-blockers are typically prescribed to treat high blood pressure (hypertension). Examples: atenolol (Tenormin), carvedilol (Coreg), metoprolol, propranolol (Inderal), sotalol (Betapace), timolol (Timoptic) and some other drugs whose chemical names end with “-olol.” These drugs slow the heart rate and lower blood pressure by blocking the effect of the hormone adrenaline. Beta-blockers are also used to treat angina and for other conditions, such as migraines, tremors, irregular heartbeat and, in eye-drop form, certain kinds of glaucoma.
How they can cause depression: While scientists don’t know exactly how beta-blockers cause depression, the three most commonly adverse effects reported with their use are fatigue, sexual dysfunction and depression.
Alternatives: For older people, benzothiazepine calcium channel blockers, another form of blood-pressure medication, are often safer and more effective than beta-blockers.
2. Anticonvulsants
Why they’re prescribed: Anticonvulsant drugs, which have long been used to treat seizures, are increasingly being used to treat other medical conditions, including neuropathic pain, bipolar disorder, mood disorders and mania. Examples: carbamazepine (Tegretol), gabapentin (Neurontin), lamotrigine (Lamictal), pregabalin (Lyrica) and topiramate (Topamax).
How they can cause depression: Anticonvulsants are believed to work by affecting neurotransmitters, which act as chemical messengers in the brain. They may, for example, limit seizures from spreading by blocking the flow of signals from the central nervous system (CNS) rather than raise the threshold for seizures. All CNS depressants, including anticonvulsants, can cause depression.
Alternatives: For seizures, phenytoin (Dilantin), which raises the seizure threshold; for chronic neuropathic pain, venlafaxine (Effexor), which affects the two neurotransmitters, serotonin and norepinephrine, that are thought to play roles in regulating pain.
3. Benzodiazepine hypnotics
Why they’re prescribed: These drugs, also known as benzodiazepine tranquilizers, are typically prescribed to treat anxiety and insomnia and to relax muscles. Examples: alprazolam (Xanax), diazepam (Valium), estazolam (ProSom), flurazepam (Dalmane), lorazepam (Ativan), temazepam (Restoril) and triazolam (Halcion).
How they can cause depression: Benzodiazepines are central nervous system depressants. If not fully metabolized in the liver, they can build up in the body to toxic levels. The resulting “hangover effect” can manifest itself as depression. Older people are more likely to experience these residual effects because their livers often lack a key enzyme needed to metabolize the drugs.
Alternatives: Give yourself every chance to sleep well naturally: Go to bed and wake up at the same times every day, avoid meals within two hours of bedtime, allow 30 minutes before bedtime for a relaxing pre-sleep ritual, and so forth. Melatonin, a dietary supplement that helps control sleep and wake cycles, may also be worth trying.
4. Parkinson’s drugs
Why they’re prescribed: One approach to treating the symptoms of Parkinson’s disease is to use drugs to adjust the levels of dopamine (a neurotransmitter) in the brain, as the motor symptoms associated with the disease result from the death of dopamine-generating cells in a region of the midbrain.
For example, levodopa, the most commonly prescribed Parkinson’s medication, is converted into dopamine on entering the brain; it’s typically combined with carbidopa, which helps prevent it from breaking down before it can reach the brain and take effect, in brand-name products such as Atamet, Sinemet and Stalevo.
Another approach is the use of dopamine agonists such as pramipexole (Mirapex) and ropinorole (Requip), which work by stimulating the dopamine receptors in the brain, thus mimicking the activity of dopamine.
How they can cause depression: Dopamine is one of three basic neurotransmitters that have been associated with depression (the others are serotonin and norepinephrine). Researchers believe that prolonged exposure to higher levels of dopamine may cause depression.
Alternatives: As many as 25 percent of all patients who are diagnosed with Parkinson’s don’t actually have the disease, so it’s important to make sure that you’re not among those misdiagnosed. Older people with essential tremors — involuntary trembling or quivering of the hands, limbs or other parts of the body — are often misdiagnosed as having Parkinson’s. There’s also drug-induced Parkinson’s, which can often be reversed if the offending medication is discontinued early enough. (Older patients, for example, frequently develop parkinsonism after being prescribed antipsychotic drugs such as Haldol, Mellaril, Stelazine and Thorazine.) A systemic neurological examination is the best way to test for Parkinson’s disease. And if you need to take levodopa, the dose can be reduced with the use of a COMT-inhibitor, a relatively new type of drug that blocks an enzyme in the body from metabolizing the levodopa before it reaches the brain.
5. Corticosteroids
Why they’re prescribed: Corticosteroids are used to treat inflammation of the blood vessels and muscles as well as rheumatoid arthritis, lupus, Sjögren’s syndrome and gout. Examples: cortisone, methylprednisolone, prednisone and triamcinolone.
How they can cause depression: Research suggests that corticosteroids lower serotonin levels in the body, and it is known that lowered serotonin levels can cause depression and other psychiatric disorders. Withdrawal from corticosteroids can also trigger depression.
Alternatives: Acetaminophen (Tylenol), aspirin, tramadol (Ultram) or, if the situation requires it, a mild opiate like hydrocodone/acetaminophen (Vicodin). As we grow older, most joint pain from arthritis comes not from inflammation (for which corticosteroids may be used) but from immobility of the joint due to joint damage from years of inflammation.
6. Hormone-altering drugs
Why they’re prescribed: Hormone-altering drugs are used to treat a variety of conditions. Estrogen (Premarin), for example, is typically prescribed for hot flashes and other postmenopausal symptoms .
How they can cause depression: Manipulating hormone levels in the body can cause a variety of problems, particularly as medications interact with the central nervous system. Studies show that changes in hormonal levels are significantly associated with the appearance of symptoms of depression.
Alternatives: Once again, it’s important to try to identify the cause of the symptoms. Review the medications you’re taking — prescription and over the counter — with your doctor to identify some problems that can be corrected without additional drugs.
7. Stimulants
Why they’re prescribed: Stimulant medications, such as methylphenidate (Ritalin) and modafinil (Provigil), are often prescribed to treat excessive daytime sleepiness, whether caused by hypersomnia, narcolepsy or sleep apnea. They’re also prescribed for ADHD and fatigue.
How they can cause depression: Stimulant medications increase the level of dopamine in the body. Researchers believe that prolonged exposure to higher levels of dopamine may cause depression.
Alternatives: As with insomnia (see benzodiazepine hypnotics, above), it’s important to identify the cause of excessive daytime sleepiness. Other medications you’re taking — whether prescription or over the counter — could be responsible. Drugs with sedating effects, for example, are among the most common causes of excessive daytime sleepiness. (These include alpha- and beta-blockers, anti-diarrheal agents, antihistamines, antipsychotics, antispasmodics, cough suppressants, epilepsy drugs, skeletal muscle relaxants, Parkinson’s drugs and some antidepressant medications.)
Nondrug causes of excessive daytime sleepiness include sleep deprivation, obstructive sleep apnea (when the throat muscles intermittently relax and block the airway during sleep) and depression. When such underlying conditions are treated appropriately, there’s rarely, if ever, any need for the use of stimulants.
8. Proton pump inhibitors and H2 blockers
Why they’re prescribed: Doctors typically prescribe these medications, which suppress the secretion of gastric acid, to treat gastroesophageal reflux disease (GERD).
How they can cause depression: While these drugs are known to cause depression, scientists don’t yet understand why they do. When any major body process is blocked, however, the body often rebels in an intense effort to fight back. Consequently, it’s altogether likely that changing the pH of the stomach could bring on changes to the central nervous system and the brain.
Alternatives: Know which foods trigger your acid reflux (spicy or fried foods, for example) and avoid them, especially in the hours before bedtime. A non-calcium-carbonate-based antacid, such as Mylanta, may also help. Many of my patients have reported relief from the home remedy of apple cider vinegar and honey (typically one tablespoon each, taken together), though I know of no scientific research that confirms the effectiveness of this approach.
9. Statins and other lipid-lowering drugs
Why they’re prescribed: Statins are the class of drugs most commonly prescribed to lower cholesterol levels, followed by fibrates and other drugs, such as ezetimibe, colesevelam and nicotinic acid.
How they can cause depression: Recent research suggests that lipid-lowering drugs may cause depression by depleting levels of cholesterol in the brain, where it plays an important role in the release of neurotransmitters.
Alternatives: A combination of vitamin B12 (injectable or sublingual), vitamin B6, folic acid and fish oil can lower homocysteine levels in the body. Homocysteine, an amino acid, inflicts damage to the inner arterial lining (endothelium) and other cells of the body, elevating lipids levels. While there are many studies that substantiate this nondrug approach and many that reject it, I’ve found that it works consistently well in older patients without posing the risk of serious side effects.
10. Anticholinergic drugs used to treat stomach cramps and other GI disorders
Why they’re prescribed: Anticholinergic medications slow the action of the intestine, thereby reducing the amount of stomach acid produced. They do this mostly by blocking the effects of acetylcholine, the neurotransmitter that causes muscles — including those in the intestine — to contract. Dicyclomine (Bentyl), for example, is widely used to treat the symptoms of irritable bowel syndrome.
How they can cause depression: Anticholinergics, as central nervous system depressants, can cause depression, sedation and cognitive impairment in older patients.
Alternatives: Using an H2 blocker such as ranitidine (Zantac) in the lower-dose formulation (75mg) can work well for the occasional attack of heartburn and acid indigestion. A calcium-free antacid (Gelusil or Mylanta, for example) may help.
Source: AARP.org
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Timely Depression Diagnosis Critical To Maintain Health Of Elderly
Depression affects approximately 30 to 40 percent of nursing home residents, but it often goes unrecognized, according to American Geriatrics Society, which can lead to lower quality of life or even suicide. Now, researchers at the University of Missouri have found a series of indicators, other than changes in mood that are associated with the development of depression in nursing home residents.
“Prompt diagnosis and treatment of depression is essential to improve the quality of life for nursing home residents,” said Lorraine Phillips, assistant professor in the Sinclair School of Nursing. “Many elderly people develop certain clinical characteristics at the same time they develop depression. Understanding these changes is essential to quickly and accurately diagnosing depression in nursing home residents.”
Changes in characteristics that Phillips found to be associated with the development of depression include increased verbal aggression, urinary incontinence, increased pain, weight loss, changes in care needs, reduced cognitive ability and decline in performance of daily living activities.
“Depression is currently diagnosed using several methods that emphasize mood symptoms including interviewing and self-reporting of depression symptoms,” Phillips said. “However, since elderly depression may appear with non-mood symptoms, these characteristics identified in this study can help diagnose depression that may be overlooked by traditional screening methods.”
Phillips found that residents with increased verbal aggression were 69 percent more likely to be diagnosed with depression than those who had not shown these changes. Decreases in activities of daily living, such as feeding or dressing one’s self, also were associated with increased depression diagnosis. The research indicates that men and women in nursing homes are equally likely to develop depression. This contrasts with the overall population, where women are more likely than men to experience depression.
To study these changes, MU researchers analyzed data on more than 14,000 nursing home residents aged 65 and older who were not diagnosed with depression at the beginning of the study. Researchers analyzed changes in various clinical factors, other than mood changes, to discover which changes were associated with the development of depression during a three-month interval of time. The data was collected from the Missouri Minimum Data Set, a federally mandated process for clinical assessment of all residents in Medicare- or Medicaid-certified nursing homes.
Phillips worked with Marilyn Rantz, a professor in the MU Sinclair School of Nursing and chair of the MU Minimum Data Set and Quality Research Team, and Gregory Petroski, a research assistant professor and statistician in the Office of Medical Research. The study was published in the Journal of Gerontological Nursing.
Source:
Emily Martin
University of Missouri-Columbia
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