Who Are We? Coming of Age on Antidepressants

[Ariella]

http://www.nytimes.com/2008/04/15/he...a1&oref=slogin

By RICHARD A. FRIEDMAN, M.D.
Published: April 15, 2008

“I’ve grown up on medication,” my patient Julie told me recently. “I don’t have a sense of who I really am without it.”

At 31, she had been on one antidepressant or another nearly continuously since she was 14. There was little question that she had very serious depression and had survived several suicide attempts. In fact, she credited the medication with saving her life.

But now she was raising an equally fundamental question: how the drugs might have affected her psychological development and core identity.

It was not an issue I had seriously considered before. Most of my patients, who are adults, developed their psychiatric problems after they had a pretty clear idea of who they were as individuals. During treatment, most of them could tell me whether they were back to their normal baseline.

Julie could certainly remember what depression felt like, but she could not recall feeling well except during her long treatment with antidepressant medications. And since she had not grown up before getting depressed, she could not gauge the hypothetical effects of antidepressants on her emotional and psychological development.

Her experience is far from unique. Since their emergence in the late 1980s, serotonin reuptake inhibitors like Prozac and Zoloft have become some of the most widely prescribed drugs in the world, for depressed teenagers as well as adults. Because depression is often a chronic, recurring illness, there are certain to be many young people, like Julie, who are coming of age on these newer antidepressants.

We know a lot about the course of untreated depression, probably more than we do about very long-term antidepressant use in this population. We know, for example, that depression in young people is a very serious problem; suicide is the third-leading cause of death in adolescents, not to mention the untold suffering and impaired functioning this disease exacts.

By contrast, the risk of antidepressant treatment is small. A 2004 review by the Food and Drug Administration, analyzing clinical trials of the drugs, did show an elevated risk of suicidal thinking and nonlethal suicide attempts in young people taking antidepressants — 3.5 percent, compared with 1.7 percent of those taking a placebo. But since the lifetime risk of actual suicide in depressed people ranges from 2.2 to 12 percent, risk from treatment is dwarfed by the risks of the disease itself.

Still, what do we know about the effects of, say, 15 to 20 years of antidepressant drug treatment that begins in adolescence or childhood? Not enough.

The reason has to do with the way drugs are tested and approved. To get F.D.A. approval, a drug has to beat a placebo in two randomized clinical trials that typically involve a few hundred subjects who are treated for relatively short periods, usually 4 to 12 weeks.

So drugs are approved based on short-term studies for what turns out to be long-term — often lifelong — use in the world of clinical practice. The longest maintenance study to date of one of the newer antidepressants, Effexor, lasted only two years and showed the drug to be superior to a placebo in preventing relapses of depression.

What do I say to a depressed patient who is doing well after five years on such a drug but can’t stop without a depressive relapse and who wants reassurance that the drug has no long-term adverse effects?

I usually say that we have no evidence that the drug poses a risk with long-term use; and since the risk of untreated depression is much greater than the hypothetical risk of the drug, it makes sense to stay on it.

This large gap in our clinical knowledge is compounded by the public’s growing and well-founded skepticism about research sponsored by drug makers. A study in the January 2008 issue of The New England Journal of Medicine, involving 74 clinical trials with 12 antidepressants, found that 97 percent of positive studies were published, versus 12 percent of negative studies.

Clearly, physicians and the public need much better data on the safety and efficacy of drugs after they hit the market, which at present consists mainly of anecdotes and case reports.

Congress recently reauthorized the Prescription Drug User Fee Act, which will expand the F.D.A.’s post-marketing drug surveillance, though I think it did not go far enough in mandating the use of powerful epidemiological strategies to monitor drugs over the long term.

Beyond these concerns, there are other important issues to consider in long-term use of antidepressants, especially in young people. One patient, a woman in her mid-20s, told me that she felt pressured by her boyfriend to have sex more often than she wanted. “I’ve always had a low sex drive,” she said.

For the past eight years she had been taking Zoloft, which like all the antidepressants in its class is known to lower libido and to interfere with sexual performance. She had understandably mistaken the side effect of the drug for her “normal” sexual desire and was shocked when I explained it: “And I thought it was just me!”

This just underscores how tricky it can be to use psychotropic drugs during adolescence — when the brain is still developing, when one’s identity is still work in progress.

The drugs save lives, and we often have no choice but to use them — even if we have questions about their long-term use. But the questions are big ones, and we owe it to our patients to try to answer them.

Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College.

[Betsy]

This is a very thought provoking article for me. There are SO many things in this changing world that I BELIEVE contribute to anxiety and depression. The ignorance of people to that fact contributes to the attitude of "Give them a pill to "fix" it". When the pill actually only complicates an existing problem and and ignores other actual life changes that could have contributed to recovery. We have set our world up for self annihilation. So sad.
Betsy

[Ariella]

That thought has occurred to me too Betsy.

Another one is that we are our beliefs. Until we introspect long enough to recognize which beliefs were chosen and which were taught before we knew we could choose, there's plenty of room to feel unfamiliar to ourselves.

[palm]

In reading that article, I could identify with Julie even though I am 52 and was put on ADS in 1995. I have forgotten who I was before the meds and now when in withdrawal, it is like my identify changes every day.

Palm

[scotty]

We were just talking about this is another thread. My belief is that paxil effectively stops that normal growth and development, when given to teens and children. We saw this firsthand with Ryan. The social skills, early intimacy, achieving goals, studying...all the things that we learn in high school are replaced with sleeping in class, the "nothing matters" attitude, the lack of empathy towards others. Key tasks missed for that age group.

So as this continues, unless recognized, we have adults who don't have the skills needed to move on to more complicated areas of life.

Then throw in the trauma of withdrawal and you have alot of very confused and unprepared children and young adults.

Ryan once told me "I don't know where I fit in the world".....how could he. His world have become this house and his brain.

If we as a society and the medical profession don't wake up soon and see what we are doing to people, there is going to be a huge price to pay. Our children are dying, they are becoming so chemically altered that they will never function in a "normal" society. Adults are trading their mental health for a flatlined life. Heaven forbid when the poop out point is reached enmass for thousands of ssri users. The very thought is terrifying to me. And what of the upcoming generation.....they have been taught that they are NOT good enough as they are. They are only good if they perform to some outlandish standard that is unachievable without swallowing a pill, but society is happy because they sit still in a classroom. They have NO idea what true life is all about and they will continue to search for the "nirvana" of the drug haze long after the ssri's poop out...if they don't start killing each other.

[elisa]

Excellent letter Alto!! I sincerely hope that you're doing a bit better!

You're absolutely correct in clarifying that severe and long term withdrawal symptoms do exist. Psychiatry is like an ostrich, burying it's head in the sand when it perceives any danger. (what their drugs and profession are concerned)

[ihatezaps]

Wow. I've been suffering with this identity crisis lately (see my most recent thread). This is the first time I've seen an article about it. Well done, NYTimes. Most of the comments are a bunch of "I can't live without my anti-depressant" bs but some get at what we talk about here (withdrawal, personality changes, memory loss, etc). I plan on leaving one tomorrow about my experience.

[Ariella]

Originally Posted by ihatezaps

Wow. I've been suffering with this identity crisis lately (see my most recent thread).

It helps to admit that the nature of the universe is change, and therefore you will infrequently have a lifelong identity. Accept today as today, and tomorrow as tomorrow.

[lov4k9s]

Originally Posted by Betsy

This is a very thought provoking article for me. There are SO many things in this changing world that I BELIEVE contribute to anxiety and depression. The ignorance of people to that fact contributes to the attitude of "Give them a pill to "fix" it". When the pill actually only complicates an existing problem and and ignores other actual life changes that could have contributed to recovery. We have set our world up for self annihilation. So sad.
Betsy

When I read your post I flashed to a movie I recently saw titled Idiocracy (staring Luke Wilson).

[Amaya's Nana]

Alto - as always, beautifully and eloquently stated. I hope you are feeling better!

[Samalabear]

Alto, your letter is wonderful. Really hits the nail on the head. With all your problems it's amazing what you have done. I really hope you are feeling better and will be fine soon.

[Samalabear]

I found this sad, this particular comment:

Cymbalta - prescribed for chronic "moderate depression" - changed my life. After 20 of my prime years without a partner, at age 50, despite being overweight, I was able to muster the where-with-all to launch myself on the seas of the competitive and crazy online dating scene, where, eventually, after kissing a few frogs, I found and have started to live with a good man. We plan to marry. My 1st, his 3rd. Now if these pills could just help me loose weight again (as they did at the outset) and finish a book I started when depressed (alas, the urgency to create may have been lost to the drug). I'm fat and happy. Is that so bad (I keep asking myself)?

She found a good man and he's been married two times before. I wonder if she's questioning herself what went wrong the two times before And they haven't married yet. It's just a sad story, but it's not my life. She sounds like she is basing her happiness on another and she's clinging -- never a good thing.

Chronic moderate depression was probably never treated at all. When this all starts backfiring she is in for a world of hurt -- possibly fat and in a major depression with no coping skills to hang onto. I found this comment devastatingly sad, one's life and happiness totally dependent on a drug.

Creativity is the best part of a person. I want mine back and I want to find the happiness that I used to feel over it, and then use that creativity to make others happy. If I am meant to find the love of my life, even in my 50s, it will only happen if I am happy with myself.

[Betsy]

Alto,
I feel for you, with my original anxiety, I couldn't tell how much I actually slept for 4 months. My best guess at that tie would have been maybe 2 - 4 hours a week. Most nights I paced the floors or cleaned the. My house was spotless, but I couldn't stop my mind from the racing. My body was in hyper protection mode from a night time invader episode. For me, when my body kicks into anxiety of any kind, that is also what happens. My body just does not go to sleep. Some people ask me if I have mania, but it's not any usual mania. From my understanding, (please correct me if I'm wrong, I'd like to know about this) Mania is accompanied by a feeling of I can conquer the world, life is soooo wonderful, euphoria with no real concern about how much spending or time spent on anything that feels wonderful to oneself. Mine is classic anxiety symptoms. Feeling 24/7 like I've just woken from a nightmare, afraid, horrible back pain, stomach pain, skin buzzing etc. But the no sleep was probably the worst. Anytime anxiety or too large of tapers have happened, that is where my body goes. When I and trouble with the liquid, that is what happened, 4 months of not sleeping on top of all the other horrendous symptoms. But with the tapering off the med and the too large of tapers what happens to my body is by far worse than the original anxiety was. I haven't ever really heard of many people who have had the extreme NOT sleeping as a symptom, except in withdrawal. I do feel for you and am so glad you are finding some bits of relief. Thank you for all the writing and work you've done in behalf of us all, You are one amazing woman!
Take care,
Betsy

[Betsy]

Alto,
Thanks for the clarification. I have NEVER considered that I might be bipolar, it's just OTHERS who ask me about it. And if I were to go to a doc, these days, in the same condition I was at the beginning of all of this they might think I had it, since their criteria has broadened so much. I'm just glad I know what I know and believe the truth....we are so accustom to just believe the docs know best. So many come here and really believe that. I'm glad you've found one that understands the truth and is working with you to get you some relief. If you and he are successful, he may inundated with patients!
Hope you have a good day!
Betsy

[scotty]

A letter in response to this article I thought was excellent:


"Re “Who Are We? Coming of Age on Antidepressants” (Mind, April 15): As a young woman ambivalent toward the medication she has consumed for years, I was comforted to learn others share the sometimes profound anxiety and skepticism that goes with drug treatment. For young people who have been medicated the better part of their lives, not knowing what their “normal baseline” is, or if they even have one, can be as unsettling as depression itself. Without disinterested parties conducting research on the effects of long-term antidepressant use, I can only speculate as to what years of this treatment has done to my mind. When it comes to treating the mind, we should do better than “caveat emptor.”

[Suzi]

An excellent and thoughtful letter, Alto. You do so much to battle the dragons. Indeed, almost all of us keep throwing what spears we can... That darn dragon hide is tough stuff, though.

[blankets]

I was just going to post this here. I thought it was an interesting article, and definitely something that I suffered with as I too took Paxil starting at a very young age.

[palm]

Alto,

You rock.

Here is what I just posted:

Peggy, it isn't too late to come off meds. At 50, I started tapering off of 4 meds that I had been on for years. I am now down to 2 meds.

Please visit http://www.paxilprogress.org as you will find a lot of support there. They recommend tapering 10% of the current dose every 3 to 6 weeks.

Anyway, I am so tired of withdrawal symptoms being confused as a relapse. Apparently, Dr. Friedman refuses to understand this concept so let me say it again.

Withdrawal symptoms, which last a lot longer than a few weeks are not a return of the illness. They are due to a way too fast tapering schedule advocated by my most doctors. To not understand that concept and to sentence people to a lifetime on meds only because of withdrawal is criminal and disgraceful.

Palm

[palm]

I am encouraged that unlike the comments on the NY Times blog, alot more people were critical of meds on the NPR blog.

Palm