Depression Versus Unhappiness – Are We Over-Prescribing?

I saw a segment on The Today Show this morning about the millions of antidepressants prescribed. Questions arose as to whether or not this is an indication of Americans wanting a quick fix or are doctors over-prescribing the medications. This opens a pandora’s box of issues ranging from who should treat depression to the state of health care (e.g. doctor’s offices becoming mills where many patients are churned in and out with little time to talk). I could go on about many of these issues, but only have time for one today and that’s the issues of what is unhappiness versus depression?

People experience depression differently, but there are a set of criteria that we use to diagnose depression. But rather than list the criteria, let me paint a picture of a depressed person for you. Symptoms vary depending on the person and the severity of their illness, but generally speaking:

• people who are depressed may have trouble experiencing pleasure in anything
• their limbs may feel heavy
• they may sleep all day or have trouble sleeping
• they may have trouble thinking and concentrating such that it affects their work
• they may have constant anger and irritation that is unusual for them
• they may go days without bathing because they just don’t care
• some people describe noticing that colors look duller
• some even feel like life isn’t worth living

This is not an exhaustive list, but some the symptoms depressed people may experience.  This is in contrast to feeling down after a relationship breakup, or having trouble getting out of bed to go to a job you hate. No amount of medication is going to prevent people from feeling bad when bad things happen. I tell patients, whatever problems they have will still be there with medication. The difference is, for a person who is depressed, medication can strengthen their foundation so they can more effectively use their emotional resources to deal with their problems. Depression exhausts your emotional reserves so that you may be unable to handle the stresses of life in your usual way. There are some who have poor coping mechanisms and have trouble dealing with the day to day problems of life and are not depressed but may feel chronic distress. This person may respond better to therapy to help them handle their problems differently.

Are Generic Medicines Just as Good?

I’ve always been a firm believer that brand didn’t matter much and you should save your money by passing up the $6 Advil for the $2 Ibuprofen. When I was in medical school and residency, we learned generic names for drugs so as not to give too much credit to the drug manufacturer and recognize the drug for it’s chemical properties (and not it’s brand name).

From time to time, I would hear of certain drugs that seem to be more effective than the generic version, however most of them were cardiac meds or non-psychiatric medications. Since the more popular antidepressants were developed in the 90′s, we (psychiatrists) didn’t have to think much about this issue because these drugs were still under patent until recently. Now some of the more popular antidepressants such as Prozac, Paxil, Zoloft and Wellbutrin are all off patent and available as generic.

What does this mean? (if you know about generics, you can skip this paragraph) Prozac is the brand name developed by Eli Lilly (the company who first developed and manufactured the drug). The chemical name is fluoxetine. Lilly paid for the development, research, and production of fluoxetine. To recoup their investment, they are allow protection for a certain number of years from any one else manufacturing fluoxetine. Once the patent expired, other drug manufacturers were allowed to produce fluoxetine and sell it. Now that’s there’s an open market for selling it, the price drops considerably.

Back to the original point – in my experience, most of my patients do just as well on the generic versions of their medications. Unfortunately I’ve had some for whom the generic was a negative experience. The most common things I’ve seen have been with sertraline (generic Zoloft) and buproprion (generic Wellbutrin). I’ve had a very few have a return of their depression when switching to sertraline and a few experienced ringing in the ears with buproprion. I emphasize this as happening only with a few patients out of many on these medications, but it’s been enough for me to reach the disappointing conclusion that for some medications, brand name does matter.

I still don’t think people should refuse to take generics, because it may not make a difference and the price differential is so great that it could be very expensive to refuse all generics to avoid the small chance that it generic may not work for you. Also, there may be a difference in quality of sertraline depending on the manufacturer and it’s hard to keep up with which company produces the version that works differently.

What’s the conclusion? If you switch to a generic or start a generic drug, you and your doctor should keep an eye out for a change in your status. Also, if you start on a new medication and it doesn’t seem to work or has bad side effects, think about whether switching to the brand version to see if it makes a difference before abandoning the drug.

How Long Until Antidepressants Work?

We in psychiatry have always said it took 3-4 weeks for an antidepressant to show a clinical effect. Those who showed improvement in the first 2 weeks were thought to be having a placebo effect. In the past 2 years, there have studies that have shown that patients can have a “real” response to antidpressants as early as 1 week after starting the medication.

When Lexapro became available in 2002, pharmaceutical reps said it was supposed to show effect in the first week.  At that time, that was the first antidepressant that made that claim.  I find the literature still unclear about what is an expected response time.  This is probably because there are other factors such as lack of support, ongoing stressors, variability in how drugs are metabolized that affect response time.

Also, another source of confusion may be in how we define “working”.  A clinical response is not the same as a full recovery, so a person may experience some lifting of their depressed mood in the first week, but still have considerable irritability, insomnia, anxiety, etc. for several more weeks.  Bottom line, I think the current literature supports early responses in the first week as being real and possible, but we still need to give the medications 4-6 weeks at a therapeutic dose to show a full response.

Depression Treatment | How Long Do I Take Medication?

Of course, the short answer to this is it depends on your needs and your individual situation.  But in general, according to epidemiological studies, once a person has one episode of depression, they have a 50-60% chance of having a second episode at some point in their life..  That second episode may be months to years later, or not at all.  After the second episode, the chance of having a third is 70%.  After third episode, the chance of a fourth goes up to 90%. 

Therefore usually doctors recommend individuals in their first or second episode be treated for 9 months to a year and then taper off the medication and see what happens.  After the third episode, since the chance of a recurrence is 90%, doctors usually recommend remaining on andepressant medication indefinitely.

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