By Ralph Tarantino, PhD
Pharmaceutical Consultant and Principal, SteriTech Solutions, LLCMiddletown, NJ
A recent analysis of the CDC’s National Ambulatory Medical Care Surveys (Health Aff. 2011;30:1434) showed that 4 out of 5 prescribers of antidepressants are not psychiatrists. Alarmed? You should be.
White, female patients over the age of 50 with some form of health coverage are the usual recipients of this treatment. Frequently, they have other chronic illnesses, and for many no true diagnosis of depression exists. As a culture we have been bombarded with the warning that “depression is a serious medical condition”; it’s a warning that should be heeded. The costs of depression with regard to human life, the health care system, and the economy in general are enormous.
It is estimated that 10% to 15% of those diagnosed with clinical depression commit suicide. The term “battling depression” is therefore literal. It’s a war with many casualties. Should 80% of the prescribers of antidepressants have only minimal training in the complex area of medical treatment? “Take two Prozac and call me in the morning.” is not the best approach.
There is another complicating factor in the pharmacological treatment of depression as exemplified by the classifications of antidepressant medications commonly used today:
- Serotonin-norepinephrine reuptake inhibitors
- Noradrenergic and specific serotonergic antidepressants
- Noradrenergic serotonergic antidepressants
- Norepinephrine (noradrenaline) reuptake inhibitors
- Norepinephrine-dopamine reuptake inhibitors
- Norepinephrine-dopamine disinhibitors
Sound a bit complex? It is. The overlap among classes is substantial. The options for changing classes, adding classes, and increasing or decreasing doses are practically limitless. It seems like a challenging task for a psychiatrist to make rationale choices in the manipulation of neurotransmitters. How much greater a challenge must it be for the non-psychiatrist? Treating a potentially dangerous condition with a complex array of pharmacotherapeutic agents and with no easily discernible treatment endpoint is—to say the least—problematic, even for an expert.
But let’s not be too tough on the non-psychiatrist prescriber. There is another issue at hand. The direct-to-consumer (DTC) advertising of antidepressants must come to an end. A patient who has been “enlightened” by DTC advertising will exert pressure on a prescriber. It is not coincidental that most of the DTC ads are for drugs that treat somewhat subjectively evaluated health problems. Subjective evaluation criteria provide the opening needed for ad agencies to peddle their pharmaceutical wares. No clear drug of choice? You can use images of dogs, walking on the beach, butterflies, and hot tubs to influence patients and prescribers alike.
Selection of an antidepressant for a patient should be made with the same scientific and medical expertise required for selection of an antibiotic. If you disagree, please let me know why. Also, let the FDA know. They recently extended the comment period (Deadline: February 27, 2012) on proposed DTC pharmaceutical advertising regulations.* This extension was prompted by new information regarding the potential for distraction inherent in some DTC adverting techniques.
Complex pharmacology, the influence of DTC advertising, and demographics all suggest that the use of antidepressants to treat the female patient is a health care issue in serious need of reform. I would appreciate your comments.
* To leave a comment regarding the proposed DTC regulation, visit regulations.gov here.
To read a related article, click here.