It’s been a tough time for antidepressant medications (ADMs). First came a report delivered in November 2006 at the annual meeting of the American Society for Reproductive Medicine that claims there is evidence that SSRIs (such as Prozac, Paxil and Zoloft) may alter sperm characteristics to the point that fertility is threatened. How depressing to find out that the infertility issues you may be depressed about may be exacerbated by the medication you’re taking for your depression! Fortunately, it appears to be a reversible phenomenon when a man stops taking the ADMs.

Next came a report issued jointly by the U.S. Food and Drug Administration (FDA) and Wyeth Pharamaceuticals, the manufacturer, warning healthcare professionals that there is an increased risk for fatal outcome with an overdose of Effexor (venlafaxine HCl) compared to the SSRIs. Given how rapidly Effexor has become a popular antidepressant because of its dual action nature (allegedly targeting both serotonin and norepinephrine), you can easily appreciate the potential risks involved when you’re giving an ADM to someone who is depressed and perhaps suicidal. We’ve been confronted by the same irony of treatments that kill before: Tricyclic antidepressants used to be the most commonly used drug leading to fatal overdoses. In fact, that was one of the principal reasons why SSRIs became popular so quickly. Not only did they have fewer side-effects and thereby increase the number of people willing to stay on the medication, but the fear of a deliberate or accidental overdose was all but eliminated. The FDA and Wyeth suggest doctors prescribe the smallest quantity of Effexor possible that is consistent with good patient management.

These two blips about antidepressant medications probably aren’t going to change anyone’s mind about the value of ADMs. Perhaps it should, though. Recently, I described a new study out of UCLA’s Neuropsychiatric Institute that showed EEG changes for people in ADM studies while they were still in the placebo lead-in phase of the study, i.e., before they even started taking genuine ADMs. I talked about the role of expectancy in altering one’s own neurophysiology and the implications for a significant portion of ADM response being attributable to placebo. The UCLA research makes the point for all to see (again) that the true merits of ADMs have been overstated. It has been far more about marketing than science. Irving Kirsch’s chapter in my new book, Hypnosis and Treating Depression: Applications in Clinical Practice, makes the point most convincingly that the drug companies have both exaggerated their therapeutic merits and not been forthright in providing accurate and timely data in the trials leading to eventual approval. That sexual side-effects of Prozac were deemed minor at best during the drug evaluation trials when it turns out they are the most common side-effect strongly suggests there is a considerable gap between what the drug companies say and what the science says.

We're still learning about these drugs, and there just isn’t good reason to be adamant about their value when so much remains to be understood about their mechanisms, side-effects, and consequences of long-term usage. Given the merits of psychotherapy in reducing depression’s severity, frequency of episodes, and vulnerability to relapses, there is a compelling rationale for wanting to do better therapy without posing the additional risks of medicating people simply as a reflexive intervention. Medications can be used skillfully, of course, but too often drugs are prescribed by people who just don't know the complexity of the ADM issues.

Something to think about...