Healthy Skepticism Library item: 23

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Publication type: news

Vedantam S.
British Officials Advise Less Use of Antidepressants
The Washington Post 2004 Dec 7

Full text:

British health officials advised doctors yesterday not to prescribe antidepressants for about 70 percent of the patients who show up complaining of depression without first trying exercise, self-help, talk therapy or just waiting a couple of weeks to see if they got better.

In issuing new treatment guidelines for doctors, the British regulators and a standards-setting panel said patients with mild depression who are able to go to work and function normally, even if they complain of symptoms such as a lack of interest in things, low energy, dark mood, difficulty sleeping or difficulty concentrating, should avoid widely used antidepressants at first because of the possibility of side effects and withdrawal symptoms.

The regulatory panel is the same one that last year triggered a major reevaluation of the use of antidepressants in children after it concluded that the drugs were associated with an increased risk of suicidal tendencies in children. The recommendations that the drugs not be used as first-line treatment for mild depression are the latest evidence that some experts are reexamining the widespread enthusiasm for the medications.

Numerous studies have shown that antidepressants are among the fastest-growing sectors of the U.S. pharmaceutical industry. A government report last week said the latest figures indicated that one in 10 American women is taking an antidepressant.

“There are some cultural differences in that, in this country, medications are prescribed for many disorders and for problems in living,” said Carol Goodheart, co-chair of an American Psychological Association task force on evidence-based practice. “It may be that the British are more conservative than the Americans in prescribing drugs.”

Stephen Pilling, a British scientist who directed the development of the new guidelines, said he is aware of “shades of difference” between British and U.S. practices. “I am confident we have taken the right line,” he said, adding that several international experts, including Americans, had contributed to the British recommendations.

“We are not saying ‘Don’t use drugs.’ We are saying ‘Use them appropriately,’ “ Pilling said.

The guidelines were issued by the National Institute for Clinical Excellence (NICE). A companion report issued by regulators at the British Medicines and Healthcare Products Regulatory Agency (MHRA) warned that some antidepressants carry risks of withdrawal symptoms and inner restlessness. The regulators also singled out the antidepressant Effexor “because of concerns about cardiotoxicity and toxicity in overdose.”

Antidepressants such as Prozac, Paxil and Zoloft belong to a class of drugs called selective serotonin reuptake inhibitors. Following the lead of the British regulators a year ago, the U.S. Food and Drug Administration ruled in October that the risk of suicidal behavior among children taking the drugs was statistically significant. FDA now requires drug manufacturers to post a warning to that effect.

The British report found no clear evidence of risk of suicidal tendencies in young adults as a result of antidepressants but said that “young adults treated with SSRIs should be closely monitored.”

Mental health experts in the United States reacted cautiously to the British announcements and said the usefulness of the recommendation against starting medication for cases of mild depression would depend on how it was defined and how long other interventions are tried.

While agreeing that talk therapy had been proved to be as effective as medications in cases of mild depression, Darrel Regier, director of research and education at the American Psychiatric Association, said patients may not have easy access to such treatment, which must be administered by trained professionals. Medications, however, can be prescribed by any general physician, he said.

Pilling said some of the simpler recommendations would be accessible to anyone: “Run around the park and go to the gym,” he said.

Explaining that 70 percent of the patients in British doctor’s offices have mild depression, Pilling added: “Many people with mild depression will be able to go to work and getting on. Someone with severe depression will struggle to get out of the house.”

Goodheart, a psychologist, welcomed the British suggestion that talk therapy be tried before medications. Most states do not allow psychologists to prescribe drugs. She described techniques such as cognitive behavior therapy and interpersonal therapy as safe, effective and long-lasting, but she was more cautious about the other suggestions.

“Watchful waiting is not really a treatment,” she said. “Once someone is diagnosed with depression . . . even if it is mild, I think we would recommend that you offer treatment.”

The British guidelines said it is appropriate to treat patients with moderate depression with antidepressants. And patients with severe depression, Pilling said, ought to be started on a combination of medication and talk therapy.

The companion report issued by the British regulatory agency said Effexor should be prescribed only by specialists and should not be taken by patients with heart disease. But patients doing well on the drug should finish their course of treatment, the British regulators said.

Wyeth, the maker of Effexor, said in a statement that higher rates of side effects in patients taking the drug occurred because the medication was used on very sick patients after other drugs had been ineffective. The patients’ underlying illnesses, not Effexor, were responsible for the problems, the company said.

“Restricting access to medication is not in the best interest of patients and is a backward step in the treatment of depression in this country,” said Allison Jeynes-Ellis, Wyeth’s medical director in the United Kingdom.

In a statement yesterday evening, the FDA said it has requested new data from Wyeth and will review it as soon as possible. “We will also work with the MHRA to fully understand the basis for their decision,” the statement said.

On Wall Street yesterday, the stock of Pfizer Inc., which makes Zoloft, fell 2.4 percent, to $27.21. Last year, Zoloft accounted for $3.1 billion of the firm’s $45 billion in revenue. Shares of Wyeth fell 3 percent, to $40.27. Effexor, with $2.7 billion in sales last year, was the single largest contributor to Wyeth’s revenue of $15.8 billion.