Medication Treatment, by
That means about 15 million more Americans were medicated in '05 than a decade previously. A huge increase in anyone's book. But the doubling in antidepressant use is not the only interesting result in this paper. In no particular order, here are some other fun facts -- Women are twice as likely to use antidepressants as men (female 13.4% vs male 6.7% in 2005); the ratio was the same in 1996. Studies consistently find that Western women are about twice as likely to report suffering from depression and anxiety disorders as men are. But these kinds of studies rely on self-report so this could merely mean that women are more willing to talk about their problems. This data suggests that they also seek treatment about twice as often.
- The peak age bracket for antidepressants is 50-64, with 15.5% yearly use. This is more than double the rate in the 18-34 bracket. This surprised me, maybe because of the influence of books like Prozac Nation (tagline - "Young and Depressed in America"). So, it looks like the increasing use of antidepressants is not because younger people, having grown up in the "Prozac Era", are more accepting of them.
- Antidepressants are a white thing - 12.0% of whites take them vs. about 5% of blacks and Hispanics. But it would be interesting to see a regional breakdown here. Are blue-state or red-state whites more likely to be medicated?
- Family income was not correlated with antidepressant use, but the unemployed were twice as likely to use antidepressants: 22% in '05. This might be because unemployment is bad for your mental health, or because mental illness is bad for your employment prospects. Or both.
- One of the questions in the survey asked people to rate their own mental health. Over 90% of Americans said it as "good", "very good" or "excellent" - including 80% of antidepressants users. This really surprised me, and suggests that these drugs are being prescribed to people who are not, overall, very unwell.
- The % of antidepressant users also using an antipsychotic drug rose from 5.5% to 8.9% in 2005. Given that the number of users also doubled, this means the number of Americans using an antipsychotic as well as an antidepressant increased by a factor of more than 3. This is worrying since antipsychotics are generally the worst psychiatric drugs in terms of side effects. While there is evidence that some of the newer antipsychotics can be of use in depression as an add-on to antidepressants, this is controversial and it's not clear that they're any better than the older alternatives, such as lithium.
What makes it especially interesting is that nothing much happened between 1996 and 2005 in terms of new antidepressants. A couple of new SSRIs, such as citalopram, were approved for sale in the US. But these drugs are very similar to Prozac (fluoxetine) which has been around since '87. Remeron (mirtazapine) hit the market in '96, but it's never been nearly as popular as the SSRIs.
So the change was a change in behaviour, a cultural or social phenomenon. For some reason, America decided to take more antidepressants. Books could be written on why this happened, and I hope they will be, because it's an important topic. But here's my personal take: the main reason why people are taking more antidepressants is that the popular concept of "depression" has become more broad. People have become more willing to label their experiences as "depression" and seek medical treatment. The notion that mental illness is extremely common - the one in four meme - is one aspect of this.
Finally, the inevitable caveats. The data here come from the Medical Expenditure Panel Surveys (MEPS) which were household surveys of "national probability samples of the US civilian noninstitutionalized population". This means that military personnel, the homeless, prisoners, and (presumably) illegal immigrants weren't included. And not everyone agreed to take part; the response rate was 70% in '96 but dropped to 60% in '05. On the other hand, the samples were extremely large (28,000 in 2005).
Olfson M, & Marcus SC (2009). National patterns in antidepressant medication treatment. Archives of general psychiatry, 66 (8), 848-56 PMID: 19652124
18 comments:
"Anyone who makes that claim has not withdrawn from an anti-depressant or other psych med."
I have, and I do. The Zoloft Defence is bullcrap.
Philip Dawdy responds: man aren't you a bundle of fun today?
Posted by neuroskeptic at August 24, 2009 12:36 PM
http://www.furiousseasons.com/movabletype/mt-comments.cgi?entry_id=2429
Neuroskeptic,
You gave me a good chuckle today. I guess you’re also not one of the congregation to bow at Dawdy’s alter to himself.
My spouse has utilized psych meds over four decades and probably longer than Dawdy is old. Ya know what…not only has she withdrawn from these meds but upon a number of occasions she’s stopped cold turkey, not that I’d recommend that approach, but fortunately she’s had no withdrawal side-effects contrary to the preacher and his sermons.
Watch out…if you keep disagreeing with Dawdy you too will find yourself excommunicated from that dogmatic site.
Warmly,
Herb
VNSdepression.com
Good post, Neuroskeptic.
(I was also surprised to see that older people were likelier than teenagers or young adults to be on antidepressants, for the same reason as you --- more media coverage about antidepressant use in young people --- but also because most mental illnesses tend to appear for the first time in adolescence/early adulthood. You would assume that most people who have access to healthcare would seek treatment as soon as symptoms appear, which, for depression, would be 18-34 rather than 50-64 for most people).
I am also surprised income isn't more of an issue; seeing a psychiatrist isn't cheap, and poorer people are less likely to have good/any insurance coverage.
Very interesting.
"This really surprised me, and suggests that these drugs are being prescribed to people who are not, overall, very unwell."
Does it suggest that?
If my father's blood pressure is 200/130, and he goes on beta blockers and it goes down to 120/80, his cardiovascular health may be considered 'good' while medicated. That wouldn't imply that there is not, overall, a real problem.
Although I suspect it's a very small part of the increase, the fact that all SSRIs (save Lexapro), mirtazapine, and buproprion have gone generic may have helped to promote use slightly. All the marketing of the branded drugs still serves to promote the concept of AD use in general, too.
There's also been quite the push by large HMOs / orgs (think GroupHealth) and other large agencies (VA, etc.) to aggressively screen and treat for depression in primary care settings. HRSA has been very, very big on this. So - more FPs prescribing, and less expensive drugs, may equate to a broader base which is more compliant with treatment.
I don't know about you, but I'm a lot more likely to a) start and b) continue a med if it's not $120 per month, or even the higher-end copay, when I'm insured.
And, of course, people have desensitized over a decade, due to marketing, due to the screening/outreach efforts (whatever one may think of them), and due to hearing about friends/family who are on medication or in treatment. It's just not a shocker anymore if someone is On Meds.
Of course, none of that has jack to do with the antipsychotics, so I could be dead wrong about all of it!
I'm curious: how have the rates changed in the UK? How do they compare across cultures and with different marketing practices?
It's always about the Americans, isn't it...
Sandra - Good question, but it might take a bit of digging to find out... I'll take a look.
Although by happy coincidence, I just this minute saw this paper finding that between 1999 and 2005 the proportion of antidepressant users in Finland went from 4.8% to 6.3%.
But the proportion of antipsychotic users fell from 2.4% to 2.2%.
A couple thoughts:
1. A lag in FDA approval for SSRI's for children--when I did my internship in 90-91, the anti-depressants of choice were the tri-cyclics.
2. Although some psychiatrists are early adopters, it probably takes awhile for most practitioners to change from the medications they have the most experience with prescribing.
3. Women are not only more likely to seek treatment for depression, but to tell their friends and encourage them to seek treatment as well.
3. The stigma of depression has lessened somewhat for men through such influences already mentioned - "The Prozac Nation", advertising, recommendations by primary care, recognition of depression following heart attacks & other significant medical problems. Also, the lower rate of depression in men is countered by a higher rate of alcohol/substance abuse. There has been a significant change is treating such as dual diagnosis cases--both for substance abuse and depression.
4. Young adults are less likely to have health insurance (in America). The age rates may not differ in the UK because of universal health care?
5. Poor adults with significant mental health problems (in America) are more likely to have Medicaid/Medicare insurance & receive treatment at public clinics where medication is often a first-line treatment.
Lindsay: I agree, that's another reason why the age distribution is weird. Nothing in psychiatry really peaks at age 50-64 - you either get ill before the age of 30, or you develop illness in old age, generally.
Income wasn't an issue, but insurance was - people with no insurance had a much lower rate of use (5%). I'd bet the uninsured were undersampled in this study, so that may mean the true % of use is a bit lower than it seems.
I am also surprised income isn't more of an issue; seeing a psychiatrist isn't cheap, and poorer people are less likely to have good.
--
Jhon
Wireless Home Alarm Security Systems
I think there are a couple of things that contribute to the rise:
1) Here in the US, antidepressants are advertised on TV. These advertisements are ridiculous, and make it sound like if you are having a bad week, you are depressed and should be on medication.
2) Our 'instant gratification' mindset. We continue to want things to be better immediately, without having to work for them, so taking a pill holds more appeal than the idea of therapy and lifestyle changes. Plenty of research shows how effective exercise, for example, can be in combatting depression (not to mention the other health benefits), but it's "too hard" or "takes too much time".
Could a factor be use of antidepressants for other effects? I've talked to several people who take antidepressants to help them sleep, even though they don't have signs of depression.
As far as I understand, though, lithium requires more on-going care. At least, it did in my husband's case. He had to keep going in for blood tests to make sure it wasn't building up to toxic levels in his system (which it was). If someone is losing functioning to depression, then wouldn't lack of motivation put them at a greater risk to build up to toxic levels without being tested?
I think that culture has an important influence in this:
The culture we are living in has no inherent meaning, and no dialogue with nature, If we are fortunate, we may have an ocean retreat from the man-made. If we are less affluent we may make special trips to connect to nature, be it at the zoo, or the botanical gardens. But for most of us nature is absent from our daily life.
We seek solace in the physical. We buy what we don't need, because it is supposed to make us feel good. We work harder to buy more, because it may make us feel better. Safer. In the process, we become alienated from our families. We spend too much time at the office, we have too much work pressure which we hope will translate into money and purchasing power and ultimately, safety from financial anxiety.
Cities are disintegrating, Developing a strong sense of community is crucial and “culture” is one of the important elements that can contribute to such a development. As cities expand, people of various ethnicities or social groups are thrown together into sharing a crowded space, and this often either forces them to abandon their identities or forces them to cling to their identities unreasonably for what they perceive as survival. The former encourages anonymity, whereas the latter fosters divides among various groups. Neither way is positive to the development of an urban city, because anonymity may create depression.
http://singyourownlullaby.blogspot.com/2009/06/depression-and-culture.html
Am I the only one not surprised by the spike in antidepressant use in the older age group? Lol. I had assumed it was the case, as depression and suicide rates spike in "late adulthood". Or so the textbooks say, anyway.
But I did join the legions of medicated Americans last week. I've had extreme fatigue for years and they've never been able to figure out why. I had mood swings and anxiety, etc, etc, though not a lot of typical "sadness". Pretty much every person in my family has moderate to severe depression.
I also have the oh-so-lovely Adult ADHD. One of my friends also has severe ADHD - and suddenly she was overtaken by fatigue, sleeping much of the day, and not feeling well. She wasn't sad. But as it turns out, it was depression, and antidepressants made her feel normal again.
Turns out that was my problem too. But I can say that I was surprised how little it took to get antidepressants. All I did was told the psychiatrist I see for ADD that "I thought I might have a little depression"...and was prescribed them, no questions asked. Yes, depression is co-morbid with ADHD, but I expected at least a few questions.
It makes me wonder how many people are prescribed them who really dont need them. No amount of therapy could make my physical side effects go away, but some people with mild depression could do just as well with learning new coping strategies to replace abnormal/unhealthy ones as they would with medication.
But I still say there's a stigma attached to taking antidepressants (and ADHD meds, for that matter! ick!). I'm part of the younger generation, too. And it's still very taboo.
The cause and cure of my Phobia!
When I was working in South East Asia I took the opportunity to learn to scuba dive. I used to dive the warm waters of the South China Sea almost every weekend. I became the president of a major scuba club in Singapore and qualified as a divemaster. Whilst taking a group of divers out on a night dive just off the island of Ko PiPi in Thailand my dive buddy got into trouble; we were following the wall of a cave when he suddenly left it and started to swim into the centre. I chased after him and grabbed his fin and pointed back to the wall. But, we couldn't see the wall any more. The beam from our torches just highlighted the inky blackness, the only point of reference was given by the bubbles of our regulators. Looking back. I was not too phased at the time although I knew that we were in a difficult situation. After what could only have been a couple of minutes but seemed like a lifetime, I saw the lights from the torches of a couple of members of the dive about 30 feet below me; I grabbed my buddy and swam down towards the lights and in doing so saw the faint blue light of the exit of the cave.
I realised afterwards that we had been carried up into the cave by the current and had we not seen the other divers coming into the cave we would most certainly have been goners. My buddy, who was an inexperienced "cowboy", got the biggest bollocking of his life from me for getting us into that situation.
The following day I began to feel fearful and after a few day this turned into a full blown phobia. For years after I was a classic claustrophobic.
Pills didn't work for me, but heard about a guy called Charles Linden who was running courses to help suffers of this kind of condition. I recently bought the course and I'm glad I did, because although I can't claim to be 100% cured I feel a darn site better and I'm confident that things will improve even more over the coming months.
If you are a fellow sufferer and interested to learn how to alleviate, if not cure the problem of panic and anxiety attacks visit his website http://bit.ly/5FlxP
All the best,
Berni Scala
Here's an excellent commentary by The Last Psychiatrist on the brave new world of antipsychotics: http://thelastpsychiatrist.com/2007/04/farewell_depression.html
I should also note that you make a poor argument when stating: "This really surprised me, and suggests that these drugs are being prescribed to people who are not, overall, very unwell."
If an antidepressant works, shouldn't it make you feel happier? Conversely, what would you say if many people on antidepressants were feeling unhappy? If that were the case, I'd say antidepressants were of dubious worth and effectiveness.
I don't think they're a panacea, and I do suspect they're overprescribed for normal sadness, but those claims would require different data.
Also, the antidepressant class of medications is being prescribed for a whole host of non-depression conditions these days (eating disorders, addictions, insomnia, irritable bowel syndrome, fibromyalgia and other pain disorders, etc.) and this means many of the new prescriptions may not be related to depression per se.
Steve: Good points. Direct-to-consumer advertising really is indefensible if you ask me. Especially when it's not just promoting a particular drug, but in fact promoting the diagnosis as well, as antidepressant DTC advertising often does ("Feeling low?...")
The government sanctioned "aggressive" screening process for depression seems to assume that all depression is the result of a mental, not physical, cause.
Hypothyroidism, a well known cause of depression, is increasingly common. Despite this, most standardized clinical pathways for depression assume that patients who are depressed need anti-depressants, or failing that, a cocktail of psych drugs. Getting doctors to do a thyroid work-up in this setting can be very, very difficult.
As to the comments about the bizarre age and sex distribution of depression. The following may be relevant as the gender and age patterns correlate to subclinical (borderline) hypothyroidism:
"It's estimated that on average, approximtely 8 percent of women, and 4 percent of men are subclinically hypothyroid. The prevalence is much higher with age, and 15 percent of women over the age of 60 and 8 percent of men are subclinically hypothyroid." http://www.thyroid-info.com/articles/subclinicalhypofaq.htm
The age and sex disparities found in patients with depression are very similar to those found in patients with borderline hypothyroidism.
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