Remember sucking candy out of a plastic neck?
Pez Dispensers, they call them. Flip back the noggin of Bugs Bunny or the Tasmanian Devil and extract a tangy little pellet. Kids love 'em. Adults, too -- now dispensing Prozac, Paxil, Abilify, Wellbutrin, Lexapro and Zoloft.
Or so it sometimes seems in today's pop-me-a-pill-I'm-unhappy world.
"We live in a fast-paced culture, so people think they can get rid of bad feelings just by swallowing," says Las Vegas psychiatrist Dr. Norton Roitman. "They think they don't have to make an effort."
Add such now-common names as Celexa, Cymbalta, Effexor and Pristiq to the aforementioned list, thanks to carpet bombing-style advertising on television. (Seen the animated one in which a woman, her body half-buried in the ground, rises once a kindly doctor arrives, presumably with a cache of Abilify?)
Few would argue that antidepressants aren't a godsend -- even life-savers -- to millions of patients with bona fide depression or bipolar afflictions. Yet antidepressants are the most prescribed -- some say overprescribed -- medication in America, sometimes seeming analogous to getting radiation treatment for a sore throat. Deep depression accounts for much of it, but so does America's deep recession -- not the same thing.
Comparing 1996 to 2005 -- the last year for which numbers were available -- a study in the Archives of General Psychiatry revealed that prescriptions doubled in that decade, from 5.84 percent of the population to 10.12 percent, translating to a jump from an estimated 13.3 million antidepressant users to 27 million, some as young as 6 years old. In a report analyzing data from 2006 and 2008, the Centers for Disease Control and Prevention reported that one in 10 U.S. adults suffers from depression.
Most commonly prescribed antidepressants are selective serotonin reuptake inhibitors and include Lexapro, Prozac, Zoloft and Paxil.
"These medications have been authorized to be prescribed for anxiety, which is a very broad field," says Dr. Ole Thienhaus of Las Vegas, who specializes in psychiatry. "Paxil started that for social anxiety disorder, so even extreme shyness can be treated with these drugs. Once you start down that road, you find more and more things. If you have a nice hammer, you find more and more nails."
Exacerbating that has been the shrinking role of therapy pioneered by Sigmund Freud, as many psychiatrists -- as outlined in a March New York Times article by Gardiner Harris that rippled big-time through the medical community -- have whittled their services down to brief consultations with patients, followed by prescriptions for pills.
"I think we have a fair number of psychiatrists, including in this community, who never practiced a different style than just a 10- to 15-minute visit, a prescription for medication and out the door, and that's a horrible way of practicing if you ask me," Thienhaus says.
One psychiatrist quoted in the Times summarized it this way: "I miss the mystery and intrigue of psychotherapy. Now I feel like a Volkswagen mechanic."
Situational depression -- loss of a job, the death of a loved one, even a pet -- is often treated with antidepressants that are otherwise indicated for major depressive disorders, Thienhaus says, adding that although the medications are largely well-tolerated physically, for many they have no effect and can divert patients from alternatives that can better assist them, such as grief support groups, counseling or crisis resolution.
Insurance policies and public expectations have contributed to the shift toward instant pill-popping.
"Insurance companies design the practice of psychiatry based on financial reimbursement for what they believe is an appropriate use of a psychiatrist, which more and more is just payment for a medication diagnosis," Roitman says. "I don't take insurance because I don't like those rules. I do a thorough diagnosis, a minimum of an hour for the first meeting and go through an array of problems that could be leading to the symptoms. If somebody is blown away because their pet died, I'm less enthusiastic about offering medication. Normal human feelings should not be framed as psycho-pathology. I was listening to a podcast where they said eventually, there will be nobody left who is normal."
Given that many insurance plans either don't contract with psychiatrists or with a very limited number of them, and that the visits are still expensive, many patients turn instead to primary-care physicians whom they see for other conditions but also can get an antidepressant prescription from as well.
"Now the primary-care physician can say, 'I didn't know this 20 years ago, but I can help you. I'll write you some Prozac,' " Thienhaus says. "The patient is happy with the prescription, the doctor is happy because he can do something for the patient, and the insurance company is happy because the cost of a visit for medication is much lower than paying for an hour of psychotherapy for weeks."
While specializing in internal medicine in Henderson, Dr. Fulgencio Antuna does dispense antidepressants, especially because, he says, "there's been a huge increase in anxiety and panic since the recession started in 2008." Should he determine the patient has moderate to severe depression, Antuna says he automatically refers them to a psychiatrist, but "in instances where they're not suicidal or paralyzed by their condition, I'll start them for a few weeks until they can get to a psychiatrist. I limit it to a very basic, low-dose medication."
Citing the recession as well, Dr. Stephen Miller, a Las Vegas internist, says he's "prescribing more (antidepressants) than I ever thought I would. Having said that, I usually talk to patients and try to go to other means. But it's hard to gauge when you see a patient for 15 minutes. In a (perfect) world, it would be great to have a combination of seeing a therapist and medication, but sometimes seeing a therapist isn't in the cards."
Patients often name antidepressants they have seen advertised on television, he says, adding that the commercials are misleading. They blame depression solely on a chemical imbalance and a lack of serotonin, a bodily compound contributing to a state of well-being that the meds can restore, as opposed to suggesting that help could also be found in talk therapy, in which there is no profit for the pharmaceutical companies.
"I don't endorse pharmaceutical companies going on TV marketing their medications," Antuna says. "As professionals, we are trained to give diagnoses and medications at the time of a visit. Cutting back (on ads) would be good."
Another element of taking antidepressants is potential side effects. "The most common side effect is sexual dysfunction," Thienhaus says. "That isn't dangerous, but it's a nuisance and people often stop taking the medications because of it. More serious side effects are gastrointestinal upset, which are usually temporary and go away. The bigger problem is once you stop these meds, people get very uncomfortable with withdrawal symptoms that are neurological. People feel like they get electric shocks, they feel lightheaded and feel like there's a (relapse) where they are constantly fearful and feel so depressed they really need the medications back. Those are real concerns."
Television viewers might also have noticed another issue: A burst of come-ons from law firms encouraging women to look into lawsuits if they took certain medications and had children with birth defects. Based on data from Finland, a recent study found a possible link between "a small risk of birth defects" and women taking Prozac and Paxil in the early months of pregnancy.
Most problematic in prescribing antidepressants, Thienhaus says, is the lack of a strong definition of major depression as a brain-based condition that would respond to the meds.
"We're in darkness there," he says, noting the different conditions and situations lumped together as depression.
"If we could whittle it down to say, like infectious disease, culture some bacteria in a petri dish and say this person will really respond to Paxil, we would have a more convincing case. But our science is nowhere near that point yet."
Contact reporter Steve Bornfeld at sbornfeld @reviewjournal.com or 702-383-0256.