Medications for Depression: A consumer guide by Lee H. Beecher, M.D.

page: 1 | 2

FDA warning on antidepressants

Antidepressant medications are proven, evidence-based tools used to treat clinical depressions. Accordingly, the public and professional communities were alerted in March 2004 by the Food and Drug Administration (FDA) that antidepressants themselves can cause worsening of depressive symptoms in a given patient. Following a Public Health Advisory on Cautions for Use of Antidepressants in Children and Adults, manufacturers of ten commonly prescribed antidepressant drugs now post warnings on package inserts and product labels to monitor adult and pediatric patients for symptoms of worsening depression and suicidal thinking. This FDA warning means that patients should have real, ongoing, accessible therapeutic relationships with those who prescribe medications for depression because the illness of depression itself may cause suicidal thinking which, in some cases, can be aggravated by antidepressant drugs as well.

The FDA's concern is that antidepressant medications such as fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), escitalopram (Lexapro), bupropion (Wellbutrin or Zyban), venlafaxine (Effexor), nefazodone (Serzone), and mirtazapine (Remeron) may be associated with increased anxiety, panic attacks, agitation, trouble sleeping, irritability, hostility, impulsivity, and pressured thinking or hyperactivity (manic symptoms). The FDA properly cautions that antidepressant medications, if not closely monitored, may actually worsen the very symptoms being treated, and thus increase suicidal thinking and suicide attempts. There are many other FDA-approved medications for treating depression in addition to the ten antidepressants listed above, and most experts agree that the advisory warnings apply to all antidepressants now prescribed.

Evidence-based research supports the use of antidepressants in adults. Clinical studies for children are less complete but do indicate benefit from medications (usually in combination with psychotherapy). I strongly advise patients not to stop taking their antidepressants because of this FDA warning.

• All of the FDA-approved antidepressant medications are likely to measurably help patients on average about two-thirds of the time. However, for a given patient, it is necessary to try an antidepressant medication for three or more weeks in adequate doses before knowing if the particular medication will help.
• Significant unwanted effects or side effects of commonly prescribed antidepres-sants include agitation, racing thoughts, severe anxiety, dizziness, sleep disturbance, or severe and persisting feelings of sedation or grogginess. Sometimes unwanted effects are temporary or can be controlled by adding a sleep aid for insomnia or anti-anxiety medication.
• Because thoughts of suicide may occur from the depressive illness itself or from the medications used to treat it, you should contact the prescribing doctor whenever you have signs of increased suicidal thinking.
• Do not stop or start antidepressant medications without consulting the prescribing doctor. If your doctor advises you to stop taking an antidepressant, do not do so abruptly. Taper the dose gradually over a week or more. Likewise, depending on the medication, increasing the dose may best be done in steps. Changing from one medication to another may be done by simultaneously decreasing the dose of the current antidepressant medication while increasing the dose of the new one.
• Regarding the ten medications named by the FDA, sedation and sleepiness occur more frequently with Serzone and Remeron. Agitation occurs more often with Prozac, Effexor, Celexa, and Lexapro. Decreased sexual desire and difficulty with sexual arousal, ejaculation, and orgasm are quite frequent side effects of Paxil, Prozac, Celexa, and Effexor; these effects occur less frequently with Remeron and Serzone. Sexual side effects, although common, go away after the drug is discontinued. Sexual side effects generally do not respond to prescribed testosterone or estrogen sex hormones.
• In bipolar mood disorders, pressured (manic) speech and thought are associated with excitability and poor judgment. Bipolar disorders can be aggravated by antidepressants and are controlled with mood-stabilizing medications such as Depakote, Risperdal, Zyprexa, Geodon, or lithium carbonate. Complex depressions and mental disorders are generally best treated by psychiatrists, who are more familiar with psychotropic medications than are other physicians.

Patients and families: part of the care team

In starting treatment for depression, the goal is for patients and their doctors to agree on and monitor a care plan, including psychotherapy. Then, keep monitoring and periodically report progress in relieving the depressive symptoms. Tell your doctor about all medications you take for all of your medical conditions from all sources.

The relationship that patients have with the doctors and key members of their treatment team is crucial to providing and receiving good care for depression. Since access to and continuity of depression care vary widely in terms of insurance coverage for mental health services, ongoing patient responsibility for care management, combined with patient and family advocacy, is essential. Patients should build their knowledge about what types of interventions and services help them and what they need to do to achieve remission from depressive symptoms.

Families and patients may need to be "squeaky wheels" with their insurance companies to obtain appropriate care. For advice and support if there are problems with insurance coverage advocacy efforts, call the Mental Health Association of Minnesota at 612-331-6840 or 800-862-1799.

Lee H. Beecher, M.D., is a psychiatrist in private practice, a clinical associate professor in the University of Minnesota Department of Psychiatry, a trustee of the Minnesota Medical Association, and president of the Minnesota Physician-Patient Alliance.

page: 1 | 2