Today I have the honor of interviewing one of my favorite psychiatrists on a topic that troubles me: overmedication in America. Dr. Pies is Professor of Psychiatry and Lecturer on Bioethics and Humanities at SUNY Upstate Medical University in Syracuse, New York and Clinical Professor of Psychiatry at Tufts University School of Medicine in Boston. His most recent book is The Three-Petalled Rose: How the Synthesis of Judaism, Buddhism, and Stoicism Can Create a Healthy, Fulfilled and Flourishing Life. He has written many articles on the topic of overmedication, so I asked him the question: Are we overmedicating with psychiatric medications today?
Dr. Pies: I often answer this by saying that we have a “twin peaks” phenomenon in this country, as regards prescription of psychiatric medications. I mean that there is evidence of both under- and over-prescribing, depending on the population studied and the clinicians doing the prescribing—as well as on some ethnic and economic factors. The answer also may depend on the particular type of “psychotropic” medication we are discussing, and the diagnosis in question.
Let’s start with the most widely prescribed class of agents, the antidepressants.
Mojtabai and Olfson found that the rate of antidepressant drug treatment in the United States increased more than four times between early 1990s and early 2000s. Of special concern, they found that the rate of antidepressant treatment increased more in the group of less severely ill individuals than in those with more severe psychopathology—not what we would like to see, all other things being equal, since antidepressants are probably more effective (compared with placebo) in moderate-to-severe depression.
In less severe cases, psychotherapy would be my preferred treatment of first choice, given that antidepressants may have significant side effects, such as weight gain and sexual dysfunction, depending on the particular medication and patient. I would also argue that antidepressants are over-prescribed in bipolar disorder, often because the condition has been misdiagnosed as recurrent major depression. Although some patients with bipolar disorder may need antidepressants, most will get little benefit from them, and may even experience increased irritability or mood instability. Mood stabilizers, including lithium, are the preferred treatment for bipolar disorder, whenever possible, but every case must be evaluated individually.
Mojtabai and Olfson have also found that much of the growth in antidepressant prescribing has been driven by antidepressant prescriptions written by “non-psychiatrist providers” (for example, primary care physicians) without providing an accompanying psychiatric diagnosis. But—is that necessarily always a bad thing? Not necessarily. Some of these primary care prescriptions may be for “unofficial” conditions like mixed anxiety, depression and insomnia, and the PCP may not code this as a “psychiatric” disorder—but antidepressants might still be of some benefit in these circumstances.
Back to the “twin peaks” issue: there is also evidence that antidepressants may be under-used in some minority or low socio-economic populations. Also worrisome is a trend uncovered by Harman et al, showing that many patients prescribed antidepressants are not getting adequate doses—so they may get the side effects without a great deal of benefit. There is also a large body of evidence showing that depression is under-recognized and under-treated in geriatric patient samples, often with inadequate dosing of antidepressants. Yet some of these older patients are the most severely afflicted. So, rather than say there is “over-medication” of depression, I would say there is a “mis-match” between severity of depression and adequacy of treatment, in many settings.
As for other kinds of psychiatric medications, my own view is that antipsychotic medications (risperidone, olanzapine, and others) are often over-prescribed, for questionable reasons—particularly in nursing homes, and for some troubled children and adolescents. These medications are useful for psychosis, such as in schizophrenia, but they are not usually appropriate for the treatment of anxiety, sleep problems, or “acting up”, such as sometimes occurs in adolescent patients or among those with dementia.
Finally, some sedative-hypnotic and anti-anxiety agents, such as Alprazolam (Xanax) or lorazepam (Ativan) may be over-prescribed in some clinical settings, but may also be inappropriately withheld, on the mistaken idea that these are highly addictive drugs. Unless the patient has a history of alcohol or substance abuse, short-term use (2-6 weeks) of these anti-anxiety agents is often warranted for severe anxiety (such as panic disorder); or insomnia that doesn’t respond to “sleep hygiene” or behavioral therapy. That said, some patients can become physically or psychologically dependent on Valium-type drugs, and when possible, only short-term use should be considered. Selective serotonin reuptake inhibitors (SSRIs) may be better choices for long-term treatment of chronic anxiety disorders, and, of course, cognitive-behavioral therapy is very effective for many types of anxiety.
Published originally on Sanity Break at Everyday Health.