Anti-Depressants Generally Safe

Q:  What is it with the over-prescription of anti-depressants? Is everyone in the United States depressed? Recently, I was talking with my co-workers about friends and family members on Prozac, Paxil and others. We all knew several people on these medications, and many of us had stories about bizarre behaviors that seemed to result.

Is it possible to abuse anti-depressants? Does anyone really know how these drugs work? Don't we all get the blues from time to time and do we really need a pill to feel better? I know they have been a literal lifesaver for some, but for others, these drugs just seem to make a bad situation worse.

A:  The newer class of anti-depressants, called SSRIs (selective serotonin reuptake inhibitors), includes a number of medications such as the ones you mentioned. They work by modifying the pathway of serotonin, one of the brain's neurotransmitters. I would agree with your suggestion that we don't really know exactly how they work - any more than we know how the brain composes thoughts or feelings.

These drugs are generally safe, with the latest warning to watch for worsening depression or suicidal thoughts when first starting the medication. Some experts do not think this warning is necessary; they propose that suicidality is a risk in people who first start SSRIs simply because people are usually started on SSRIs when they have reached a low point in their depression and have sought a doctor's consultation. The established adverse effects in SSRIs include insomnia, agitation, sleepiness, nausea and headache, but not bizarre behavior.

These medications do improve depressed mood in many people, and I have known them to be extremely useful. Depression is difficult to "measure"; that is, the diagnosis of depression is made by a health care provider putting together a constellation of symptoms, the social situation and the description of day-to-day function.

Because of this and because the impact of depression is so individual, statistics are hard to come by. That said, it's estimated that 50% to 60% of people respond to their first anti-depressant after about two weeks of use. About 90% of people have better moods given more time on a particular medication or after a change in anti-depressant medication.

I wonder if the behaviors you notice are more related to a depressed person trying to cope rather than a direct effect of the medication. If you are concerned about someone close to you, you may suggest they seek psychotherapy or a specialist's consultation.

Julie L. Mitchell, MD, MS, is an Assistant Professor of Medicine at the Medical College of Wisconsin. She practices internal medicine at the Froedtert & Medical College General Internal Medicine Clinic - East. Her column appears in the Milwaukee Journal-Sentinel.