Wednesday, December 08, 2004

Soaring antidepressant use, part two

People are responding to my post about the many uses of antidepressants in the clinic. Dave Schuler, of the Glittering Eye, asks:

1. Has the drug in question been approved for the use for which
the physician is prescribing it?

2. Does the drug in question have demonstrated efficacy for the
symptoms the physician is attempting to treat?

3. Has the drug been approved for the target population viz. children?

There are also larger moral and ethical questions WRT mood-altering drugs.
At what point do the effects on the emotions of the patient constitute
a removal of the patient from the human condition which includes
feeling pain and grief?

And a few more: should a physician who is taking mood-altering
drugs be required to refrain from surgery? Disclose the situation
to patients? Undergo greater supervision?

I've been working on his questions. The FDA's web site provides info (try here and here). According to Micromedex, here are FDA-approved and off-label uses of some antidepressants in adults. Note: Don't panic if your meds are off-label, or if your illness is not on this list. There may be studies showing that your med is helpful for your condition. Ask your doctor to explain why you are taking your medicine. (For definitions, check here and here.)

Prozac FDA approved: Depression, bulimia, obsessive-compulsive disorder, panic disorder, pre-menstrual dysphoric disorder. Off-label uses: Post traumatic stress disorder, Raynaud's syndrome, fibromyalgia, body dysmorphic disorder (which often has depressive and obsessive features)

FDA approved uses: Depression, OCD, Panic disorder, PTSD, social anxiety disorder, pre-menstrual dysphoric disorder. Off-label uses: dysthymia. Possible indication for pediatric OCD.

FDA approved uses: Depression, OCD, social anxiety disorder, PTSD, generalized anxiety disorder, pre-menstrual dysphoric disorder. Off-label uses: pathological gambling.

Celexa FDA approved: Depression. Off-label uses: tension headache, panic disorder.

Lexapro FDA approved: Depression, generalized anxiety disorder. Off-label uses: "anxiety with depression."

Effexor FDA approved: Depression, generalized anxiety disorder, social anxiety disorder. Off-label uses: Pre-menstrual dysphoric disorder.

Wellbutrin FDA approved: Depression, smoking cessation.

If anyone sees errors in the above, please e-mail me. All of the listed meds have demonstrated a degree of efficacy that is considered significant, in clinical trials. Placebo rates in the studies do tend to be somewhat high. (Also problematic are the "side effects" reported with sugar pills, which can be greater than the reported side effects of the meds. Kind of a "reverse placebo effect." Some do feel worse on the placebo.) The most improvement occurs when you are doing more than just taking a pill...i.e., therapy.

I believe that only Prozac has been approved for children, but I defer to my child psychiatrist colleagues on this one, as the Zoloft-sellers have also been making hints about this. (Paging Dr. Baker!)

One of our greatest challenges is to determine when an antidepressant is indicated, and when people are seeking a "quick fix" for a condition that isn't really an illness. If a patient has stopped functioning, is unsafe, or is deteriorating because lack of appetite is causing malnutrition, we reach for these meds readily. Often it's not so clear-cut. The DSM helps.

Should doctors taking mood-altering drugs have more supervision and more disclosure? We're already required to disclose these things to medical boards, which then decide if we can be trusted with a license. We also have to disclose this info to managed care companies with whom we contract. The focus is on competence, whether you're medicated or not. I'm interested in what others think about this. (Paging Dr. Maurice...)
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