A recent article in the prestigious British Medical Journal seems to confirm an increased risk for suicidal behavior among adults taking popular antidepressants. This follows evidence that certain selective serotonin reuptake inhibitors (SSRIs) may have a similar effect among children and adolescents.
As with the controversy over certain painkillers, public policy about the use of Prozac, Paxil, Zoloft and other antidepressants must balance the known benefits with the newly emerging risks. This month’s Facts of Life takes an evidence-based second look at second-generation antidepressants.
Their names—Prozac, Paxil, Zoloft—are familiar ones in a country where about one in five people suffer from depression or similar mental disorders. These so-called “second-generation” antidepressant medications have been the treatment of choice since 1985.
Coming In Second
Second-generation antidepressants include selective serotonin reuptake inhibitors (SSRIs) and other similar drugs that work primarily by increasing the amount of time that the hormone serotonin circulates in the connective gap between nerve cells in the brain. Serotonin helps nerve cells communicate with one another, communication that often lags in depressed brains.
SSRIs like Prozac are called second-generation because they are now prescribed more often than earlier-introduced “first generation” tricyclic antidepressants. Tricyclic drugs work in a similar way to SSRIs, but they are toxic at smaller doses and tend to have more serious side effects.
Taking Stock
The new antidepressants are a success story, an effective treatment for millions and a market winner for many drug companies. But researchers are just beginning to examine the 20 years’ worth of data available for the drugs to answer some pressing questions about their use. Are all second-generation antidepressants equally effective? How often do serious side effects like suicide occur? And should the medications be used sparingly in certain groups, like children and pregnant women?. A review of the cost effectiveness of depression treatment concluded that there are few studies that compare the cost-effectiveness of behavioral and drug-based therapies for depression.1
The Facts:
- Approximately one in five Americans has a mental disorder such as depression, anxiety disorder, bipolar disorder or a similar condition that can be treated with second-generation antidepressant drugs.
- A 2004 meta-analysis of antidepressant medications, including seven SSRI drugs, concluded that the medications had a “modest beneficial effect” on patients with combined depression and substance abuse disorders.
- A new systematic review of studies including 87,650 patients found a twofold increase in suicide attempt rates in SSRI patients compared to those taking a placebo or other therapies than tricyclic antidepressants.
- Second-generation antidepressants may be preferred over older tricyclic drugs as a first line treatment for bipolar depression, according to a 2004 systematic review.
- Most studies of antidepressant treatment for people age 55 and older exclude patients with other serious health problems, making it difficult to conduct medication trials with a large number of study participants.
- Rates of stroke and brain hemorrhage in patients taking SSRI drugs are very low, despite the fact that serotonin can affect blood clotting and blood vessel diameter in the brain.
- The Center for Science in the Public Interest’s review of studies on SSRI treatment for children found that industry-funded studies are 50 percent more likely to report positive treatment outcomes than government or university-funded studies.
- A systematic review of unpublished research on SSRI treatments for adolescents suggest that many SSRIs, with exception of Prozac, are more risky to the health of teens than published data would suggest.
- A meta-analysis of studies of antidepressant treatment for obsessive-compulsive disorder in children found that the older tricyclic antidepressant clomapramine (Anafranil) was significantly more effective in treating the disorder than four SSRI drugs.
- The “best buys” in second-generation antidepressants, based on safety, effectiveness and cost, are generic fluoxetine (Prozac and Sarafem), citalopram (Celexa) and buproprion (Wellbutrin), according to a 2005 Consumers Union report.
Catching the Problem Early: