Last week I attended a lecture presented at the Department of Psychiatry Grand Rounds at a major Southeastern University. The presenter, a psychiatrist employed in a student counseling center at the same university, discussed the historical evolution of the orientation of university counseling centers. Her audience was largely comprised of other psychiatrists both practicing and in-training. “Grand rounds” is considered an educational event. Doctors can receive continuing education credits for the attendance.
The presenter explained that historically, counseling centers viewed most of the students presenting for services as experiencing adjustment problems in transitioning to adult roles. Assuming adult responsibilities, moving away from home, pressures to achieve high grades in a competitive atmosphere were viewed as adjustments that understandably could create some temporary angst. In contrast to the previous perspective, now more counseling centers are run by psychiatrists trained in identifying major mental disorders.
What the presenter failed to address is whether the shift in orientation has resulted in better outcomes. More young people are being labeled and medicated; that’s a fact. According to the presenter, prescriptions for antidepressants exceed prescriptions for antibiotics at the presenter’s university. Since the presenter did not even address the issue of whether the change in orientation represents a good thing, I decided to do some investigating.
Suicide prevalence seemed an obvious index that might offer a barometer for assessing whether the shift in thinking is associated with better outcomes. The CDC report informs us that suicide rates have tripled since 1950s for all persons 15 to 24 years of age. The American Association of Suicidology reports that suicide rates for this age group remained stably high between the late 1970s and mid-1990s, but have declined by 28.5% since 1994, while still exceeding rates in earlier periods. In contrast to rates of suicide for young people generally, suicide rates on college campuses have declined since 1960 which is accounted for by more females (who have far lower suicide rates than males) being included in later samples (Schwartz, 2006). Others have specifically examined how antidepressant treatment availability relates to rates of suicide. Kessler et al. (2005) contrasted rates of suicidal behavior for all ages during 1990-1992 with 2001-2003 and rates of psychiatric treatment in the two epochs. Kessler et al. concluded, “Despite a dramatic increase in treatment, no significant decrease occurred in suicidal thoughts, plans, gestures, or attempts in the United States during the 1990s.” Thus, there is little evidence that the dramatic shift in orientation from a developmental perspective to a pathology orientation has improved outcomes.
During the presentation, conspicuous by its absence was the lack of discussion of the black box warning from the FDA. The FDA advisory states “Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) and other psychiatric disorders.” The finding of more thoughts about suicide in antidepressant treated compared to placebo treated was replicated in the “Treatment of Adolescents with Depression Study”, a large multisite study examining antidepressant efficacy in youth. During the presentation there was no discussion of whether the counseling center takes any extra precautions in monitoring the students who are placed on antidepressants. Given, that Grand Rounds are part of the training for new psychiatrists, the topic of how to discuss these issues with patients and how to properly monitor might have been appropriate.
In some states, there are informed consent laws. Doctors are required to discuss both the benefits and potential harm of recommended treatments. Many people remain on antidepressants for over two years. The problem for a young person opting to take antidepressants is getting off of them. Possible withdrawal symptoms include mania, motor problems in the jaw, depression and anxiety, and nausea (Ceccherini-Nelli et al. ,1993; Haddad, 1997; Lejoyeux & Adés, 1997; Stoukides & Stoukides, 1991). For young people beginning careers, opting to take an antidepressant during college means that they may need time off from work later to detox from prescription drugs. The imperative of discontinuing antidepressants is high for women. For young women, continuing on antidepressants during pregnancy carries severe consequences. Antidepressants are associated with increased risk of autism in the baby (Croen, Grether, Yoshida, Odouli, & Hendrick, 2011). Antidepressants consumed during gestation are associated with heart malformations in the baby and problems in establishing proper lung function after birth (Chambers et al., 2006; Gentile, 2011; Udechuku, Nguyen, Hill, & Szego, 2010). During the presentation, there was no indication that a cost-benefit analysis is routinely addressed prior to providing prescriptions.
Later in the week, I attended the graduate Biology seminar at another university. The presenter discussed the efficacy of curcumin (found in turmeric) in preventing breast cancers and other cancers. She presented her data, which were pretty convincing. I asked the presenter about curcumin as an antidepressant, which I knew had been shown to be effective in animal work, and she told me that curcumin is being tested in clinical trials as an antidepressant. As I sat there, I wondered why student counseling centers are not recommending interventions with fewer side effects. There is a literature on omega-3s preventing and ameliorating depression and anxiety. Recently, Glaser and Kiecolt-Glaser published a study showing that omega-3s are effective in reducing anxiety in medical students during examinations. There is a literature on the antidepressant effects of exercise. Are psychiatrists totally ignorant of these other interventions which have been proven to impact biological causes of behavioral depression? To their credit, counseling centers do still offer counseling along with drugs. However, there was little indication that psychiatrists give time for the psychotherapy to work prior to providing medications. What could be the rationale for prescribing medications with black box warnings and severe withdrawal symptoms when efficacious and less harmful treatments are available? Of course, there was also no mention of Irving Kirsch’s work on the lack of efficacy of antidepressants, anyway. I guess the psychiatrists will have to watch Leslie Stahl’s “60 Minutes” broadcast this Sunday to learn about this.
Chambers, C. D., Hernandez-Diaz, S., Van Marter, L.J., Werier, M. M., Louik, C., Jones, K.L., Mitchell, A. A. (2006). Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. New England Journal of Medicine, 354(6), 579-587.
Croen, L. A., Grether, J.K., Yoshida, C. K., Odouli, R., & Hendrick, V. (2011). Antidepressant use during pregnancy and childhood autism spectrum disorders. Archives of General Psychiatry, 68 (11), 1104-1112.
Kessler, R. C., Berglund, P., Borges, G., Nock, M., Wang, P. S. (2005). Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990-1992 to 2001-2003. JAMA, 283, 20, 2487-2495.
Kiecolt-Glaser, J.K., Belury, M. A., Andridge, R., Malarkey, W.B., & Glaser, R. (2011). Omega-3 supplementation lowers inflammation and anxiety in medical students: A randomized controlled trial. Brain, Behavior, and Immunity, 25 (8), 1725-1734.
Schwartz, A.J. (2006). Four eras of study of college student suicide in the United States: 1920-2004. Journal of the American College Health, 54 (6), 353-366.
Schwartz, A. J. (2006). College student suicide in the United States: 1990-1991 through 2003-2004. Journal of the American College Health, 54 (6), 341-352.
TADS (2007). The Treatment for Adolescents with Depression Study. Archives of General Psychiatry, 64(10), 1132-1144.