Overtreatment, Bereavement, and Antidepressants

A recent paper argues that prescribing antidepressants shortly after the death of a loved one is problematic . . . and a few days later, a Harvard academic publicly suggests prescribing antidepressants FOR bereavement. Wait, what?

A recent study published in JAMA Internal Medicine found that “older men and women whose partners died within the past month are at an increased risk of heart attacks and strokes.” They found a 0.16% rate of heart attack or stroke among the recently bereaved, compared to 0.08% among controls- meaning that among the recently bereaved, there were an additional 8 cardiovascular events per 1000 patients. The authors appropriately recommend proper management of cardiovascular disease among the bereaved.

However, in response to the article, Subu Subramianian of the Harvard School of Public Health stated, “Doctors could simply encourage the bereaved person to have more interactions with friends and family.” This makes good sense. But, he followed this by stating:

“Or they could prescribe antidepressants and sleeping pills.”

On what evidence this recommendation rests is unclear to us. An email asking for clarification was not returned. But it is difficult to make the case that prescribing SSRIs to older adults who are are bereaved (but do not meet criteria for a mental disorder) is a good idea. Especially given that a rigorous study found that exercise alone was superior to exercise + sertraline (Zoloft) for depression among older adults. Adding Zoloft to exercise alone increased relapse rates. But, the nuances and data on this issue are apparently not on the radar of such experts. Instead, antidepressants are recommended – ironically, in an era of evidence-based medicine, where clinical decisions are supposedly made on the basis of rigorous research data.           

Many prescribers have a bias towards overtreatment- that is, for intervening with the use of prescription drugs rather than the alternatives. This partially results from the recent emphasis on evidence-based medicine, where randomized controlled trials serve as the highest form of evidence. It’s important to realize that overtreatment is not unique to psychiatric practice- but is the case for many conditions which physicians seek to identify and  treat, such as high blood pressure or metabolic problems. Many such medical conditions can be treated effectively without drugs, but prescribers naturally have a bias towards writing prescriptions. As the old saying goes, when all you have is a hammer, everything looks like a nail.

Of course, recent bereavement is not a medical condition. And many patients receive SSRIs without being formally diagnosed with a mental disorder. But the drug companies and associated Key Opinion Leaders have done a highly effective job of convincing non-specialists that these drugs are broadly helpful. It seems doubtful that OB/GYNs or gerontologists, for instance, would be highly informed regarding the details of the Great Antidepressant Debate: The fallacy of serotonin imbalance; perturbation of normal neurotransmission, including downregulation and the risk of increased chronicity; the efficacy of alternative approaches; the potential for SSRIs to cause mania, sexual dysfunction, emotional numbing, and tardive dysphoria; the under-recognized difficulties many experience when they try to discontinue SSRIs . . . sadly, these issues may be more familiar to readers of this blog than to many prescribers.

Apparently many prescribers and researchers think of SSRIs as magic bullets – apparently highly effective magic bullets that have little downside or risk attached. Clearly this contradicts the actual data, but this mistaken impression drives both overtreatment and SSRI sales.

Recommended Reading: Anatomy of an Epidemic, Pharmageddon, Overtreated, Overdo$ed America