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 EpidemicPharmageddonOvertreatedOverdo$ed America

 

5 COMMENTS

  1. As a retired hospital and nursing home chaplain I can state that what the bereaved need is not some pill that’s going to deaden them to their emotions and feelings but someone who is willing to sit down and listen to them as they work through and process their grief and sense of loss.

    This takes time, often a lot of time. It’s not something that’s accomplished in two weeks, a few months, and sometimes not even in a few years. What they need is someone who will just listen as they talk about their dead loved one, sometimes over and over and over. Many people get tired of listening to this and want people to stop the process. Walking with people in their grief is not an easy things to do.

    So, it’s no wonder that the bereaved are going to be encouraged from here on out to pop SSRI’s. Many people would rather have them numbed to their feelings than to have to listen to them. And besides, now that you can be labeled as having MDD after two weeks of grieving it’s very lucrative to psychiatrists and the drug companies to have you pop the pills! Way to go to the DSM-5 committee that thought this up in order to spread the net of pathology wider and wider. Call me cynical but I find this all to be very disgusting and disturbing.

  2. You’re right, Stephen, apparently almost everything the psychiatric industry stands for and does is “disgusting and disturbing.” I’m working on trying to enlighten some religious leaders, because one would think the religions would want to stop human rights abuses by the psychiatric community. But I also know that the psychiatrists cover up pastoral sins for the religions, so I don’t know if I’ll be able to make any headway. But I’m glad at least one pastor agrees psychiatry’s crimes against humanity are “disgusting and disturbing.”

  3. I am not an expert in statistics but it seems the differences quoted in this exert from the article are insignificant, particularly if the elevated risk disappears after 30 days. If someone who is knowledgeable could comment on this, I would be most appreciative.

    “The researchers found that within 30 days of their partners’ deaths, 0.16 percent of the bereaved group had a heart attack or stroke. That compared to 0.08 percent of the non-bereaved group that had a heart attack or stroke over an equivalent period.””

    Regarding offering someone sleeping pills, I don’t have a problem with that as long as the person is making a fully informed choice which of course, as we all know, rarely happens. But not being able to sleep while grieving could be torturous to some people and I do feel they should be given the option of sleep meds as long as full disclosure has taken place.

    But prescribing SSRIs is absolutely absurd to someone who is grieving. In my opinion, any doctor who does is committing malpractice.