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On Thursday, Feb. 24 we discussed anti-depressants. Are they over-prescribed? Have more effective ones been developed? Now that SSRIs have been around since the 1980s, do researchers have a good idea of what the long-term effects are?

Our panelists were Dr. John Goethe, the Director of IOL Research and Depression Initiative at Hartford Hospital, Dr. Surita Rao, hdepartment head for Behavioral Health at St. Francis Hospital, and Andrew Winokur, UConn's director of the Neuropsychopharmacology Treatment, Research and Training Center (NTRTC) in the Department of Psychiatry.

 Anti-Depressants. Are They Over-Prescribed? Are They Effective?(02/24/2011) 
11:54
William Weir: 
Hello and welcome to the Hartford Courant’s Thursday webchat. Today???s topic is "Anti-Depressants: Are They Over-Prescribed? Are They Effective?"

We???ll be taking readers??? questions, with the help of three panelists -
- UConn???s Dr. Andrew Winokur, director of the Neuropsychopharmacology Treatment, Research and Training Center in the Department of Psychiatry.
- Dr. Surita Rao, department head for Behavioral Health at Saint Francis Hospital and Medical Center
- Dr. John Goethe, the Director of IOL Research and Depression Initiative at Hartford Hospital

One thing our panelists have asked is that we emphasize that any information given here is not a substitute for personal consultation with your doctor.

We will be starting in a few minutes at 12 noon.
Thursday February 24, 2011 11:54 William Weir
12:00
William Weir: 
OK - welcome again, and we are now taking readers' questions.
Thursday February 24, 2011 12:00 William Weir
12:02
[Comment From LyndaLynda: ] 
I took Chantix successfully, for 6 weeks. However the depression I still have is worse then any depression I have ever had. It's more like a severe funk, taking Wellbutrin, slowly getting back to life. I have no energy, or motivation. It doesn't feel like any depression I have had before. Is there something else I could ask my doctor for. I quit with Chantix once beofre, but because I felt lifeless and could sleep all day, like now, I went back to smoking and the feelings went away. Chantix takes you to the gates of hell, but I don't want to go back to smoking, nor do I want these feelings. HELP?
Thursday February 24, 2011 12:02 Lynda
12:05
William Weir: 
Dr. Goethe, perhaps you'd like to take Lynda's question.
Thursday February 24, 2011 12:05 William Weir
12:09
William Weir: 
I looks like Dr. Goethe is having some technical problems. Dr. Rao, would you take on Lynda's question?
Thursday February 24, 2011 12:09 William Weir
12:10
Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital: 
Sure.
Thursday February 24, 2011 12:10 Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital
12:12
William Weir: 
One of the criticisms often heard about antidepressants is that they're over-prescribed. Would any of you like to address this?
Thursday February 24, 2011 12:12 William Weir
12:12
Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital: 
There have been multiple clinical reports of Chantix potentially causing agitation and other sudden mental status changes in people. I, personally have decided to no longer to use it to treat nicotine dependent patients. However, I still use Wellbutrin (Buproprion). In terms of your lingering depression, you might consider adding an adjunctive medication such as another anti-depressant of a different class (SSRIs) or an a-typical anti-psychotic at a low dose.
Thursday February 24, 2011 12:12 Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital
12:13
Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital: 
I can address this.
Thursday February 24, 2011 12:13 Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital
12:15
[Comment From PamPam: ] 
Are antidepressants really more effective in treating depression than say therapy, meditation, diet, exercise, or other things that are known to naturally elevate seratonin levels in the brain? What do the studies really show.
Thursday February 24, 2011 12:15 Pam
12:15
[Comment From LyndaLynda: ] 
Ok Thank you so much Doctor Rao
Thursday February 24, 2011 12:15 Lynda
12:18
Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital: 
Thanks, Bill. The newer anti-depressants are extremely safe. They are no more effective than older anti-depressants. However, the safe side-effect profile allows them to be prescribed by internists, family practioners, pediatricians, Ob-Gyn physicians in additional to psychiatrists. There are pros and cons to the extensive prescribing of anti-depressants. They are very helpful for alot of people who would have otherwise remain untreated and potentially get worse including the most serious symptoms including suicidal thoughts. However, many people need psychotherapy and the lifestyle changes to truly recover from their depression even if they are taking anti-depressants. Also, natural grief or sadness to life events is sometimes too easily medicated. This is a medical as well as a societal problem. We as a society often want to believe there is a medication that will cure everything.
Thursday February 24, 2011 12:18 Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital
12:19
[Comment From BarbaraBarbara: ] 
I have parents that have been on anti-depressants for over 10 years. They don't help them at all. Every time a bad situation happens in their lives they go into the hospital. the nurses in the psych unit say people who use medications come back and the people who dont use them dont come back. Is anyone getting feedback or surveys from these nurses who say doctors see patients in hospital for two minutes and prescribe at least 3 or 4 medications?
Thursday February 24, 2011 12:19 Barbara
12:20
Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital: 
Hello Barbara, I will be glad to answer your question.
Thursday February 24, 2011 12:20 Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital
12:20
Andrew Winokur, M.D.: 
Lynda,
There are some published reports indicating that Chantix may produce some negative effects on mood, thinking and behavior in some individuals. While this does not happen with great frequency, it has been reported to occur on occasion. Based on your observation that Chantix seems to have caused some negative reactions for you, it is potentially a good idea for you to not continue using Chantix, but that decision is best made in consultation with your provider. Wellbutrin has been shown to be effective for smoking cessation as well, and is FDA approved for that use, marketed as Zyban, which is the same drug (Bupropion). Welbutrin is also a proven effective antidepressant drug. Like all antidepressants, Wellbutrin needs to be taken for a period of time, and potentially, the dose may have to be increased, again, under the supervision of your provider. If Wellbutrin by itself is not sufficiently effective to help with your symptoms of depression, there are other medication options that could be added on along with the Wellbutrin. Your provider could give you information regarding other options that can be safe and potentially effective to use along with Wellbutrin.
Thursday February 24, 2011 12:20 Andrew Winokur, M.D.
12:22
[Comment From LyndaLynda: ] 
Thank you Doctor, i have been off Chantix for over a month.
Thursday February 24, 2011 12:22 Lynda
12:23
William Weir: 
Dr. Winokur,
If anti-depressants such as Prozac and Zoloft are all SSRIs, working on the same chemical (serotonin) in the brain, why do some work better for some people than others?
Thursday February 24, 2011 12:23 William Weir
12:24
Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital: 
People with mood disorders particularly need to learn and practice coping skills so that negative life events do not cause a spiral into depression. In most hospitals, the treatment team including the physician put serious thought and consideration into the entire treatment plan including the medication regimen. I would encourage you to talk to your parents about signing releases of information for their caregivers so that you can get some direct feedback from the therapist and/or the psychiatrist who is treating them in the hospital. Perhaps you could suggest a family meeting so you can fully understand the rational behind the treatment decisions and help support your parents.
Thursday February 24, 2011 12:24 Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital
12:24
[Comment From CarolCarol: ] 
I have been on Effexor XR for several years now started taking for peri menopausal sxs so for about 4 years now maybe longer my question is how long can a person be on depression meds and does it no longer work after being on it for so long. I feel fine somedays but other days I can be in a down mood. I have no side effects so would like to continue but am concerned about length of time. Thank you.l
Thursday February 24, 2011 12:24 Carol
12:27
Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital: 
Hi Carol, thanks for your comment. I am preparing a response.
Thursday February 24, 2011 12:27 Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital
12:27
Andrew Winokur, M.D.: 
Pam,
There are many well conducted studies that have demonstrated that antidepressant drugs can be effective to alleviate symptoms of depression. However, no antidepressant drug works well for every patient. There are also a number of studies that have demonstrated the effectiveness of psychotherapy for the treatment of depression. Forms of psychotherapy that have been particularly well established to be effective treatments for depression include cognitive-behavioral therapy (cbt) and interpersonal therapy. Other forms of therapy may also be helpful for some patients with depression, but they have been less well studied. For people with mild to moderate depression, several studies have shown cbt to be comparably effective to treatment with antidepressant drugs. One large study sponsored by NIMH reported that for patients with severe depression, antidepressant drug therapy was more effective than a psychotherapy treatment such as cbt. Good diet, regular exercise and other health promoting behaviors are important for everyone to follow, but individuals with moderate to severe depression are likely to require treatment with more well established effect treatment interventions, rather than just relying on these measures. Since untreated severe depression carries a risk of suicide in some cases, we do believe that it is important for individuals suffering with such symptoms to have a complete evaluation conducted by a mental health professional, and to be open to including an evidenced-based treatment approach in their overall regimen.
Thursday February 24, 2011 12:27 Andrew Winokur, M.D.
12:27
[Comment From garygary: ] 
What antidepressants might be best tried for somebody in their 80s with the usual old age problems? heart, incontinence, etc
Thursday February 24, 2011 12:27 gary
12:31
Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital: 
Carol, there are extensive clinical reports that many anti-depressants stop working inexplicably after working well for many years. For women in their reproductive years, (until they are completely in menopause) hormones do have significant effect on the course of mood disorders. Some women's brains are more sensitive to hormonal shifts. This can result in premenstrual dysphoric disorder or even peri-menopausal worsening of their depression symptoms. Check with your doctor to see of your Effexor dose needs to be increased. An adjunctive medication may need to be added or you may have to switch to another anti-depressant from a different class. A consult with your Ob-Gyn maybe helpful too. He/she may have some additional input.
Thursday February 24, 2011 12:31 Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital
12:32
[Comment From 12341234: ] 
what are your feelings on the use of medicinal marijauna for psych reasons?
Thursday February 24, 2011 12:32 1234
12:32
Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital: 
1234...I am preparing a response to your question....
Thursday February 24, 2011 12:32 Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital
12:35
Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital: 
1234, as a physician specializing in addiction psychiatry, I am very much opposed to the use of medical marijuana for psychiatric illnesses. I have treated hundreds of patients who began to use marijuana in their teens and 20's to self medicate depression, anxiety, and difficult family life. As with all addictive drugs, the marijuana eventually stopped working sometimes leading to the development of paranoia and a worsening of their anxiety. In addition, they often developed an addiction to alcohol or other drugs. It is best to treat depression with non-addictive medications.
Thursday February 24, 2011 12:35 Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital
12:35
John Goethe, MD: 
1.agree with previous comments re Chantix
2.re Carol's question about risk of long term exposure to Effexor: altho some psych as well as some medical medications can cause side effects that only occur after long periods of exposure, such is not the case with the antidepressant class of medications. If you have never had problems during your 4 yrs on Effexor it is unlikely that you will in the future. Of course, periodic discussions with one's provider about the need for continuing medications is part of usual care so you may want to bring this up at your next MD visit.

3.Re the question from Mr Weir re some antidepressants working better than others, etc: the SSRI's primarily affect serotonin but other classes of drugs for depression affect norepinephrine or other neurotransmitters or combinations of brain chemicals. While there is much that is not yet known about how these drugs work, it is clear that some people respond to one drug better than others and determining what is best for any individual often requires trying various options until you find one that works.
Thursday February 24, 2011 12:35 John Goethe, MD
12:36
[Comment From RayRay: ] 
Are there any negative physical side effects from being on anti-depresssants such as Wellbutrin for a long time?
Thursday February 24, 2011 12:36 Ray
12:37
Andrew Winokur, M.D.: 
Barbara,
The input from nurses, social workers and other allied health professionals who have important interaction with patients is always important to consider. However, it is a much more complicated determination to make in terms of how long to keep a patient with depression on an antidepressant medication and when to have them go off their treatment. I key issue is whether a patient responds adequately to an antidepressant medication in the first place. If they do not respond well, it makes sense to stop treatment with that drug after an appropriate treatment trial, which might typically take about 8 weeks. If a patient does respond well to an antidepressant drug, many studies have established that it is good practice to continue treatment with that same antidepresant drug for an extended period of time, which might be for several months, and can sometimes be for years. Some studies have clearly established the benefit for patients who respond well to an antidepressant drug and then are kept on a maintenance therapy regimen for an extended period of time. In your parents case, I am not clear if they actually responded well to the antidepressant drug in the first place.
Thursday February 24, 2011 12:37 Andrew Winokur, M.D.
12:40
[Comment From BrianBrian: ] 
I have currently been on Lexapro 10 mg for the past 7 months for Anxiety/panic. I had been on this before but went off for about a year until the latest event. Can I possibly drop down to 5 mg and have that as a maintenance dose.
Thursday February 24, 2011 12:40 Brian
12:42
Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital: 
Hi Ray, Wellbutrin is safe and well tolerated for the long run. The current consensus is that if a patient has had two or more episodes of clinical depression, they are strongly recommended to stay on the anti-depressant that helped them recover without any reduction in dosage. For patients who have had three or more episodes, it is vital they remain on the medication to prevent future episodes of clinical depression. In addition, they need to make the lifestyle modifications mentioned in a previous exchange above and must take advantage of one or more courses of therapy.
Thursday February 24, 2011 12:42 Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital
12:42
[Comment From anonymousanonymous: ] 
Are some people simply unable to tolerate anti-depressants? Over the course of 10 years multiple doctors and pyschs have tried to treat me with them. Finally one doctor figured out it's more anxiety than depression - yet many say these conditions often go hand in hand.
Thursday February 24, 2011 12:42 anonymous
12:44
John Goethe, MD: 
Re Brian's question about reducing Lexapro: If the symptoms for which Lexpro was prescribed resolved on a given dose, it is usual practice to consider carefully and gradually reducing the dose after 9-12 mos(assuming that the symptoms have not returned). This step should be under medical supervision because the amount and speed of the reduction is important and can be tricky(eg, SSRI's such as lexapro when tapered too quickly can cause "withdrawal symptoms").
Thursday February 24, 2011 12:44 John Goethe, MD
12:44
Andrew Winokur, M.D.: 
Carol,
Effexor and other similar antidepressant medications do seem to provide relief for some women who are dealing with perimenopausal symptoms. Antidepressant drugs are used in some patients for extended periods of time, and there is little indication that serious medical side effects or toxic effects are likely to occur with long term treatment. All antidepressant drugs can cause some side effects, but the good news is that most have a benign profile in terms of causing medical problems, such as to the heart, liver,kidneys or other organs. It is always prudent to have a physician follow your treatment with such a medication, and have a full check up and some lab tests at least on an annual basis. Effexor is a drug that is used in a quite wide dose range. If it seems to be helping some, but not sufficiently or not enough of the time, a simple first step, in consultation with your provider, might be to try increasing the dose a bit to see if that helps to produce a more pronounced or sustained positive effect. One other issue to keep in mind with Effexor is that you should not miss doses of the Effexor. People can experience uncomfortable physical symptoms if they have been on Effexor for a period of time and then go for a day or two without taking it. We refer to these uncomfortable symptoms as withdrawel reactions. Therefore, even if just going away for a weekend, you always want to make sure to have your medication supplies with you.
Thursday February 24, 2011 12:44 Andrew Winokur, M.D.
12:46
[Comment From Joyce JohannsonJoyce Johannson: ] 
This is not a question -- but I wanted to mention that finding the right medication for an individual patient is one of the biggest hurdles facing medical professionals. In the 50th anniversary issue of the Journal of Psychiatric Research, which was released recently, there is an article about a clinical study that medical professionals using an online reference database, called Referenced-EEG by CNS Response, Inc., were able to significantly improve their success in treating patients with depression, including patients with treatment-resistant depression. In the 12-week depression study conducted at 12 medical sites, including Harvard, Stanford, Rush and Cornell, physicians achieved a 65 percent success rate in treating patients with depression, compared to a 39 percent success rate in the control group. These results were highly statistically significant. The subjects in the study, selected through a randomized process, had failed an average of four previous treatments for depression. The study is interesting for patients and medical professionals alike. There is information about it online at http://www.cnsresponse.com/ if you'd like to learn about it.
Thursday February 24, 2011 12:46 Joyce Johannson
12:46
[Comment From BobbieBobbie: ] 
My son is a 36 yr old male who has been on Effexor XR 75 mg for more than 8 years. After being switched to a generic form, he became increasingly depressed despite increasing his dose to 150 mg. His depression did not decrease and he began having severe memory problems. He currently is back on the Brand name 75 mg, his depression has lessened somewhat but the memory problems persist. His psychiatrist has not suggested another anti-depressant . What to do?
Thursday February 24, 2011 12:46 Bobbie
12:49
Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital: 
Hi Anonymous, there are people who do not respond well to antidepressants or even have a negative emotional response to them. if mutliple antidepressants have been tried and you just do not respond well to them, some creative treatment opton may have to be explored. an example would be a medication on the bipolar spectrum such as lamotrigine. Anxiety and depression do go hand in hand in the brain . Antidepressants , particularly SSRI's [ selective, serotonin reuptake inhibitors] are the first line treatment for anxiety. higher doses may be needed however and all anti-depressants take several weeks to show respnse..
Thursday February 24, 2011 12:49 Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital
12:50
[Comment From JenJen: ] 
I have taken Wellbutrin and Lexapro for peri-menopausal depression. I don't like the side effects that these cause me. I don't get depressed all the time, but maybe for a week here and there. My doctors laugh at me when I ask them for a "happy pill" I can take on an as needed basis. Is there such a thing?
Thursday February 24, 2011 12:50 Jen
12:52
John Goethe, MD: 
Reply to "anonymous":
1.some people are more sensitive to antidepressants than others, possibly because of differences in the genes that control how humans metabolize drugs; however, with the large number of antidepressant agents now available it is almost always possible to find an option that can be tolerated(altho that does not mean that the drug will be effective).
2.yes, anxiety and depression frequently co-exist.
3.altho the class of drugs most often used for anxiety is referred to as "antidepressants", many are useful in anxiety as well; some anxiety disorders respond better to specific types of psychotherapy(eg, Cognitive Behavior Therapy)than to medication.
Thursday February 24, 2011 12:52 John Goethe, MD
12:52
Andrew Winokur, M.D.: 
Gary,
It is very prudent to be mindful of the safety of antidepressant drugs with respect to be in your 80's. That being said, it is common for people in their 80's or 90's to be treated with an antidepressant drug, and have that drug be very helpful for them and also to not cause any significant health problems. You should also know that most companies that develop new antidepressant drugs have conducted studies with their antidepressant drug in older populations, so that physicians have direct information on how the drugs are tolerated in older folks. The key issue is to go over your medical health history very carefully with your provider, as well as assessing whether the type and severity of depression problems warrants a trial of an antidepressant drug. Depending on the presence of certain specific health problems, such as heart problems, high blood pressure, liver problems, etc, some antidepressant drugs may be safer to consider using than others. Another major issue to consider is that many elderly individuals are taking many other medications (6-12 is not uncommon for the number of different medications taken by someone in their 80's. Most of these drugs are metabolized by the liver. This raises the issue of potential drug interaction problems through effects of some antidepressant drugs on liver metabolism. Thus, another key topic to discuss with your health provider is what other medications you are currently taking, and whether an antidepressant drug recommended would be likely to fit well, and not cause drug interaction problems along with the rest of your medications.
Thursday February 24, 2011 12:52 Andrew Winokur, M.D.
12:53
[Comment From barbarabarbara: ] 
no they did not respond well it made them worse, been through it all with them first dad then mom. I just seems too long with no good happening with either one. I've been supportive done everything. I think nature could have taken it's course from the beginning sometimes you need to cry and mourn if there is a death medications just prolong it by not allowing nature to take it's course.
Thursday February 24, 2011 12:53 barbara
12:54
William Weir: 
Panelists and readers, here is the 5-minute warning. We'll be wrapping up in a few minutes. Doctors, any final points you'd like to make before we go?
Thursday February 24, 2011 12:54 William Weir
12:55
[Comment From BrianBrian: ] 
SSRI's and Blood preessure...any issues there
Thursday February 24, 2011 12:55 Brian
12:57
Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital: 
Thank you for allowing me to participate in this webchat. I would like to finish up by saying with all the limitations, today's safe anti-depressants have significantly helped physicians and patients dealing with clinical depression. However, therapy, learning coping skills, some acceptance of life's tribulations and lifestyle modifications such as exercise and reducing sugar and refined carbohydrates are essential to recovery. Self medicating with alcohol and drugs is not helpful and may lead to a second illness.
Thursday February 24, 2011 12:57 Dr. Surita Rao, Chair of Psychiatry, St.Francis Hospital
12:59
John Goethe, MD: 
Brian/blood pressure and SSRIs: Concerns about antidepressants and blood pressure have primarily been with the MAOI drugs, not often used now, and with venlafaxine at higher doses(not an SSRI but affects serotonin and noradrenergic systems), but no SSRI's.
Thursday February 24, 2011 12:59 John Goethe, MD
12:59
Andrew Winokur, M.D.: 
Ray,
We have to start with the old principle of never say never. There are rare instances of serious negative physical side effects associated with the use of anti-depressant drugs, but such occurrences are quite rare. Looking on the more positive side, as a class, the antidepressant drugs really have a very favorable safety profile with respect to serious medical problems. They all can cause some side effects, but those side effects tend to be temporary and more in the nature of nuisance side effects than medical hazardous side effects. Since your question included mention of the antidepressant drug Wellbutrin, I can add that the medically serious side effect with Wellbutrin has been the occurrence of seizures. However, this is a very uncommon problem overall, and it is mainly in individuals who are prone to develop seizures from other causes that Wellbutrin should be avoided. Also,, the occurrence of seizures in early studies was mainly related to the testing of very high doses that were above the now established FDA guidelines for using Wellbutrin. I believe that if Wellbutrin is used within the FDA dose range that has been approved, and also if an individual has been carefully screened to rule out a history of seizures, the risk of developing a seizure on Wellbutrin is very low, even if the individual uses Wellbutrin for many years.
Thursday February 24, 2011 12:59 Andrew Winokur, M.D.
12:59
John Goethe, MD: 
Thanks you for the opportunity to participate.
Thursday February 24, 2011 12:59 John Goethe, MD
12:59
William Weir: 
Doctors and readers, thanks for joining us in today's webchat. It's been a lively discussion, thanks to your questions and answers. A replay of today's chat will be available at courant.com/cthealth.
Thanks again!
Thursday February 24, 2011 12:59 William Weir
1:01
 

 
 
 
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