Widespread use of SSRI antidepressants drives soaring health care costs in Canada

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From Women and Health Protection

In a recent report commissioned by the working group, Women and Health Protection, researcher Janet Currie documents the vast increase in the use of SSRI antidepressants among Canadians. The number of SSRI prescriptions dispensed in Canada went from just under 9 million in 1999 to over 15.5 million by 2003. In her report, entitled The Marketization of Depression: Prescribing SSRI antidepressants to women, Currie questions the science behind the drugs and their real-world effectiveness. She draws attention to the serious harms that these drugs can and do cause, as well as to their addictive properties.

Currie also points out that two-thirds of SSRI users are women. “The clinical trial results for SSRIs raise many questions about their effectiveness, and yet hundreds of thousands of Canadian women are being exposed to these potent brain chemicals, sometimes for many, many years despite their many risks and side effects,” says Currie.

Currie suggests a number of reasons for the increasingly widespread use of these drugs, one of which is an increased acceptance of the view that depression is a biologically-based phenomenon. Hand-in-hand with this view has come an era of aggressive marketing tactics by pharmaceutical companies. “One has to ask—is there a reason why depression rates have soared so dramatically in the last 15 to 20 years at exactly the same time as SSRIs came onto the market and have been aggressively promoted by drug companies?” she says.

Currie’s report effectively documents the full gamut of issues relating to SSRI use. It looks at the expanding definition of depression and links what appears to be an epidemic of depression and mental illness to the marketing of drugs designed to treat these conditions. Currie adds that in Canada, “depression is the fastest rising diagnosis made by office-based physicians. Visits for depression have almost doubled since 1994 and 66% of office visits for depression in 2004 were made by women.” Her report further states that 81% of physician visits for depression in 2004 resulted in a recommendation for an antidepressant—almost always an SSRI or a related drug.

At a time when health care costs are soaring out of control, the report indicates that total antidepressant drug costs were estimated to have risen 347% from 1993 to 2000. Eighty-eight percent of these additional drug costs were due to SSRI antidepressants.

Convincing doctors and their patients that depression and other emotional disorders are widespread and woefully under-treated, and that this is an alarming and costly situation, makes good business sense for the drug companies. However, “their effectiveness in delivering this message, which has resulted in huge profit margins for big pharma, is what is truly alarming,” says Currie.

To see the complete document, The Marketization of Depression: Prescribing SSRI antidepressants to women, visit www.whpapsf.ca/en/index.html

Women and Health Protection is a national working group that conducts research and advises Health Canada on the impact of Canada’s drug regulatory system on women’s health. Founded in 1998, it is made up of consumer organizations, researchers, health providers and women’s health activists.

What are SSRI antidepressants?

Selective serotonin reuptake inhibitors, often called SSRIs, are a group of drugs commonly prescribed for depression and anxiety. These drugs are sold under brand names, such as Prozac, Paxil, Zolof, Celexa, Luvox and Effexor (which belongs to a related class of dual action SSRIs). Over 15 million prescriptions for SSRI antidepressants were written in Canada in 2003, and the number continues to grow. Two-thirds of these prescriptions were for women.

Why are so many SSRIs prescribed to women?
There are a number of reasons for the widespread use of SSRI antidepressants by women. One reason is the dramatic increase in the number of women diagnosed with depression or other mood disorders. A second, related factor is the approach to treatment for such disorders, promoted by drug companies and endorsed by many medical practitioners. But a primary cause is related to the expanding definition of depression itself.

Women may experience anxiety and mood swings as a result of normal hormonal changes that accompany life cycle events such as menstruation, pregnancy, lactation and menopause. In addition, women can experience many external stressors related to inadequate housing and child care support, parenting, playing multiple roles, working in high pressure jobs, poverty, sexual abuse, violence and lack of extended family support.

There is no question that severe clinical depression is a real disease and it is understandable why people turn to antidepressants in the hope that medication will bring relief. But a broad range of mild emotional discomforts are now seen as illnesses requiring medical treatment. Mood swings, anxiety and mild depression are not new to women. What is relatively new is that over the last several decades, sadness, mild depression and anxiety have come to be labelled as medical problems or disorders. Data from IMS Health shows that in 2003, for example, it is estimated that there were 4.8 million visits to medical practitioners by women for depression where a drug was recommended.

The increase in the number of women diagnosed with depression, sometimes when symptoms are minimal, has come on the heels of an approach to treatment known as “biological psychiatry.” In this approach, rather than looking for social, cultural and economic and life stage factors that might be making a woman depressed or anxious, doctors are taught, and patients have come to believe, that the cause of symptoms is biological. This makes it seem logical that a drug is needed and appropriate.

It is no accident that this shift in thinking about how to handle mild depression has occurred at the same time as the development of the SSRI drugs, along with extensive marketing campaigns by the companies that manufacture them. In the 1980s, pharmaceutical companies began to aggressively promote the idea that depressed people needed SSRIs to elevate their serotonin levels, just as a diabetic needs insulin. Drug companies continue to promote this theory long after it has been seriously questioned by many researchers.

Safety concerns with SSRIs
SSRI antidepressants can affect mood and functioning. Some people feel that their mood improves when taking an SSRI. But, as with other drug therapies, SSRIs can also cause harm. Some of the negative effects already documented include agitated depression (that can lead to suicide); agitation, extreme restlessness, and muscle spasm; sexual problems (affecting sexual desire, arousal and orgasm); effects on pregnancy and newborns (such as birth defects and withdrawal symptoms at birth); gastro-intestinal problems, such as stomach pain, dry mouth, nausea, vomiting, weight loss or weight gain.

Many of the clinical trials conducted to evaluate the safety and efficacy of SSRIs have lasted only six weeks, with some trials lasting up to six months or a year. As a result, there are limits to what we know about the harms SSRIs may cause. By contrast, patients often take SSRI antidepressants for much longer periods of time, sometimes for years.

As well, no SSRI antidepressants are approved in Canada for use on persons under 19 years of age. There is little evidence that SSRI use for adolescents is effective, and there is increasing evidence that they may cause substantial harm, including suicidal thoughts and gestures, hostility and aggressiveness. Nevertheless these drugs are prescribed for adolescents at an increasing rate.

SSRIs and addiction
Some people taking SSRI antidepressants find it very difficult to either reduce their dose or eliminate the drug completely. The main problem is what is known as a “rebound phenomenon,” whereby the symptoms that led to drug therapy in the first place (for example, sadness or anxiety) temporarily become worse when trying to reduce or eliminate the drug use. As a result, many people continue drug therapy indefinitely, thinking they need it, sometimes with an increased dosage or the introduction of other psychiatric drugs. The effects of withdrawing from the drug may take days or even weeks to appear.

SSRI antidepressants can cause serious harm and are potentially addictive. The frequency at which these drugs are prescribed would suggest that they have been shown to be highly effective, but the evidence does not bear that out. In fact, many trials of SSRIs have shown them to be only marginally more effective than placebos.

If you want to stop taking an SSRI
DO NOT stop taking your medication without the assistance of a practitioner who is familiar with SSRI withdrawal therapy. You may go through severe, even life-threatening withdrawal symptoms if you reduce or stop your medication use abruptly. Professional help is needed to safely withdraw from these drugs.

The withdrawal effects are often the same as the symptoms for which the drug was prescribed and can include increased depression, insomnia, agitation, electric shock sensations and more. Experiencing these symptoms while withdrawing from a drug is not necessarily a sign of illness.

Alternatives to SSRIs
There are many known alternatives to drug therapy for mild depression and anxiety. A regular regime of exercise can be an effective treatment. In one three-year study, people who had been diagnosed with mild to moderate depression experienced a significant improvement after a twelve week cardiovascular exercise program. Others have found dietary change has improved their moods as well.

Talk therapy (or psychotherapy) has also been found to be at least as effective, and sometimes more effective, than antidepressant drugs. When researchers have followed patients for a year following treatment they have found that patients who have undergone psychotherapy have fewer relapses than those treated with antidepressants alone. Other forms of counselling have also shown to be effective.

Alternatives to taking SSRIs can also be found at the societal level: addressing cultural and lifestyle issues and providing appropriate supports can remove or lessen the many external stressors faced by women trying to hold it all together. Although making the necessary societal changes is beyond the capacity of each of us as individuals, collectively women have worked together to share experiences, form groups and become part of movements for change.

For women suffering from symptoms of depression, anxiety and other mood disorders that make it difficult to carry out their day-to-day responsibilities, it can be helpful to understand that the underlying cause is not a defect or imbalance within the individual. It is actually a normal reaction to a life without adequate support.

For more information on SSRIs, visit Women and Health Protection: www.whp-apsf.ca or call: 1-888-818-9172.

SSRI Antidepressants: Their Place in Women’s Lives
Diane Saibil (Women and Health Protection, 2005)

Selective serotonin reuptake inhibitors, often called SSRIs, are a group of drugs commonly prescribed for depression and anxiety. These drugs are sold under brand names such as Prozac, Paxil, Zoloft, Celexa, Luvox and Effexor. Over 15 million prescriptions for SSRI antidepressants were written in Canada in 2003 and the number continues to grow. Two-thirds of these prescriptions were for women. This fact sheet explores some issues about SSRI use: why it is so common, what effects these drugs have and some alternatives to taking SSRIs.

Also available online at www.whp-apsf.ca/en/documents/ssri.html