The most widely prescribed drugs in the United States are not for pain or cholesterol management, heartburn or hypertension.
They're for depression.
Doctors last year wrote 232.7 million prescriptions for antidepressants, more than any other therapeutic class of medication, according to the latest data from IMS Health, a market research firm. That represents an increase of 25 million prescriptions since 2003 and translates into an estimated 30 million patients in the United States who spent $12 billion on antidepressants in 2007.
The explosion in antidepressant scripts has set off a raging debate about whether such widespread usage means that more people in need are being treated or that the medication is being overprescribed.
Charles Barber, author of a new book, "Comfortably Numb: How Psychiatry is Medicating a Nation," said antidepressants can be very effective for people with severe and disabling mental illness.
But he said heavy marketing by drugmakers, Americans' quest for a quick fix and a wider acceptance in popular culture have resulted in the use of antidepressants as "an instant cure for all emotional difficulties."
"There is a confusion between major clinical depression, which is clearly a biological illness where medication is appropriate, and being depressed," Barber said. "Life's problems, or having a feeling of sadness or dislocation, have been medicalized."
'Not a magic cure-all'
Antidepressants are among the top-selling products for several big drugmakers. According to IMS Health, the biggest-selling brands last year were Wyeth's Effexor, which had $2.8 billion in U.S. sales; Forest Laboratories' Lexapro, at $2.6 billion, and Eli Lilly's Cymbalta, at $1.9 billion.
The increased use of these drugs has resulted in studies to gauge their effectiveness.
One study, published by British researchers in February in the online journal PLos Medicine, looked at data from 35 clinical trials for the antidepressants Prozac, Effexor, Serzone and Paxil that had been submitted for review to the Food and Drug Administration.
The researchers concluded that the drugs benefited the most severely depressed patients, but found that they were only about as effective as a placebo for those who were mildly or moderately depressed. They suggested that many people now taking these drugs don't need them.
J. Douglas Bremner, a psychiatrist and head of Emory University's clinical neuroscience research unit, said, "The bottom line is that antidepressants don't work as well as people think."
He continued, "I prescribe antidepressants because sometimes they are better than nothing, but they are not a magic cure-all. And they have been overused."
'Undermedicated'
A widely cited 2006 study on depression funded by the National Institute of Mental Health found that using more than one antidepressant, or trying a different medication when the first does not work, can result in effective treatment and recovery for many people who suffer from major, chronic depression.
In the study, researchers found that one in three people with major depression who had not previously benefited from an antidepressant became symptom-free after adding a second medication. It also found that one in four became symptom-free after switching to a different antidepressant.
Robert Bransfield, a psychiatrist and secretary of the New Jersey Psychiatric Association, said there "certainly is a trend toward more use of medication" and less use of psychotherapy, in part because many health-insurance plans will not pay for such care. But he said antidepressants remain essential for treating many patients.
"I am still seeing more undertreatment than overtreatment," Bransfield said. "I think people are undermedicated when you look at the negative impact of mental illness on our society."
Bransfield said the PLos study looked at clinical trials with short-term usage of mostly older drugs and in settings that do not mirror the real world. In treating patients, he said, doctors can try different and sometimes multiple medications along with therapy to achieve positive results.
"They [the British researchers] have made incorrect assumptions," Bransfield said. "The misuse of antidepressants is low compared to the people who need them and don't get them."
'Lifestyle enhancers'
Author Barber, who has lectured at the Yale University School of Medicine and worked at shelters for the mentally ill homeless in New York City, said antidepressants have been marketed by the pharmaceutical companies as "lifestyle enhancers."
In the past few decades, he added, the Diagnostic and Statistical Manual of Mental Disorders, the bible of American psychiatry, has greatly expanded the number of psychiatric conditions that have provided a rationale for wider uses of the medications.
Carolyn Robinowitz, president of the American Psychiatric Association, said in any given year, one in five Americans experience a mental-health disorder, and only about one-third of them seek help.
She said physicians should be careful about prescribing antidepressants, but added that studies show that 70 to 80 percent of people with depression get better with a combination of the right medication and talk therapy.
"So many people are wedded to the notion that people should just pull themselves up by the bootstraps, and they see a weakness of will," she said. "But these can be real disorders, and like other disorders, people can benefit from medication."
