The Overuse and Over-prescribing of Psychiatric Medication?
Any therapist who has been in practice a few years can likely think of an instance where a new client tells the story of how they initially went to their primary care physician with their concerns about symptoms of depression and/or anxiety, and were offered an anti-depressant, or anti-anxiety medication, usually an SSRI. Many of these patients report that psychotherapy was not raised as an option, but that they were provided a referral, when they asked for one.
While these case examples raise concerns about the over-use and over-prescribing of psychiatric medications, the assertion that psychiatric medications are overprescribed is hard to test. How can one tell if too many medications are being prescribed? Maybe the increased use of medications reflects a response to a real need?
However, several lines of evidence and argumentation suggest that medications may be overprescribed. First, a recent article in article in Pro Publica* noted that pharmaceutical companies are still paying physicians to tout (provide talks and serve as “consultants”) the benefits of their medication. This article goes on to identify 22 physicians who were paid more than half a million dollars since 2009, by pharmaceutical companies, and notes that four most highly paid physicians were psychiatrists. Second, the continuing proliferation of ads for psychiatric medication and the suggestion that more is better (arguments in favor of adding atypical anti-psychotic medications to an anti-depressant medication is but one example of this trend) continue to be made in the face of evidence that this approach is not likely to be significantly beneficial. A recent review that notes that there is a potentially small benefit shown, i.e. benefits were “small to minimal” for patient quality of life and in reducing functional impairments, when atypical anti-psychotics were added to anti-depressants. Moreover, this same review noted that notable risks of adverse reactions were present, when atypical anti-psychotics were added to anti-depressant medication. Third, the trend of influencing physicians, by giving gifts, starts while physicians are in training. In a recent article in the Journal of General Internal Medicine***, a national survey concluded that it was still quite common for pharmaceutical companies to pay for gifts, such as meals, for medical students. Finally, critics of the proposed DSM V have repeatedly raised concerns that new diagnoses are being created, which is in effect creating a market for more medication. This argument is made quite forcefully by Allen Frances, M.D., a Professor Emeritus at Duke, and formerly the chair of the DSM 4 Task Force and the chair of the department of psychiatry at Duke University School of Medicine, Durham, North Carolina. ****
While these arguments clearly do not make for a rock solid case that medications are being overprescribed, they all raise concerns that there is a continued push to rely on medications to treat psychiatric and psychological problems. This push for medication based treatment often appears to be at the expense of psychotherapy which in many instances (particularly the treatment of anxiety disorders and mild to moderate depression) has shown to be as if not more effective than medication.
*http://www.propublica.org/article/dollars-for-docs-the-top-earners
**Adjunctive Atypical Antipsychotic Treatment for Major Deprssive Disorder: A Meta-Analysis of Depression, Quality of life, and Safety Outcomes, by Spielmans, G.I., Berman, M.I., Linardatos, E., Rosenlicht, N.Z., Perry, A, and Tsai, A.C., in PLOS Medicine, March 12 2013. or at http://www.plosmedicine.org/article/info:doi%2F10.1371%2Fjournal.pmed.1001403
*** Changing Interactions Between Physician Trainees and the Pharmaceutical Industry: A National Survey, by Kirsten E. Austad BS, Jerry Avorn MD,Jessica M. Franklin PhD, Mary K. Kowal BA, Eric G. Campbell PhD, & Aaron S. Kesselheim MD, JD, MPH. Journal of General Internal Medicine, February, 2013. or at http://link.springer.com/article/10.1007%2Fs11606-013-2361-0
****see a recent interview with Dr. Frances, at http://www.opednews.com/populum/printer_friendly.php?content=a&id=163929, or check our his blog at http://www.huffingtonpost.com/allen-frances/terrible-news-dsm-5-refus_b_2473321.html
Finally, thanks to Ken Pope, Ph.D. for highlighting many of these articles on his list-serve, and at http://kspope.com/
Peter Perrotta, Ph.D. 