The ups and downs of antidepressants

Antidepressants have helped countless women reclaim their lives, but some still say pill-popping is fraught with peril

Get happy?
Antidepressants have helped countless women reclaim their lives, but some still say pill-popping is fraught with peril


It was party time. In the living room, a Craig David CD was blaring. The sound of the British crooner was underscored by a steady backbeat of highball glasses hitting tabletop and stilettos skittering across tile. Every few verses, the doorbell would ring and the reliable hum of a good housewarming would rise to a roar of greeting.

When Anne* heard the dull scrape of furniture being pushed back against the walls, she knew this celebration was going to become the stuff of house-party legend.

But Anne didn’t feel celebratory. Holed up in her kitchen, she observed the goings-on of her friends and family like a timid child lost in a shopping mall. Busying herself with canapés and dirty cocktail glasses, she tried to tune out the nagging inner voices: “Look like you’re having fun.” “Hurry, think of something smart to say.”

A quick check in the reflection of the microwave door told her she looked good—her new low-rise Sevens sat snugly on her hip bones and her slinky camisole exposed just the right amount of bottle-bronzed skin. It was her insides that didn’t match. Anne suffers from depression.

“I couldn’t find a way to fit in,” says the pretty blonde. “It was like I was watching the world go by—observing it but hardly participating. I couldn’t find the energy or the confidence to leap into life and really grab it.”

“Half-me” is how Anne describes her depressed self. When wrapped in the blues, life for her becomes colourless. Watching the tall, usually vivacious 30-year-old succumb to depression is like watching a high-definition television turn black-and-white, mute button pressed.

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Research suggests Anne is not alone. While some estimates put the incidence of female depression at one in 20, some claim it’s more like one in five. What’s certain is women suffer depression at double the rate of men. Not surprisingly, women also use antidepressant medication at more than double the rate of men. (There is some evidence to suggest that women comprise as much as two-thirds of SSRI users—that’s selective serotonin reuptake inhibitors, most commonly used to treat depression.) What’s more, those numbers show a sharp increase over recent years. The number of SSRI prescriptions dispensed in Canada went from less than nine million in 1999 to more than 16.5 million by 2004. And, according to data collected by IMS Health, in 2001 the antidepressant market was an almost $900-million business; today, it’s worth more than $1 billion.

Putting high-usage patterns together with big dough has some women’s health advocates raising their eyebrows and pointing fingers—at the big, bad pharmaceutical companies or prescription-pad-waving doctors, take your pick. They argue that drug companies are medicalizing a nonmedical issue in order to sell more drugs, and that physicians are too hasty to dispense drugs when other options, such as some time reclined on a therapist’s couch, could do the trick. They foretell a Valley of the Dolls world in which women pop pills as a cure-all for life’s ills, and soccer moms follow Lynette on Desperate Housewives and raid their kids’ attention-deficit meds for a pick-me-up.

“Suddenly, everyone is depressed!” says Janet Currie, a Victoria-based health-policy researcher. “You go to a dinner party and it seems like nearly half the people there claim to be depressed and on drugs. But are they clinically depressed? The definition [of depression] has been dumbed down to mean melancholy, boredom or even sadness after breaking up with your boyfriend. But doctors still prescribe these get-out-of-my-office-quick pills and we take them without fully understanding they are chemicals that come with risks. These are psychiatric drugs that stimulate the serotonin system much like street drugs like cocaine and ecstasy do.”

Currie argues that brain-altering drugs (all antidepressants affect the brain’s neurotransmitters, the chemicals that send messages between brain cells) are inappropriate in most cases and she points to research that suggests many cases of depression recover without pharmaceutical intervention. She wonders why more women aren’t seeking out talk therapy, for example.

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But Dr. Diane Whitney, clinical director of the women’s program at the Centre for Addiction and Mental Health in Toronto, notes that long waiting lists and limited access to psychotherapy (such as in remote areas) are problems for many.

So while the health protectors, health practitioners and prescription-drug manufacturers wax and wane, Anne has found her own truth—and it comes in a tiny pink-and-blue capsule.

On March 26, 1990, Newsweek’s cover proclaimed “Prozac: A Breakthrough Drug for Depression.” Four years later, in her 1994 memoir, Elizabeth Wurtzel declared us a Prozac Nation. Released in the United States in 1987, Prozac had become the mood-altering drug of choice—and it was legal. Women, kids, even puppies were popping the pill. But the backlash was just as swift and sweeping; there were media reports of increased suicide rates among those using the antidepressant and, soon, the star drug plummeted in popularity.

Tragic tales from the Prozac era have fuelled the fire of antidrug campaigners. Now, new happy-making medications claim to offer all the relief without the same side effects.

“We’ve seen the development of antidepressants that are much better than the old class of drugs; they have far fewer side effects,” says Dr. Donna Stewart, professor and chairperson of women’s health at the University of Toronto’s University Health Network. “These drugs are more tolerable, [so] it’s easy to prescribe them.” While Prozac came with high incidences of sexual dysfunction, Dr. Stewart says today’s drugs are more easily tolerated, with the most frequent complaints limited to nausea, slight sleep disruption and nervousness.

In the past, dry mouth, low blood pressure, constipation and changes in heart rhythm were the more common complaints. A study published in 2002 in the Canadian Journal of Psychiatry said there are reports of nervousness and agitation, dizziness, headaches and sleep problems associated with antidepressant use in 10–32 percent of cases. But low libido is the complaint that gets the most press. And that, too, may be about to change.

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In March, a new antidepressant, Wellbutrin XL, was made available in Canada that claims to have a low incidence of sexual dysfunction. Its maker, Biovail Corporation, touts the antidepressant as one with excellent tolerability—which is one of the reasons prescription rates are expected to grow steadily.

“Women are seeking help at higher rates because of greater social awareness and empathy about depression and that’s affecting the number of prescriptions. But further influencing antidepressant prescribing patterns is a new generation of drugs that gives doctors more, and better [as in, more tolerable], options for their patients,” says Robert Chalmers, director of marketing for Biovail Pharmaceuticals Canada.

Dr. Whitney agrees. “No medication is completely benign, but antidepressants such as Paxil and Celexa are easy to prescribe because the side effects are generally minimal and little dosage adjustment is required.” Which once again begs the question, is drug-taking the best course of action, especially given the number of people who now clutch prescriptions for these drugs?

“I’m sure there are women who get prescribed antidepressants who don’t need them,” Dr. Stewart says, “but there are even more who need them and don’t get them. That’s a bigger problem.” In Dr. Stewart’s view, it’s the fear-mongering we should worry about, as it may be keeping women from seeking help.

Women are afraid for good reason, though, says Currie. With depressed patients anxious for relief and doctors who may be looking for a quick fix for their patients, combined with pharmaceutical companies in business to sell drugs and make a profit, Currie’s fear is that the patient’s best interests may not be served in the long term.

How best to serve the interests of women struggling with depression is highly debatable. Anne wishes more of her friends would seek help and get happy. She lived two years of her life barely functioning. Currie recommends, however, that people should be offered—and should try—alternatives to pharmaceuticals first.

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For some practitioners, the solution is simple: if depression has a biological root, prescribe; if the cause is social, hold off. And then there’s the matter of sorting the biological problems from the social ones.

“In most cases of depression, there is both a biological and an environmental component,” says Dr. Stewart. Genetics, environment and disposition can account for the statistics stacked against women. “If a patient is saying things like, ‘I’m happy, my marriage is good, my work is fine, everything is great, but I can’t stop crying,’ then, sure, likely this is mostly biological. Versus someone who says, ‘My life is terrible and my husband is cheating.’ But what’s important to realize is that when the body is under acute stress for a length of time, it goes through biological changes. The adrenal glands work overtime and can cause an increase in stress hormones—a biological component for depression is created. So even those people who can chalk their depression up to bad times will benefit from an antidepressant.”

To say she has benefited is understating the advantages, says Anne, who, after experimenting with various herbal remedies, started taking Effexor XR more than a year ago. “It’s like I was driving along believing the windshield was clear and my visibility was fine. Then, the windshield gets cleaned and, wow, the world is so much brighter. After starting antidepressants, I’m me, only better.”

For Anne, the difference is night and day and the argument over antidepressant use is black-and-white: life is short, get happy, period. For others, such as Currie, the grey area is wide and fraught with dangers, such as antidepressant dependence and health risks. She points to the lack of long-term clinical studies and urges women to seek non-pharmacological alternatives. She also argues that many cases of depression eventually go away on their own.

In the end, though, it comes down to personal choice.

As for Anne, she isn’t going to lose another day. Her wedding is weeks away and, when she walks down the aisle in her strapless white gown and heels, her best accessory will be her smile.

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