NEAL CONAN, host:
This is Talk of the Nation. I'm Neal Conan in Washington. Doctors know that antidepressants like Zoloft and Prozac help kids and teenagers, as well as adults. But they don't know much about their long-term effects. In an op-ed piece in the New York Times recently, Dr. Richard Friedman described a patient, now 31 years old, who started taking this medication when she was 14.
She credits the drugs with saving her life, but doesn't know who she is without them. And he admits that doctors know a lot more about the course of untreated depression than they do about the physiological and psychological effects of taking antidepressants for 15 or 20 years. Dr. Friedman joins us shortly, and we'll try to get some answers.
Later on in the hour, we'll talk with "Ask Amy's" Amy Dickinson about politics in the workplace. If arguments over Clinton, Obama, McCain, and Bush rage in the cubicles of your office, send us an email now. The address is email@example.com.
But first, did you grow up on antidepressants, and how has it affected you? Tell us your story. Our number is 800-989-8255. Email us, firstname.lastname@example.org. You can also join the conversation on our blog. That's at npr.org/blogofthenation.
And we begin with Dr. Richard Friedman, a professor of psychiatry at Weill Cornell Medical College. He wrote an op-ed in the New York Times called "Who are we? Coming of age on antidepressants." He's with us from our bureau in New York. And Dr. Friedman, nice to have you on the program today.
Dr. RICHARD FRIEDMAN (Weill Medical College, Cornell University): Thank you. It's nice to be here.
CONAN: And I mentioned your patient called Julia. Tell us a little bit more about her.
Dr. FRIEDMAN: Yes, well, you know, this was one of those experiences where, you know, something is hidden in plain sight. She said to me one day, after being on antidepressants for a very long time, that she'd never really considered what she felt like off of them. She had really no sense of who she was outside of being on an antidepressant.
She'd been depressed many, many times in her life. But she asked that question, you know, what would I have been like, in a sense, if I hadn't been taking antidepressants all these years? And it stunned me.
CONAN: In a sense, it's an identity crisis of sorts.
Dr. FRIEDMAN: Yes. You know, I mean, most people her age are in the business of trying to figure out who they are and where they are going in life, and she was doing this under the influence and, as I would say, with the benefit of an antidepressant. But she asked a really interesting and fundamental question.
CONAN: There was another of your patients, who you don't name, but a woman in her mid-20s, who said that she'd been pressured by her boyfriend to have sex more often than she would like, and said, you know, I have always had a low libido.
Dr. FRIEDMAN: Yes. Well, in this case, she had actually mistaken the side effect of a medication for her normal development. No one had explained to her that, you know, antidepressants frequently get in the way of sex drive, interest, performance, and she was taking an antidepressant which is well known to cause sexual dysfunction. She just assumed that this was her normal libido.
CONAN: Again, she didn't know who she was without the drugs.
Dr. FRIEDMAN: Correct.
CONAN: And it may not, I don't know when she started taking them, but may have always felt this way. So, of course, she thought that was normal for her.
Dr. FRIEDMAN: Yes. I mean, it's a problem, I think, especially with the treatment of younger people. You know, if you are in your 30s and 40s, and you have a pretty good sense of who you are, or you have the benefit of knowing it, you know what your normal baseline is like. And, if you take a medication, you can tell, sometimes, what the side effects are because they are different from how you felt beforehand, but not in this case.
CONAN: And, I guess, there is no real way to test, you know, acceptably, or over an acceptable period of time, and say, all right, here's the effect of a drug in a clinical test over 20 years.
Dr. FRIEDMAN: Well, no. It's just not feasible, and it would be impossibly expensive and impossible to conduct an experiment like that.
CONAN: So, basically, because of the way drugs are approved for use, there's really no way for us to know these answers.
Dr. FRIEDMAN: Well, actually, I think there is a way to learn more about that. We may not have a definitive answer, but, you know, if you consider that the way drugs are currently tested in the country, you know, in order, basically, to get FDA approval for a medication, a drug company has to conduct two clinical trials, where they basically give the drug and compare the effect of the drug to a placebo in two different studies.
And typically, this is done with, at most, a couple of hundred patients and usually over a pretty short period of time. We're talking about four to six weeks, and, if you think about it, the testing and approval of a drug doesn't really correspond very well to the way physicians use the drug in the real world, which is over months and years.
CONAN: And, as you also point out in your piece, people are understandably skeptical about some of these trials.
Dr. FRIEDMAN: Yes. Well, they have reason to be skeptical because, as the public has learned recently, and has suspected for a long time, that the pharmaceutical industry cherry-picks those studies which it reports.
Most of the studies that are positive, meaning that the drug outperforms placebo, about 97 percent of them are published. There was a piece in the New England Journal of Medicine in January. Whereas only about 12 percent of studies where the drug did no better than placebo actually made it to the light of printed day.
CONAN: We're talking with Dr. Richard Friedman about his op-ed in the New York Times called "Who are we? Coming of Age on Antidepressants." If you'd like to join us, 800-989-8255. Email us, email@example.com. Jill is on the line, calling from Louisville in Kentucky.
JILL (Caller): Hi.
CONAN: Hi, Jill. Go ahead, please.
JILL: Thank you for taking my call. I just wanted to say, I'm in my mid-30s now, but I started taking Prozac when I was 16, which was in 1989. So that kind of dates me, but I have found that, I have tried going off medication, and I've tried different antidepressants. Prozac is what I credit with saving my life, as was mentioned by the doctor on the call earlier - on the show.
But I have found that, when I am on the medication, that is my authentic self, and I have no problem with, you know, coming of age on antidepressants because while I am on the medication is when I can enjoy my hobbies and my interests and my family and my friends and, you know, made it through college successfully, worked successfully, married for 15 years.
All of it, none of those things would have been possible without the medication. So I don't see - I don't think it's a covering up of one's personality. I really think it's really a wonderful thing to be able to live and enjoy life.
CONAN: I wonder if we could get a response from Dr. Friedman.
Dr. FRIEDMAN: Jill, that's wonderful to hear that the drug was so effective for you, and you make a really critical point, which is that depression is the thing that we really most have to worry about. Because that's the thing that gets in the way of people's ability to live life to the fullest, to enjoy their friends, to work, and your experience of actually responding to the medicine and seeing how rich your life was and how authentic your sense of self is on the medicine is critical. I'm much more worried about untreated depression than the hypothetical risk of the long-term treatment with these drugs.
CONAN: And I have to ask. At this point, do you expect that you're going to be taking Prozac for the rest of your life, Jill?
JILL: Well, actually, I currently take Zoloft. I expect I will be on something the rest of my life, yes. And, you know, it does concern me. When I'm 60, are there going to be side effects? But the fact of the matter is, that's just kind of one of those risks I have to take in order to be a successful functioning human being and mother and wife. And I guess the only time it really concerned me was, I tried to go off of it for pregnancy, and I just was not able to. So I am concerned about, did it affect - it doesn't appear to have affected my son, who is three. But that's been my only - you know, the biggest concern for me is what it might have done to him that we don't know about. But he seems to be fine.
But I'm just very thankful for shows like this because, when I was diagnosed as a teenager, it was a huge stigma. I was hospitalized for a week. And actually, you know, it was a big quiet, oh, where did she go. What's wrong with her. It was horrible, that aspect of it. So I praise shows like this. I thank you so much, for getting - you know, mental illness is not a personality flaw, and it's not something that anyone chooses. So thank you for your work and your time.
CONAN: Well, Jill, thank you for the call. And good luck to you and to your son, too.
JILL: Thank you so much.
JILL: Continue the terrific work.
CONAN: Appreciate it. Joining us now is Dr. Norman Rosenthal. He's studied antidepressants for more than 25 years, and he's medical director of the Capital Clinical Research Associates. He's in a studio at member station WAMU here in Washington, D.C. And Doctor Rosenthal, thank you for joining us today.
Dr. NORMAN ROSENTHAL (Medical Director, Capital Clinical Research Associates): Great to be here.
CONAN: And I wanted to ask first about Jill's concerns about possible side effects when she turns 60 or so.
Dr. ROSENTHAL: You know, I think we all live with that. I think there are so many of us who are on chronic medications, whether it's for blood pressure, whether it's for heartburn or the acid blockers or Nexi-- or Lipitor and all the cholesterol drugs, and I think that we don't really know.
What I liked about Jill's answer is that she realizes that she's taking some of that responsibility. She said, this is a risk I have to take. And I think that we as consumers or patients need to understand that we're participating in that risk along with our doctors because the doctors really don't know. The studies, as Dr. Friedman pointed out, just haven't been done over that period of time.
CONAN: And what about his questions about, well, the psychological effects of somebody who's grown up since 12,13,14 on antidepressants?
Dr. ROSENTHAL: You know, I thought he raised a fascinating question, and it's a little bit like the old poem, "The Road Less Traveled." You know, you take one path, and then you wonder what would happen had I taken the other path? And, of course, you never really know completely because for, in Jill's case, 20 years or so, she's taken one path, and what would have happened?
But I think those of us who've been in practice for years have seen the impact of long-term depression in young people, and we can compare that with people who have been treated for years with antidepressants. And it's quite a contrast. You know, in the one case, with depression, you see, besides, of course, the suffering and the risk of suicide, you see the cognitive difficulties, with the academic problems they cause, the social difficulties, and the problems with self-esteem, which are so crucial in forming a person's identity.
So this is what happens if it's untreated. And if it's treated, then people have got a chance to feel good about themselves, function well. Remember, these adolescent and young years are crucial years where crucial skills are being acquired. And, in a way, if those years go by, to some extent they can never really be recaptured. And so that's a huge cost of not treating, of the other path that wasn't taken.
And just, you know, one last thought was what Jill was saying, there are times most people chronically on antidepressants will do a little experiment. They'll go off the antidepressant for a little while. And they say, I forgot, but I think what they're really saying is, I did a little experiment. I wanted to just see how it was without the antidepressant, and, you know, sometimes it's OK. But most of the time, especially in people who end up on chronic medication, it's a nasty surprise to find those self-doubts and aching pains of the soul come back again.
CONAN: Stay with us, Dr. Rosenthal. Also with us still, Dr. Richard Friedman. We'll talk more about the experience of growing up on antidepressants in just a moment, about what we know and what we don't about long-term effects.
If you came of age while taking antidepressants, how did they affect you? 800-989-8255 or send us an email. That address is firstname.lastname@example.org. And you can check out what other listeners have to say on our blog at npr.org/blogofthenation. I'm Neal Conan. It's the Talk of the Nation. Stay with us. This is NPR News.
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CONAN: This is Talk of the Nation. I'm Neal Conan in Washington. And "Ask Amy's" Amy Dickinson joins us a bit later to talk about politics, not the office politics, but politics at the workplace. If arguments over Clinton, Obama, McCain, and Bush rage from the cafeteria to the corner office, send us an email. The address is email@example.com.
Right now, we're talking about growing up and discovering who you are while on antidepressants. They're the most prescribed class of drug in the United States according to the CDC. And, as we heard, Dr. Friedman argues, there's still too much we don't know about their long-term effects, especially when it comes to teens and young adults. There's a link to his New York Times op-ed, "Who are we? Coming of Age on Antidepressants," on our blog at npr.org/blogofthenation.
Dr. Richard Friedman, a professor of psychology at Weill Cornell Medical College. Also with us, Dr. Norman Rosenthal, medical director of the Capital Clinical Research Associates. And, of course, we want to hear your stories. If you grew up on antidepressants, how have they affected you? 800-989-8255. Email us, firstname.lastname@example.org. Dr. Friedman, it occurred to me that you might have some pretty good questions for Dr. Rosenthal.
Dr. FRIEDMAN: I do. I wondered what Dr. Rosenthal would think about how we could answer the question after these drugs come to market. What kinds of things could we do to better answer the question of the long-term side effects and risks of these drugs? Because, as I'm sure everyone knows, Dr. Rosenthal knows this better than most people, that post-marketing surveillance is just not very good in this country.
Dr. ROSENTHAL: Yeah, I think, Dr. Friedman, that you made an excellent point in your op-ed piece, that there has been recent congressional mandating of better post-marketing surveillance, but that, perhaps, it doesn't go far enough. I think your point that, in the clinical trials, we're only really treating a few hundred people for a short amount of time. And I think that's why, naturally, side effects are going to emerge.
And we've seen that with drugs, where they have been recalled, or drugs where they have gotten a black-box label, which is a serious warning to doctors, to warn your patients about potentially dangerous side effects. And these only emerge after the event, and I think that it's a little unrealistic to expect the pharmaceutical companies to do a thorough job of policing themselves. I think that is a job for regulators, and I think we just need a lot more of it.
Dr. FRIEDMAN: Yes.
CONAN: Let's see if we can get a caller on the line. And this is John, John with us from San Francisco.
JOHN (Caller): Hi, thanks for taking my call.
JOHN: I have a different perspective on this. I just turned 40 and, when I was 15, survived a really traumatic experience, after that, showed major signs of depression, anxiety, and so forth. The only thing my parents wanted to do, at that time, was send me to talk therapy. And I did it, I think, a few times. It didn't really work. From that point, until I was 30, I had trouble sleeping. Basically, every night was depressed, dropped out of college, and it was something that we just didn't talk about in our house.
And the one other observation that I'll make is, I'm really glad that you have these two doctors on because I feel that much of the coverage about young people and antidepressants is slanted towards the few, unfortunate, sad cases where teenagers or young people kill themselves, and not to the great number of people that are helped by the drugs. And I'm currently on one. I switched around a couple of times, but if I don't - if I'm not on it, I can't really sleep effectively. It makes a huge difference.
CONAN: So, in that description that we heard earlier, of the road not taken, you took the road taken. You didn't take the medications. I'm just trying to do the addition in my head. They may not have been available when your incident happened.
JOHN: They were within a few years, and it was just something that, at least in my family, you never talked about. I was ashamed about it. And, for people who say they're not being their true selves, not being able to sleep and being anxious and being depressed - that isn't a life worth living. It's not something that's enjoyable and good.
CONAN: Dr. Friedman, you wrote in your article, you're utterly convinced that these drugs save lives.
Dr. FRIEDMAN: Yes. I think if you look at all the information in aggregate, and you ask yourself, you weigh on one side, what is the risk of depression when it's not treated? About two to 12 percent of people who are depressed will kill themselves in their lifetime, two to 12 percent.
And, if you look at the risk of the drugs, and people have learned about this recently because the FDA has required that these drugs carry a warning, a so-called black-box warning, which basically tell doctors and the public that these drugs have a slightly increased risk of some suicidal thinking and feeling during the first 4 to 6 weeks of treatment, that that risk, compared to the risk of the untreated disease, is so small that, on balance, it's much, much better to treat depression. The real risk, the real killer in this story, is untreated depression, and I'm so glad to hear this story in the sense that, you know, he learned - you know, the family had a hard time coming to terms with this, and I think a lot of people don't really understand that depression is a disease. It's not the same thing as everyday unhappiness. Depression is a lot more than just feeling sad.
CONAN: John, thanks very much.
JOHN: Thank you.
CONAN: And good luck to you. Another point, Dr. Rosenthal, that he brings up. There are a lot of people who also think that these are drugs that are overprescribed. That they're given away too freely, and, in fact, we are overmedicating a lot of kids.
Dr. ROSENTHAL: Yes. I found John's story very poignant. And, because I don't think medicines necessarily have to be the first resort, but they certainly shouldn't be a last resort. I think that the initial attempt to get some psychotherapy, to talk about it, to see if it resolves by itself was a reasonable thing to do because there are different kinds of depression. Some are situational and will clear up, some are recurrent, some are chronic, etc., etc.
There are many different kinds, and they may call for different kinds of treatments. However, when the therapy didn't work and didn't get him to sleep, that was when, I think, immediately something might have been done differently by way of introducing the medicine sooner, rather than later.
And I think still, too frequently, there's a sort of dichotomous way of thinking in psychiatry, that, you're either going to give medicine or give therapy, but cognitive behavior therapy, particularly, has been found to be extremely effective in depression. But, when you combine it with an antidepressant, you get an even bigger boost. So I think that we need to understand that some people have got this core, biological predisposition that may require medicine, and that medicines and therapy do not rule each other out.
CONAN: Let's talk with Melissa, Melissa calling us from across the bay in Berkeley, California.
MELISSA (Caller): Hello. Hi. Thank you for having me on the line.
CONAN: Go ahead.
MELISSA: Well, I'm calling because, actually, I myself have never been depressed, but my little sister was, or is. I'm not really sure because the distinction you just made between chronic and situational depression is really significant in her situation. I think that she was depressed, and it took a long time for our family to realize what that meant and, for me in particular, to just understand.
Why can't you get out of that? Why can't you go to school? Why aren't you eating? Just do it. And once you, as a family, sort of start to understand, OK, this is something that is really chemical. It's an imbalance in her head, and she does need the medicine, then we became more accepting of her need to go on antidepressants.
However, my concern is multifold. One is, how do you know when it's situational versus chronic? And the concern that there might result a psychological dependence on the medication because you become afraid of who you are without them. And, at the same time, she's highly, highly intelligent. She studies psychology, is very aware of how these drugs work, and what her illness means to her, and how it influences her behavior. And she is constantly worried that, A, what happens if I go off of them? But also, who am I really? And am I an OK person if I'm not on these drugs? Can I survive if I'm not on these drugs?
And it's very difficult to know how to guide her, and, even listening to this conversation, part of me wants to say, you should tune in and listen to this and part of me wants to resist from doing that because I don't want to add to more questions about whether or not who I am on these drugs is who I really am. I know she asks herself that constantly.
CONAN: Dr. Friedman, this seems to be one of the things that you were writing about.
Dr. FRIEDMAN: I think the thing in this case that is so puzzling is the issue of what happens when people are depressed and the dichotomous way of thinking about depression. You know, there are lots of depressions that occur in the setting of a stressor and that occur because of a situation that makes a person very unhappy.
And, when that happens, the temptation is to think that the treatment has to be just psychological because there's something that triggered it. Sometimes there are depressions, very, very serious depressions that occur even in the absence of any stress at all. But I think the thing that's important to remember is that, once you develop the syndrome of depression, in a sense, regardless of how you got there, there are certain things that help. Talk therapy helps. Medication helps.
In general, if the depression is more mild or moderate, it's very hard to show that any one particular treatment is better than another. But, in general, the more severe the depression becomes, where there is a disturbance of sleep and appetite, and there's suicidal thinking and a complete loss of self esteem, then it's very important to start thinking about biological treatment.
And I think the issue that you raise, a lot of people are concerned about, Melissa, which is, if you start taking an antidepressant, and you feel better, does that mean you become dependent on it? In a sense, we know that antidepressants are not just effective in treating depression acutely, that is getting people to feel better, they are also very effective in preventing relapses.
And depression is a chronic illness that's characterized by recurrences and relapses, and the question of how long someone needs to stay on an antidepressant to remain well really depends on their individual history. And, in some cases, depression is very much like hypertension. That is, if you stop the antihypertensive that keeps your blood pressure normal, it just pops right back up into a range which could be harmful to you, and some depressions are like that.
CONAN: Well, Melissa, we wish your sister the best of luck.
MELISSA: Thank you. Me, too. Thanks for your help.
CONAN: Yeah, I bet you do. Bye-bye. Let's go now to Lauren, Lauren calling us from Syracuse, New York.
LAUREN (Caller): Hi, how are you?
CONAN: Good, thanks.
LAUREN: Good, OK. My comment is basically that, I've been depressed now for about 13 years, some of it situational, some of it related to stressors, this on medication, off medication. This current particular bout that I'm in has been incredibly stressful and a lot longer than I'm used to. And I went from one medication, and I went to a stronger medication.
And then, recently, after I came back from vacation and I was feeling pretty good both at work, at home, after vacation, and the fact that I didn't have the money to fill my prescription, I went off my medication. And it's been about a month, and recently, I realized how important it was to be on it.
I went off the medication and was OK for a few days, and then I just started getting more agitated, more irritated, couldn't sleep well, couldn't get out of bed, and then, finally, the other day, I just had it, broke out the credit card, filled the prescription. And now that I'm back on it, just knowing that when I'm on it, my functionality increases so much, I feel a lot better being back on the medication.
CONAN: And did you have any of those questions that Dr. Friedman was talking about, about questions about who am I off this medication? Might I be a better or more interesting or, or, well, you know, might I have benefited somehow from the pain when I was growing up? Am I getting off easy, letting myself off easy?
LAUREN: Well, fortunately, I've had the experience of being able to be off the medication. My bouts of depression have been three bouts. The first two were about six months to a year over a 13-year period. So I know who I am when I'm off the medicine. I know what life is like. How I can function. How I feel.
And this particular time around, you know, my father passed away last year, it has a significant, you know, is a significant aspect of my current depression. So when I'm off of it, I don't know who I am because the medicine brings me to a level where I can function. I can be the Lauren that I know that I am, and that I know that I have been.
So, in my particular experience, this time around, I need it. I'm confident that I will be able to, you know, exercise, eat better, and the situation will improve. And I'll be able to, you know, surface from this bout of depression, but right now, I can't get out of bed without it. I've got to take it. If I don't take it every morning, I'm struggling. And especially because recently I went off the medication, it was so enlightening to see how important it was to take it.
CONAN: Lauren, thanks very much for the call and good luck to you.
LAUREN: Thank you. Thank you for your time.
CONAN: Bye-bye. We're talking with Dr. Norman Rosenthal and Dr. Richard Friedman about growing up on antidepressants. You're listening to Talk of the Nation from NPR News. Dr. Rosenthal, I was wondering, you listened to that last call, and how important it is to be able to have it when you need it.
Dr. ROSENTHAL: You mean the medications?
Dr. ROSENTHAL: Oh, sure. You know, it's really intriguing. And, in listening now, we've heard from Jill, from John, from Melissa, and from Lauren, and, in all these people, we've heard how the medications have turned their lives around. And, in several cases, we hear how, when they go off the medications, the depression relapses. And then they go back on, and they feel better.
I think, as a practicing psychiatrist, and I'm sure Dr. Friedman will agree, we've just seen this again and again and again. People going on, off, on, off, in a sense being their own experimental design. And then you see how these many double-blind studies come up negative, and you really realize that something's going on with these double-blind studies, why they're not coming up positive more frequently, given how successful these drugs are in the field.
So I know that these double-blinds are the gold standard, and, of course, we have to abide by that because that's our scientific yardstick. But I think that this field experience with the antidepressants is really worth something, and I think, somehow, we're just not capturing it adequately in our experimental design.
But there are two more things that I just wanted to comment on. The first is, quote, "situational depression." I think one should be very leery about blaming the depression on a situation because situations are always coming up. And a depressed person will always find a reason to be depressed, which may really not be the reason, but it may just be the way that person is interpreting reality, through the dark glass of the depression.
And finally, I do really agree with Dr. Friedman about this alleged dependence on antidepressants. A little bit like the way they used to think that spectacles would make your eyes weaker, and that, if you didn't use them, your eyes would be stronger. And there's really no data for that, and I think the same applies to antidepressants.
CONAN: And Dr. Friedman, let me ask you - end with you by asking you the same question you sort of asked yourself in your op-ed piece. What do I say to a depressed patient who's doing well after five years on such a drug but can't stop without a depressive relapse, and who wants reassurance that the drug has no long term adverse effects?
Dr. FRIEDMAN: Right. Well, I would say, I'm comfortable with the uncertainty, and I would say the following. That we know with such certainty, such clarity, the devastating impact of depression on people's lives, that there's no question that, if this medication has helped you, it's going to continue to help you, and you should continue to take it.
CONAN: Doctors, thank you very much for your time today. We appreciate it.
Dr. ROSENTHAL: Thanks very much.
Dr. FRIEDMAN: Thank you.
CONAN: That was Dr. Richard Friedman, professor of psychiatry at Weill Cornell Medical College, with us from our bureau in New York, and Dr. Norman Rosenthal, the medical director of the Capital Clinical Research Associates, who joined us from member station WAMU here in Washington, D.C.
Up next, our every-other-Thursday visit with "Ask Amy's" Amy Dickinson. With so much talk about politics around the office water cooler this week, she'll give us some tips on surviving the campaign season at work.
If you'd like to join that conversation, if politics has been raging in your office lately, give us a call, 800-989-8255, or drop us an email, email@example.com, and you can check out what other listeners have to say on our blog at npr.org/blogofthenation. I'm Neal Conan. Stay with us. It's the Talk of the Nation from NPR News.
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