SSRI antidepressants: their place in women’s lives
Written by Diane Saibil in collaboration with Women and Health Protection,
with thanks to Janet Currie and Peggy Kleinplatz for their helpful comments.
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.
Why are so many SSRI drugs prescribed for women?
There are a number of reasons for the widespread use of SSRI antidepressants by women. One 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.
The expanding definition of depression
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 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, 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 and 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.
Do SSRIs cause harm? 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 effects already documented are:
- agitated depression (that can lead to suicide);
- sexual problems (see box for more details);
- effects on pregnancy and newborns;
- gastro-intestinal problems such as stomach pain, dry mouth, nausea, weight loss or weight gain, and vomiting;
- agitation, extreme restlessness, and muscle spasm.
Many of the clinical trials conducted to evaluate the SSRIs lasted only six weeks, with relatively few lasting up to six months or, occasionally, a year. As a result, there are limits to what we know about the harms they cause. By contrast, patients often take SSRI antidepressants for much longer periods of time, sometimes for years.
Are SSRI antidepressants addictive?
People taking SSRI antidepressants find it very difficult either to reduce their dose or eliminate the drug completely, a phenomenon described in detail by various authors (see For more information below). The main problem 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 drug use. As a result, many people continue drug therapy indefinitely, thinking they need it, sometimes with an increased dose 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 with 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.
Are there alternatives to SSRIs?
If a person does need treatment, psychotherapy, also referred to as “talk therapy”, is a well-known alternative. Talk therapy has been found to be at least as effective as, and sometimes more effective than, antidepressant drugs. When researchers have followed patients for a year following treatment, they have found that patients treated with psychotherapy have fewer relapses than those treated with antidepressants. (See “The Myth of the Magic Pill”, listed in For More Information below.)
A range of health care and social service professionals in different settings are trained to provide psychotherapy and counselling. While some are covered by government health insurance, other options are only covered by private insurance plans, and often in a limited way. This spotty coverage can be a factor leading to more prescribing of SSRIs by physicians who are paid through government insurance.
A regular regime of exercise can be an effective treatment for depression and anxiety. For example, in one three-year study, people who had been diagnosed with “mild to moderate major depressive disorder” experienced significant improvement after a twelve week cardio-vascular exercise program. Exercising three times per week, as long as the exercise was vigorous enough (as defined by a public health standard), was sufficient to achieve this effect. While an exercise regime may not be a realistic choice for everyone, it is an option worth exploring where possible.
Alternatives to taking SSRIs can be found, not only at the level of the individual, but also at a 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”. Making the necessary societal changes is beyond the capacity of each of us as individuals, although 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.
Alternatives such as exercise programs and talk therapy may take longer or more effort to show results, but they cause no harmful side effects and are more likely to get at the cause of the depression; and if an exercise regime becomes habit-forming, that’s an added bonus, since it may also improve other aspects of one’s health.
Other alternatives that some people have found helpful include mindfulness meditation, light therapy and dietary change.
If your doctor suggests an SSRI antidepressant...
Some women go into their doctor's office expecting a prescription for an SSRI antidepressant. Sometimes the prescription is completely unexpected. Since SSRIs entered the market, medical practitioners have been encouraged by the manufacturers and through their own professional organizations to look for signs of depression and anxiety in their patients. As a result, SSRI antidepressants are prescribed in many circumstances where they may not be necessary. It is worth thinking about whether a prescription for an antidepressant drug is what you really need. If a medical practitioner suggests an SSRI prescription, you might want to ask her or him:
- What exactly are you being treated for?
- Why is this particular treatment being recommended? Are there data showing that it is effective for your particular problems?
- What are the risks of taking this drug?
- For how long are you likely to be taking the drug?
- What alternatives to drug therapy are there?
- What can be expected if you don’t take the drug?
If you are taking an SSRI and want to stop
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 many others. Experiencing these symptoms while withdrawing from a drug is not necessarily a sign of illness.
* Although Effexor is not technically an SSRI, it is part of a related class of dual-action SSRIs. The information in this fact sheet applies equally to Effexor and others in its class.
SSRIs and sexual relationships
SSRI antidepressant use can have a negative impact on sexual desire, arousal, and orgasm. These effects appear to be especially severe in women who take an SSRI while using some hormonal contraceptives. What is particularly worrying is that the adverse affects may not end when a woman stops taking the drug. The effects appear to take a long time to wear off and may have a long-term impact on sexual functioning. As noted by Janet Currie, a writer on this topic, “Because SSRI use can lead to a worsening of depression, emotional blunting or detachment, reduced emotional activity, memory loss and confusion, these effects, in conjunction with sexual dysfunction, can negatively affect intimate relationships.”
Adolescent use of SSRI Antidepressants
No antidepressants are approved in Canada for persons under 19 years of age. In the US, there is one antidepressant approved for those aged 8 years and over, but it comes with a strong warning about the potential for serious adverse effects, including becoming suicidal. As pointed out in the Therapeutics Initiative Newsletter (Spring, 2004), there is little evidence that SSRI use with adolescents is effective and increasing evidence that the drugs can cause substantial harm, including suicidal thoughts and gestures, hostility and aggressiveness. Nevertheless, these drugs are prescribed for adolescents at an increasing rate. Before agreeing to drug therapy for adolescents in their care, women may want to consider supporting the adolescent to improve sleep habits and diet and get regular exercise, as well as through consistent parenting and assistance with practical problem-solving about school and other stressors.
FOR MORE INFORMATION
The Marketization of Depression: The Prescribing of SSRI Antidepressants to Women, by Janet Currie, on the website of Women and Health Protection, at www.whp-apsf.ca. Hard copies are also available.
The Antidepressant Solution, a step-by-step guide to safely overcoming antidepressant withdrawal, dependence and addiction, by Joseph Glenmullen (Simon & Schuster, 2005).
The Myth of the Magic Pill, by Barry Duncan, Scott Miller and Jacqueline Sparks, at www.talkingcure.com/reference.asp?id=66
Women and Health Protection is financially supported by Health Canada. The views expressed herein do not necessarily represent the views of Health Canada.
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