Doctor's supervision key with antidepressants

Medical Matters

May 11, 2007|By Judy Foreman | Judy Foreman,Special to the Sun

How can I decide whether to take antidepressants?

Untreated depression is a terrible disease, and antidepressants help millions of people. But they should be taken under tight medical supervision, said Dr. Alexander Bodkin, chief of clinical psychopharmacology research at McLean Hospital in Belmont, Mass.

During the first few days of taking an SSRI-type antidepressant, many people feel intense agitation, even panic.

This is actually "a sign that the SSRIs are on the way to making you better," Bodkin said. But precisely because these feelings can be so scary, it is important for doctors to stay in close touch with patients and for patients to report any distress immediately.

Despite anecdotal reports of adverse reactions to antidepressants in children and adolescents, particularly with SSRIs such as Prozac and Zoloft, there are actually no cases of related suicides in all the pediatric clinical trial data that the Food and Drug Administration reevaluated in recent years, said Dr. John Mann, professor of psychiatry and radiology at Columbia University and director of research for the New York State Psychiatric Institute.

In a 2004 report, the FDA noted that spontaneous reports of suicidal thinking and nonfatal suicide attempts occurred at the rate of about 4 percent in young people taking antidepressants, and only 2 percent in those taking placebos.

For this reason, the FDA made manufacturers put a "black box" warning on antidepressants for people up to age 18. But even during this time, noted Mann, "nearly all the suicides in children and adolescents were in people NOT taking antidepressants."

New figures from the Centers for Disease Control and Prevention show that in the months after negative stories about antidepressants first came to light, the number of youth suicides actually went up -- from 1,601 in 2003 to 1,828 in 2004 -- after many years of declining numbers. This rise in youth suicides parallels a 20 percent drop in antidepressant prescriptions, Mann said.

Is estrogen taken through a skin patch or gel safer than pills for postmenopausal women?

Probably, at least in terms of minimizing the risk of blood clots, according to a new study called ESTHER, published in February in the journal Circulation.

The French researchers in this study looked at 271 women ages 45 to 70 with deep vein blood clots and 610 women without them.

Scientists correlated their risk with whether they used hormone therapy and if so, whether they used oral forms or types delivered through the skin.

They found that oral hormone users had four times the risk of blood clots, compared with non-hormone users and those using transdermal preparations.

"The study is important," said Dr. JoAnn Manson, chief of the division of preventive medicine at Brigham and Women's Hospital in Boston and author of Hot Flashes, Hormones and Your Health. It adds to the mounting evidence that the route of administration of estrogen matters, at least in terms of the risk of blood clots.

This study did not address whether transdermal estrogen might offset other risks of oral hormone use, such as an increased risk of breast cancer or stroke. So far, there haven't been large-scale studies to assess these other risks.

A different study that looked at hormone pills, not patches, published in April, suggested that starting hormone therapy right at the beginning of menopause, as opposed to many years later, does not increase the risk of heart attacks, as a landmark 2002 study had suggested.

In general, estrogen taken orally passes first through the liver, where it can increase the synthesis of clotting proteins, inflammatory markers and have other effects.

The advantage of medications delivered through the skin is that they do not pass through the liver en route to the bloodstream and hence have minimal effects on the liver's metabolism.

A new, continuing study called KEEPS is also comparing oral estrogen with the patch, as well as evaluating progesterone (Prometrium) to determine the effects of the hormones on plaque in artery walls, memory and cognitive function, blood-clotting factors, glucose and lipid levels and other variables. The study is still recruiting patients who are within three years of the onset of menopause. Go to or call 617-732-9870) for details.

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