Today there is another rather lousy article about depression and the use of anti-depressants in the Los Angeles Times. They report there is a drop in the use of anti-depressants over the past year.

First came the warning of a possible link between selective serotonin reuptake inhibitors and suicidal thoughts among children and adolescents. Then came a drop in sales — 14% last year compared with the year before. Now research has found that a single medicine typically does not effectively treat depression for most people and that those with depression often stop taking the medicines altogether.

The change is probably correctly attributed to the warnings of suicidal behavior with children and adults. This news and the type of articles I've been finding in the press about depression is spreading a lot of misinformation. Despite that, it is probably good news that the use of anti-depressants has dropped. It's been clear for awhile that many people who had a less than clinical level of depression have been prescribed anti-depressants. Most treatment of depression is by family physicians.

As Medpundit, a family physician puts it:

This is one of the reasons healthcare is as expensive as it is. We spend money trying to smooth away every little wrinkle in life. Grouchy wife or mother? An anti-depressant will even out your moods. Angry young man? Prozac will make you happy. Or at least, it will make you not care.

She also notes that she'd gladly refer all of her depressed patients to psychiatrists, but there aren't enough of them around.

Buried in the middle of the LA Times article is one statement that seems to be missing in most discussions about anti-depressant medication in the press. Researchers have been telling us for many years that clinical depression (not the "blues") is best treated by anti-depressants and psychotherapy. But psychotherapy requires an investment in time and determination to solve the problem. As Dr. Baker of Mental Notes explains:

Lots of folks dont want to pay for psychotherapy -- and neither does their insurance company -- although with a competent doc, this is much more likely to be the appropriate approach to the problems (and, to a lesser extent, the sadness) of everyday living. Partly this is due to the abundance of poor psychotherapy provided by under-trained clinicians going on out there, but I also think it represents a culture intolerant of delayed gratification, as well. And, intended or not, lots of folks have been persuaded by pharmaceutical marketing practices into believing that a pill is, indeed, pretty close to a cure-all.

I have a suggestion that I think could become a new standard of care for depression. I'd suggest that the indications for anti-depressants be limited to (1) those people who show neuro-vegetative signs of depression, especially significant sleep deprivation due to insomnia or sleep disturbances and a significant loss of weight due to loss of appetite, (2) a moderate or high risk of suicide as indicated by a lethal and available plan, and (3) after a course of psychotherapy of say six sessions produced insufficient improvement in functional impairments in relationships, productivity at work, keeping up with chores, etc, that the therapist refers the patient to their physician for a medication evaluation.

What does everyone think?