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Most antidepressants are now prescribed by primary care
physicians, whose patients may never see a psychiatrist, because of
concerns about cost or the perception of stigma attached to mental
illness. Prozac, Paxil and other modern antidepressants became
hugely popular in part because drug companies convinced family
physicians that they were safe enough to use without a
psychiatrist's intervention. Antidepressants are the third biggest
selling category of drugs in the world behind cholesterol and
heartburn pills.
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Some psychiatrists speculated yesterday that their family-care
colleagues might lose confidence in the drugs and become reluctant
to prescribe them.
"We're hoping that doesn't happen, because primary care
physicians have a major role to play in combating depression," said
Dr. James H. Scully Jr., medical director of the American
Psychiatric Association. "We hope they won't be scared off."
Dr. Robert Lee, a San Francisco physician of holistic medicine
who sometimes prescribes antidepressants, said: "I don't think
people already taking them will be concerned. But a lot of people
who I think would benefit from these meds already won't take them
because of various stigma reasons, so I'm a little concerned that
this will raise that barrier even higher."
Dr. Lee said the new warning would not make him hesitate to
prescribe the antidepressants.
He said, "People can get agitated from them, but I've never seen
somebody get suicidal from them."
Dr. Joseph Gonzalez-Heydrich, chief of psychopharmacology at
Children's Hospital Boston, said: "I've heard anecdotally that a lot
of antidepressants were being prescribed by pediatricians without a
lot of training or experience. I think the warning is appropriate.
If it makes prescribers more vigilant or parents more vigilant,
that's a good thing."
Dr. Gonzalez-Heydrich said that a sizable minority of children
became more agitated and irritable on the antidepressants in
question. "If we see it, we take them off it or reduce the dose," he
said. "Doing it that way there are a lot of kids we feel do benefit
from these medications, especially long term. But they're not for
everybody."
Dr. Harold Koplewicz, director of New York University's Child
Study Center, said, "The fear I have about this warning is that many
teenagers will not get the medicine because it will build resistance
among their parents, and that's really a tragic outcome." He noted
that suicide rates in teenagers had gone down in the United States
and Sweden as use of the drugs increased.
Several primary care doctors said that they had prescribed
antidepressants with success for so many years that it was unlikely
the F.D.A.'s new warnings would lead them to stop. Still, the
warnings have given them pause, they said. They may think a bit
harder before prescribing them to patients who are simply stressed,
they said. And they will watch how the warnings play in the legal
field, some said.
"We're going to continue to use these drugs pretty freely until
we start seeing the ads in the newspapers from lawyers saying, `Have
you or your family member been prescribed these drugs? If so, you
may have a case,' " said Dr. Phillip Kennedy, a family practice
physician in Augusta, Ga. "When the big L word, liability, raises
its ugly head, that's when things will really change."
Spokesmen for drug companies said that they would emphasize to
physicians that the F.D.A.'s warning did not conclude that
antidepressants cause suicide. "My hope is that people won't make a
link with the drugs," said Jennifer Yoder, a spokeswoman for Eli
Lilly & Company, maker of Prozac. "I think the message will be
that suicide is an inherent part of the disease of depression, and
physicians should carefully monitor their patients."
Critics of the medicines said the F.D.A.'s warning was long
overdue.
"These warnings are not as strong as I would like, but they're an
important first step," said Tom Woodward of North Wales, Pa. Mr.
Woodward's teenage daughter, Julie, hanged herself six days after
starting therapy with Zoloft.
David Tuller and Terry Aguayo contributed reporting for this
article.
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