To a psychiatrist, the idea of selling Prozac or Lexapro over the counter seems unthinkable. These medications, after all, carry a black box warning, and their adverse reactions can include the induction of mania as well as a usual laundry list of side effects.
Furthermore, used alone as a one-shot attempt to treat depression, they are not terribly effective. A trial of a single antidepressant will be effective about 30% of the time – about as often as a placebo – and it’s not until we try switching or augmentation strategies, or adding psychotherapy as part of comprehensive treatment, that we begin to see more robust success rates in the treatment of depression. Finally, there is the risk that a lay person might misdiagnose sadness or demoralization as depression and inappropriately treat himself.
With so much that can go wrong, why would I even ask such a provocative question?
So let me play devil’s advocate for a moment. We live in a country where 40,000 people a year die of suicide, and countless others are impaired or disabled with respect to their occupations and relationships because of depression and anxiety. And then there are those who are able to hide their symptoms, but live with psychic torment and suffering.
If you believe that the morbidity and mortality of psychiatric illness can be prevented with appropriate treatment, then you’re left to ask why people don’t get treatment for their psychiatric illnesses. The political mantra is that people don’t seek care because of stigma. Advocates for those with severe mental illnesses contend that people don’t seek treatment because they don’t believe they are ill. And then there are the difficult realities: It can be very hard to find a psychiatrist or even a nonphysician therapist. According to Dr. Thomas Insel, the former director of the National Institute of Mental Health, half the counties in this country have no mental health professionals at all. And while medical care of any type is expensive, psychiatry can be even more so in terms of out-of-pocket costs, because 45% of psychiatrists don’t participate with health insurance networks, compared with 89% of other physicians. Finally, some patients have had bad experiences with psychiatrists, or with the treatments that have been offered, and they are not open to the idea that there is a better experience to be had. So stigma, access to care, awareness that one has an illness, cost, and prior negative experiences all are deterrents to getting mental health treatment.
As it stands, most psychotropic medications are prescribed by primary care physicians. I don’t know what constitutes a psychiatric evaluation in these settings, but it’s not unusual for a patient to be given a year’s supply of medication without referrals for psychotherapy. I also don’t know how closely primary care physicians and nurse practitioners monitor patients, or if they warn them of the risk of mania or suicidal impulse. If medication trials are unsuccessful, or only partly helpful, do primary care physicians know how to switch and augment these agents? I’m sure this depends on the individual clinician, but chances are that some patients who seek treatment for psychiatric conditions are not treated adequately. Presumably, there is some evaluation and monitoring, and the patient has a prescriber to call if something goes wrong, so this is a better scenario than letting the patient pick up a bottle when she goes to buy deodorant.
The antipsychiatry lobby would howl at the idea of offering antidepressants over the counter. They would contend that selective serotonin reuptake inhibitors cause violence and disability, and such a move would cause the rates of suicide, homicide, and mass murders to soar. And those who feel that psychiatry has overextended its arm to embrace normal human reactions and sufferings such that every discomfort calls for a pill would be appalled at the idea that people could be self-diagnosing and self-treating either transient distresses or serious mental illnesses.
So what would be the upside to having over-the-counter SSRIs? For starters, if you believe that medication alone constitutes treatment for depression – and certainly it does for some people – then it would allow people with no access to at least begin the process of getting treatment. It also would allow people to begin medications anonymously, without concerns for stigma or the consequences of being identified as a psychiatric patient. Certainly, if medications were available over the counter, there would be a percentage of people who would take them and get tremendous relief from their symptoms. The question would be whether the good done for some would outweigh the harm done to others.