On the difficulties of defining a drug by its danger

A recent display in the campus center lobby involving recreational drugs has stirred a range of responses among Allegheny students, from the tepid to the irate. The display presented short blurbs on several pharmaceuticals one might hypothetically expect to encounter among adults: alcohol, tobacco and marijuana, familiar fare; ecstasy and heroin, perhaps not as prolific, but still endemic; and, to the surprise of many, antidepressants.

“Messing with your mood can be a messy affair,” the sign read. “People taking antidepressants often develop a dependency on the drug, which opens them up to sleep problems, irritability, and sexual dysfunction.”

Tautological puns aside, the information is not necessarily inaccurate. (More on that in a bit.) What irked students’ sensibilities seemed to be the inclusion of a prescribed drug for a symptomatically identifiable clinical disorder among what essentially amounted to a basic know-your-college-risks PSA.

Chris Sexauer, a former Allegheny student, posted an image of the antidepressants section of the display to the college’s Facebook page.

Sexauer wrote, “By including antidepressants in your (hilariously misinformed) presentation of recreational drugs, you have explicitly placed myself and any other member of your community that is or has been prescribed antidepressants as drug-seeking individuals. In simple terms, you equate the psychiatric use of medications with ‘getting high.’”

Below the post, several commenters expressed similar sentiments.

According to a CDC briefing from 2011, as of 2008 roughly 11 percent of the United States population over the age of twelve takes anti-depressants. In contrast, according to the National Institute of Alcohol Abuse and Alcoholism, 86.8 percent of people ages 18 and over reported that they consumed alcohol at some point during their lifetime. In 2014, nearly 16.8 percent of U.S. adults smoked cigarettes (as per a CDC survey). And the 2011 World Drug Report put out by the United Nations gauges marijuana use in the United States at about 13.7 percent (this, of the total population—the percent would likely be inflated if we cut out everyone under 12 years old out of the denominator).

Prevalence is not the same as potency, however. According to the National Survey of Drug Use and Health, only 6.6 percent of people ages twelve and older have admitted to using ecstasy in their lifetime. Of the same age group, according to the same source, as of 2011, heroin use clocks in at (a relatively paltry) 1.6 percent. These drugs are orders of magnitude more lethal than the aforementioned consumables; no one would deny the dangers imposed by them based on usage rates alone.

How jarring, still, must it have been for the students who use antidepressants as a tool of mitigation over a medical quandary listed among the causes of liver disease, lung cancer, overdose and death? By raw probability, extrapolating rate of use from the CDC-surveyed estimates, some 200 of the (ballpark) 1800 students that attend Allegheny take prescription antidepressants. And I have a hunch that access to higher education and access to better medical care are at least correlated, meaning that the above estimate is likely a conservative one.

Still, it is worth considering that perhaps the sign did not mean to indict antidepressant use as morally reprehensible, or as recklessly puerile, but simply that one needs to take physiological considerations as well as psychological ones.

According to the aforementioned CDC report, in the interval between 1988 and 2008, antidepressant use among people ages 12 and up has increased by 400 percent. (Whether this percentage referred to a proportion of the population, or a proportion of total prescriptions written, accounting for dosage, etc. was unclear.)  This, according to Julia Calderone, author of “The Rise of All-Purpose Antidepressants,” a 2014 article in Scientific American can be attributed to a certain class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs). According to the article, pharmaceutical companies pushed for FDA approval for the use of SSRIs for a wide range of ailments in the early 2000s.

Though many drugs’ patents have expired, and funding for studies for official approval has slowed, doctors continue to prescribe SSRIs for a host of things beyond Major Depressive Disorder including, but not limited to, anxiety disorders, bipolar disorder, obsessive-compulsive disorder, premenstrual dysphoric disorder, arthritis, panic disorders, migraines and premature ejaculation.

So how exactly does this putatively wonder-drug work, and what are the possible physiological consequences that the display putatively wanted to warn against?

Consider the three claims listed on the display: sleep problems, irritability and sexual dysfunction.

A 2001 review published in the Primary Care Companion of the Journal of Clinical Psychiatry examined the physiological causes behind the most common SSRI side effects, which include sexual dysfunction, weight gain and sleep disturbance.

According to Andrew Winokur, MD & PhD, and Nicholas Demartinis, MD, in an article for the Psychiatric Times titled “The Effects of Antidepressants on Sleep,” SSRI therapy often causes more frequent awakenings and arousals, and suppresses REM sleep, decreasing overall sleep efficiency.

Similar sleep disturbances, according to Winokur and Demartinis, can be caused by monoamine oxidase inhibitors, tricyclic antidepressants, and selective serotonin-norepinephrine reuptake inhibitors.

Other antidepressants, including some pharmacologically distinct TCAs, trazodone, nefazodone, mirtazapine and buproprion have been found to have positive effects, including decreased sleep latency (the time it takes to get from full wakefulness to sleep) and increased REM sleep.

Concerning one’s sex drive, according to WedMD, between 20 and 45 percent of SSRI users report less sexual activity, and both men and women may experience a decreased ability to orgasm (or a diminished intensity thereof).

The “irritability” claim of the display may stem from one of the many unpleasant effects of discontinuing SSRIs. Roughly 20 percent of people who stop taking SSRIs report some form of malaise. According to PsychCentral, reducing or ceasing any dosage of SSRIs may induce flu-like symptoms, including headaches, dizziness and irritability. Whether the latter is itself a symptom of withdrawal, or simply engendered by the nature of the other symptoms, or (worst-case scenario) a relapse of depression, is unknown.

So the symptomatic claims made by the display stand up to scrutiny. Still, the possible side-effects of a clinically prescribed drug are best discussed between doctor and patient. I think it reasonable to assume, however, that the display was not targeting patients of depression who follow a controlled treatment schedule. Rather, the disclaimer was likely aimed at anyone who has not sat down with a professional psychiatrist—anyone who may simply wish to give a couple pills a try to ease their January blues.

According to a study by the Center on Young Adult Health and Development, 61.8 percent of college students are offered prescription stimulants, such as Adderol or Ritalin, by their peers, and 31 percent admitted to having used them. Could not a student similarly find themselves offered prescription antidepressants for “nonmedical” purposes?

No research appears to have been done on the nonprescription abuse of antidepressants, specifically.

Unlike the anti-anxiety medication Xanax, which produces immediate effects, antidepressants take several scheduled doses to take effect. According to England’s National Health Service, antidepressants typically take a week or longer for the effects to become noticeable. Mayo Clinic’s website explains that SSRIs, specifically, may take many weeks before the effects on mood become noticeable.

Furthermore, while SSRIs are not addictive sensu alcohol, tobacco et al., they can cause a physical dependency after long-term usage that may produce the above-mentioned physical symptoms after stopping medication.

If one were tempted to pinch a pill or two from a friend, therefore, the matter would be a useless gesture, particularly if the pills were pinched only to combat quotidian stress of a college student.

But could such a gesture be fatal? According to Medscape, the 2013 Annual Report of the American Association of Poison Control Center’s National Poison Data System listed 2.2 million toxic exposures which resulted in 2,113 deaths. Of these, antidepressants were involved in 4.2 percent of all exposures (being the fifth most cited class of toxicity in the report).

Antidepressants themselves become a hazard for overdose when they are involved in unusual combinations: according to RxList, an online drug index, SSRIs and MAOIs should not be used alongside other compounds that may increase serotonin levels in the brain, notably, other antidepressants. St John’s Worts and amphetamines should also be avoided.

Mayo Clinic lists several unpleasant (but not necessarily fatal) interactions between alcohol and MAOIs, the worst of which is a dangerous spike in blood pressure. Fatalities, according to NPS Medicine Wise, a nonprofit informational organization, result from combining antidepressants with ecstasy, cocaine, amphetamines or LSD.

All things considered, antidepressants seem pretty tame compared with the other scheduled drugs appearing on the display. But that should never—NEVER—be an excuse for anyone to experiment with any pharmacological compound.

The abovementioned generalizations are just that—they apply to the general populace of antidepressant users who are on a controlled treatment plan with a psychiatrist. I will agree with the purpose of the display to this extent: no one should approach this class of drugs without receiving the requisite diagnosis and prescription from a trained professional.

I do not think this display meant to equate the dangers of antidepressants with those of, say, ecstasy. I think instead it purposed to display a spectrum of controlled substances: on the one end, the truly perilous, for which no prescription may be written, and no justification may be had in taking them for anything other than a solipsist “high.” On the other end, relatively innocuous, commonly prescribed medications that still have dangerous potentials if not used as advised. Nothing about this presumption, by the way, insinuates that clinically depressed persons take antidepressants for a “high.”

In the middle falls the semi-recreational, semi-medicinal, ever-controversial marijuana. As of writing this, cannabis use is legal in 23 of these United States; metaphorically and literally, it is the half-way point between SSRIs and cocaine.

The inclusion of antidepressants was awkward; the informative section of the display, far too short. Brevity may be the soul of wit, but an explication never hurts.