When patients want feel-good medicine

Ethics Forum. June 4, 2007.

How should physicians respond to requests for mood-altering drugs?

The request for antidepressants by patients who don't meet the clinical diagnostic criteria is remarkably common. Patients may request these medications for improvement of mood symptoms, work performance, academic performance or social performance. What is the ethical response?

Reply:

The question about prescribing antidepressants for individuals who do not meet strict clinical criteria for a depressive illness comes at a time of close scrutiny of prescriptions for off-label use of medication in general, and psychotropic medications in particular.

On the one hand, there is concern about the influence of pharmaceutical-company money and marketing on prescribing practices, especially where evidence of medical efficacy is thin. On the other hand, there is decreasing stigma for antidepressant use, increasing rates of antidepressant prescribing and extended indications for certain antidepressants in the treatment of, for example, anxiety disorders, smoking cessation, and specific types of pain. Consequently, the number of people who have ever taken an antidepressant has grown. Many may have had exposure to an antidepressant for one indication -- for example, smoking cessation -- and found corollary benefits, such as an increase in energy and concentration. They may want to continue even after the initial indication for the medication has resolved.