Fairy Tales are fictional short stories. In other words, fairy tales are made up. This blog is entitled ‘The Anti-Depressant Fairy Tale’ because much of what you ‘know’ about anti-depressants is made up. If you thought that low levels of serotonin caused depression, you’d be wrong. If you thought that anti-depressants cure depression, you’d be wrong. And if you thought that anti-depressants caused no major long-term harm, you’d be wrong. So indulge me for 10 minutes; let me tell you a story. But alas, this story is no fairy tale. This story is the truth.
In the early 20th century the medical profession made some important advances. Specifically, they managed to determine the specific biological abnormalities underlying prevalent illnesses. For example they figured out that Diabetes occurred due to high blood sugar levels. Once they had this information regarding the causes of the disorder, they developed medicine that directly targeted that biological system i.e. insulin lowers blood sugar levels. During this time researchers also developed a number of antibiotics (e.g. penicillin) that were designed to target specific biological systems in the treatment of scarlet fever, diphtheria and pneumonia amongst other illnesses. So far so good, Doctors had evidence as to what microbes caused illness and then they developed treatments to kill those microbes.
Then a funny thing happened. In developing these new treatments for medical illnesses, Doctors began to notice that some drugs had interesting side effects. Of specific interest in this story was the development of Isoniazid and Iproniazid. These drugs were designed and successfully used in the treatment of Tuberculosis. However Physicians soon began to notice that after taking these drugs their patients seemed to be ‘energized’ and some clients, who were previously bed ridden, were said to be ‘dancing in the wards’.
This prompted some doctors to believe that these drugs could be useful in nullifying the symptoms of psychiatric disorders. In the 1950’s anti-depressant drugs were introduced to the world of Psychiatry, not with the promise of curing depression, but with the aim of providing a tonic that would make the effects of depression less severe. Despite this, with no evidence as to the long-term effects of this class of drugs, it wasn’t long before anti-depressants were advertised as little magic happiness pills that could take away our blues (See David Healy’s “The Antidepressant Era” for the interesting tale of how this happened).
Let me break this down. With medical diseases they designed drugs based on evidence of what caused the illness. For example, they developed Isoniazid to kill microbes associated with Tuberculosis. Yet in psychiatric disorders like depression, we had the drug treatment long before we had any idea of what caused depression. Of course it was not long until people started asking this question but the answer was not easy to find. What psychiatrists did know was that anti-depressants tended to increase the amount of serotonin in the biological system. Therefore, in a backwards science fashion, they concluded that low levels of serotonin caused depression. This cued 50 years of developments in the multi-billion dollar anti-depressant industry. Incidentally the other commonly used term used to describe antidepressants; Selective Serotonin Reuptake Inhibitors (SSRI’s). For those of you interested in the science, SSRI’s work by blocking the reuptake of serotonin into the presynaptic cell, thereby increasing the amount of serotonin in the synaptic cleft available to bind to the post synaptic receptor. For those of you who want the take home message; SSRI’s increase the amount of serotonin in our biological systems!
Now here is where is gets real interesting. As of 2012, there is absolutely no evidence that people who are depressed have low levels of serotonin. Just read that again. For half a century we have been feeding people drugs designed to increase low levels of serotonin in order to cure depression, and yet people with depression don’t have low levels of serotonin. And don’t just believe me on this. The top Psychiatrists in the world have rejected the serotonin theory of depression on multiple occasions in the last 20-30 years (see the end of this blog for examples). I wonder how many of my friends know that. In fact, I wonder how many Medical Doctors who prescribe anti-depressants to depressed patients know that SSRI’s target a biological system that has nothing wrong with it.
But anti-depressants are not sugar pills that have no effect on our biological systems. Anti-depressants do indeed inflate the amount of serotonin in our bodies. The problem with this is that once our body realizes that we have excess serotonin, it tones down the entire serotonin system i.e. in attempting to return to equilibrium, the brain sends out signals telling our bodies to produce less serotonin. Researchers have found that over the course of time, these changes that occur in our biological system are very difficult, if not, impossible to reverse. In other words, anti-depressants may be causing abnormalities in normal biological functioning!
I guess knowing this information makes a couple of things unsurprising.
Firstly, if anti-depressants cured depression then we would expect the amount of disabled mentally ill to have decreased since the introduction of Prozac in 1987. And yet, between 1987 and 2004 the amount of people seeking disability in the US increased from 3.3 million to 5.7million, that is 410 new people every day!
Secondly, if anti-depressants cured depression then we would expect people who take anti-depressants to fare significantly better than those receiving a placebo sugar pill. But this is not what the research shows. Although short-term use of anti-depressants seems to cause little harm or gain compared to placebo (though we can experience physical dependence within 2-4 weeks), the long-term effects of taking antidepressants may be detrimental. Ironically, the exact pill that makes the promise of helping us to live better may function to restrict the way in which we live! One major example of this is the re-analyzed data from the infamous STAR D trial. The results showed that participants taking anti-depressants recorded only a 2.7% remission (recovery) rate, which is far worse than those who experience a natural un-medicated course of depression. Other research suggests that people who take anti-depressants are more likely to relapse, are more likely to experience a continuation of depressive symptoms, are less likely to return to work, are more likely to be on long term disability and are more likely to be incapacitated (see below for some interesting references).
So lets dispel this fairy tale right now;
1. Serotonin has nothing to do with depression.
2. Anti-depressants do not cure depression.
3. We don’t really know what anti-depressants are doing to our bodies but early indications suggest that they may be irreversibly altering our biological make up.
4. The long-term effects of antidepressants may be detrimental.
We get sold the story that scientists have spent many years developing this little magic pill for happiness. And we believe them because we don’t have the time to learn of these complicated things. And trusted medical professionals, who also don’t have the time to look into these things, usually corroborate this message which they may have learned at fancy five star lunches put on by Psycho-Pharmaceutical companies! But the actual evidence for the utility of anti-depressants is not representative of the confidence that we, as a society, have in these pills. We believe that SSRI’s kill depression in the same way that penicillin kills infection. But what is interesting about penicillin is that once the infection has disappeared drug treatment stops. And yet people who take anti-depressants tend to take them for the rest of their lives.
We all know why we have become so reliant on anti-depressants; everybody wants to be happy and taking a pill is far easier than seeing a shrink! And yet as a result of playing The Happiness Game in this way, or as a result of believing the Anti Depressant Fairy Tale, it is likely that people who take anti-depressants will end up far worse than if they would have taken no medication at all, and just waited for time to pass. I think it is time for people to have access to this information before they make any decisions regarding the use of anti-depressants.
Note 1: I am far from an expert on these things. However should you want further information then this extraordinary situation is superbly documented in the book “Anatomy of an Epidemic” by Robert Whitaker, finalist for the 1999 Pulitzer Prize for Public Service (see also http://en.wikipedia.org/wiki/Anatomy_of_an_Epidemic). I am also much appreciative to Dr. Rob Purssey for his help in putting together this blog.
Note 2: If you are currently taking anti-depressants then please do not come off them cold turkey. This is because if you have taken anti-depressants in the long term then it is likely that you have developed psychological and physiological dependence on them. Instead discuss potential options with a medical professional.
The Serotonin Theory of Depression?
“Although it is often stated with great confidence that depressed people have a serotonin or norepinephrine deficiency, the evidence actually contradicts these claims” Elliot Valenstein (Professor of Neuroscience, University of Michigan).
Elevations or decrements in the functioning of serotonergic systems per se are not likely to be associated with depression.” –NIMH.
“…there is no “real” monoamine deficit” Stephen M. Stahl (University of California, San Diego and Creator of The Neuroscience Education Institute).
“We have hunted for big simple neurochemical explanations for psychiatric disorders and have not found them” Kenneth Kendler (Professor of Psychiatry, Virginia Commonwealth University).
After more than a decade of PET scans measuring chemical depletion “There is little evidence to implicate true deficits in serotonergic, noradrenergic, or dopaminergic neurotransmission in the pathophysiology of depression.” Krishnan and Nestler, AJP
Other interesting sources
E.Weel-Baumgarten,“Treatment of depression related to recurrence,” J Clin Psychiatry & Therapeutics 25 (2000):61-66.
D. Goldberg. “The effects of detection and treatment of major depression in primary care.” British Journal of General Practice 48 (1998):1840-44.
C Dewa.“Pattern of antidepressant use and duration of depression-related absence from work.” British Journal of Psychiatry 183 (2003):507-13.
W. Coryell. “Characteristics and significance of untreated major
depressive disorder.” American Journal of Psychiatry 152 (1995):1124-29.