After I complained about lack of outrage in Daniel Carlat’s Unhinged, Bruce Charlton pointed me to this essay (registration required) by Simon Sobo, a psychiatrist. Sobo says something I may end up repeating every time the subject of antidepressants comes up:
Rat pups that are isolated from their mother and littermates produce ultrasonic sounds that are indicative of stress. SSRIs [the most popular type of antidepressants] reduce these sounds (Oliver, 1994). Is a chemical imbalance being corrected? I doubt it.
That’s a nice summing-up. Prozac (an SSRI) really does something, but the notion that it returns to normal something broken is absurd. Sobo also gives an example of how the anti-anxiety effect of such drugs works in practice:
Mrs. L. had originally required 40 mg of Paxil (paroxetine) per day to recover from a postpartum depression. After 12 months on the medication, an incident happened that disturbed her. During her lunchtime, she was visiting her 1-year-old son at his day care center when one of the workers began screaming at another infant instead of picking her up. The next day Mrs. L. went shopping during her lunch break. Later that week a co-worker became tearful during the course of a conversation with Mrs. L. regarding her own child’s day care center. Only then did Mrs. L. wonder about her decision to go shopping the day after she had witnessed the day care worker’s inappropriate reaction. She wondered if her Paxil had made her indifferent when ordinarily she would have reacted and worried about such a thing.
My research about mood suggests that depression is due to defective entrainment of a mood oscillator. It’s caused by something missing from the environment. “Chemical imbalance” has nothing to do with it.
“Chemical imbalance” has nothing to do with it.
Well, yes and no. There are definite biochemical markers in depression, markers of inflammation and oxidative stress for instance, which antidepressants appear to act upon (at least in part). Also, the co-morbidity of, e.g. heart disease and depression would seem to mean that in at least some cases, physical illness causes depression.
I am reading the article by Simon Sobo and Mrs. L.’s case. She did not quit the SSRI but adjusted the dose, so there is still place for its use.
I liked this part: “viewing the patient’s needs and her clinical presentation in terms of a psychological narrative”
I have been taking antidepressants for 10 years now , with a great deal of success and minimal side effects. I was reluctant to take one since I believed that there should be a natural alternative to treat the symptoms I was having.
Prior to taking antidepressants I was increasingly irritable , fatigued and unable to concentrate. Most mornings I had a hard time getting out of bed. I suffered from panic attacks and overwhelming anxiety. Each month was getting worse and worse for two or three years. This was NOT a case of the blues.
My doctor called this depression and treated it with antidepressants. Whatever you call these feelings they failed to respond to numerous earlier treatments of healthy eating, exercising, meditation and psychotherapy. As far as the placebo effect goes it seems incredibly unlikely since I tried numerous over-the-counter herbal , vitamin and prescription medications – some with strongly negative effects-, and each greeted by me with a great deal of hope that it would be the pill to make me feel better. They all failed until I found celexa. The only other pill that helped the anxiety at all was ativan, which did nothing for the fatigue and lack of focus . So I have a problem with studies that show placebos being as effective as SSRIS, since I tried dozens of “placebos” and junk remedies to no avail until I found the one that worked for me. It changed my life.
There is a major difference between serious depression and the “blues”. I don’t doubt that antidepressants are way over-prescribed , much like ritalin. But that doesn’t mean that everyone on them would be just as well without them.
“Also, the co-morbidity of, e.g. heart disease and depression would seem to mean that in at least some cases, physical illness causes depression.”
Let’s say it together: “correlation does not imply causation”. A more likely scenario is that both heart disease and depression have a common cause: life stress. Stress has been liked to both heart disease and depression.
I have never seen or heard any argument by which heart disease acts as a causative agent for depression. However I’m always happy to learn, should you have any reference.
To the extent a chemical balance is being corrected, I think it’s a symptom, not a root cause.
I’m with Joe Griffin and Ivan Tyrrell on this: usually “depression” is proximately caused by excessive worry, and more properly is caused by basic human emotional needs being unmet.
See for example:
https://en.wikipedia.org/wiki/Human_Givens
Am J Med. 2008 Nov;121(11 Suppl 2):S20-7.
Depression in patients with coronary heart disease.
Carney RM, Freedland KE.
Behavioral Medicine Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri 63108, USA. carneyr@bmc.wustl.edu
Abstract
Approximately 20% of patients with coronary heart disease (CHD) have major depression and 20% have minor depression at any given point in the course of their illness. Depression causes significant psychological and social morbidity, and is a risk factor for further cardiac morbidity and mortality. Although there are many possible biological and behavioral mechanisms, the causal pathways through which depression increases the risk for cardiac events and death are not well understood. Despite the morbidity associated with depression, and the devastating impact it has on the quality of life of patients with CHD, it is underdiagnosed and often left untreated. This article describes screening techniques for use in primary care and cardiology settings, and discusses the safety and efficacy of available treatments for depression in patients with CHD.
PMID: 18954589 [PubMed – indexed for MEDLINE]
[My emphases.]
“2. Correlation does not equal causation. In practice, this is used to mean that correlation is not evidence for causation. At UC Berkeley, a job candidate for a faculty position in psychology said this to me. I said, “Isn’t zero correlation evidence against causation?” She looked puzzled.”
– Seth Roberts
As the writer who finally got relief from antidepressant medication indicates, clinical depression is a serious, sometimes life threatening condition, which does respond to treatment with antidepressant medications. While excessive SSRI dosage can lead to emotional numbing, appropriate doses are a chemical short cut to “don’t sweat the small stuff,” and definitely help patients to manage stress more adequately with less impairment of function and better quality of life.
I am on psychiatric medications and have been for 12 years. I have succeeded at always being by myself and alone, without much loneliness or a feeling that I need others. I am currently taking a class at UC Berkeley and I noticed the students react differently from me. Also, I see my coworkers acting differently from me, too. I am very indifferent to many things. I see the Berkeley students worrying about their classes and saying “this class is really difficult,” when I am thinking “how come I didn’t see it as difficult, but everyone else did.” I am not doing badly, and I am not the best in the class. I just wanted to show that my reaction is different from a lot of people’s reaction. I did notice that my medication was doing this to me, and I always thought this was a way that my medicine helped me: that I didn’t feel as affected as others. Also there are some “human” feelings that I don’t have, that people who are not on psychiatric medications, have.
Thanks, Seth, for putting these up. It really helps me. I hope you continue to post things like this.
Joe writes:
>…so I have a problem with studies that show placebos being as effective as SSRIS
The experience you describe isn’t actually inconsistent with the placebo hypothesis. You say that you tried numerous “herbal , vitamin and prescription medications” before you found one that worked for you. Let us suppose for the sake of argument that depression left untreated gets worse for a while but eventually gets better on its own. Either because your brain adjusts somehow, or events in your life change – different job, different relationships, etcetera – in ways that make you happier.
While depressed, you try an herb. No change. Try a different herb. No change. Try drug A. No change. Change the dosage. No change. Switch to drug B. No change. Switch to drug C, and…start to get better.
As long as your depression motivated you to keep experimenting with different drugs it is absolutely guaranteed that you’d be taking *some* drug when you eventually got better. And you would naturally have the impression that this drug worked better than all those “weaker” drugs you tried first. One interesting question is if it had gone the other way – if you had tried the “strong” stuff first and then switched to the herbals when it doesn’t work, especially if you had been told the herbal stuff *was* the strong medicine – would you have had the same experience? The placebo studies suggest you would have.
Close friend of mine got depressed after a relationship she’d committed to went really, really bad over a long drawn-out period of time.
This environmental problem seemed to leave a mid-term dent in her emotions. She was eventually put on antidepressants. Over the phone, I could tell whether she’d taken her pills or not within about one sentence. She did not seem cold and distant; her mood was just very low, bordering on tears, all the time, unless she took the pills.
She gradually weaned herself off the pills as whatever was awry recalibrated itself. A new relationship probably helped, but the pills undoubtedly helped her to hang on in there until things reset. Eventually, I could no longer tell the difference between her with and without pills.
I would not say this unless I felt quite sure of my observations. I can pick up on very, very small changes and inner disturbances in this person, and although I generally have a bias in favour of drug-free solutions, it is impossible for me to harbour any regrets about this course of treatment in my friend’s case. There may have been a drug-free way, but we didn’t know it. She was able to keep earning a living and whatnot, and now she seems good as new.
The drugs don’t cure problems – they support recovery. If your problem is that you fundamentally hate yourself, or you have no good niche in society, and you never solve these problems, you’re supporting life-with-the-problem instead of the recovery. My friend’s problem was not purely one innate to her personality; it was circumstantial, so it healed itself in time as circumstances changed.
G: The anecdote about your friend is consistent with the hypothesis that antidepressants are glorified placebos. See, for example, the story that’s presented at the beginning of this article in Mother Jones magazine:
“Is it Prozac? Or Placebo?”
The story concerns a woman whose life was transformed by taking an antidepressant during a clinic trial — except that she found out at the end of the trial that she had actually been in the placebo group, not the drug group.
The “chemical imbalance” myth persists for at least two reasons: It provides drug companies with a simple (simplistic?) message to use in marketing campaigns. Also, the medical establishment apparently think that patients are less stigmatized when they’re told that their depression stems from a brain disease.
It’s interesting to note that, in reality, it’s not at all clear that the chemical imbalance myth leads to less stigmatization. Psychologists who studied this question found that the brain-disease explanation leads to more stigma than the theory that mental illness is the product of traumatic experiences.
For more information about that last point, see this truly outstanding article that appeared a few months ago in the New York Times Magazine:
The Americanization of Mental Illness
Laura: that sounds like Alexithymia, which can occur on or off psychiatric medication.
+1 to what G said, with the addition that good therapy (ideally CBT) will help change the situation.
Seth, what’s the current research on the reactive/endogenous depression divide, does it actually exist?
The FDA does not require all of the studies undertaken on efficacy of antidepressants to be submitted for analysis when considering approving these drugs — it only requires two successful studies be shown, even if another eight were unsuccessful. Were the results of all the studies to be submitted together, these drugs would not be approved — they do not produce results that can be distinguished from placebo.
The psychologist Irving Kirsch conducted a meta analysis of available research on SSRIs that showed 75% of the ‘effects’ the cause are from placebo, and he proposes the remainder of that effect is because the strong side-effects of ADs make their placebo effect stronger. It would be great if ADs were tested against “active placebos” (placebos which also produce side-effects).
Kirsch discusses his results in this opinion piece in the Huffington Post:
https://www.huffingtonpost.com/irving-kirsch-phd/antidepressants-the-emper_b_442205.html
I’m sympathetic to experiences like Joe and the other commenters describe, but it seems unlikely the benefits they describe are actually from the ADs being prescribed.
“depression is due to defective entrainment of a mood oscillator. It’s caused by something missing from the environment.”
can you expand on this. specifically is the “defect” of entrainment genetic? Are you suggesting that some people are susceptible to depression due to their genes?
It seems to me that altho morning light (which i assume it what’s missing from the environment) may make it less likely to succumb to depression, that most depression arises when people simply don’t get what they want/expect, i.e., it a form of extreme unhappiness.
[also, i goggled “defective entrainment of a mood oscillator” and was unable to find the phrase. is it a phrase that is commonly used in psychology? ]
Peter, please see the linked paper (“Self-experimentation as a source…”), in particular Example 2, for details of my ideas about depression. It’s morning faces and morning light that are missing from modern life but were present during Stone Age life. In an environment with plenty of both, the genes that now cause the “sticky switch” behind many cases of bipolar disorder would have been neutral or even beneficial, since persons with those genes would have had more predictable moods, less dependent on the entraining events of a single day.
@ Alex – I feel a stigma about being helped by placebos!
It feels like kind of an insult to human dignity and all that, but maybe, maybe. Heh.
@ James – She did receive talking therapy (counselling I think; don’t think there was any CBT) and she felt sure it helped. I think she was lucky to have several close friends who were available round the clock most days; I live nearby and others work with her.
Really, you met her now you’d never guess what a state she was in.
what happened to the taubes post
Vic, turns out it was a mistake to post it. Perhaps I will post it later, perhaps the person to whom it was sent will post it.
I was a night person starting at the age of 18 when I went to college; before that starting in the summers at around 10 or so I would stay up late and sleep in, and was rather sleep deprived during the school year…
As an adult I suffered from a lot of dysthymia and clinical depression — I had a lot of suicidal ideation; I did a lot of therapy — I suffered a very stressful and traumatic childhood and therapists encouraged me “to uncover the emotions I was repressing that were at the root of my depression”. I was even intellectually attached to psychoanalytic thought and published some theory; it was tied to a quest to save my self. At the age of 41 I started trying anti-depressants; between then and age 51 I tried 4 of them to no avail.
Meanwhile I was going to bed at 3:30 in the morning and getting up around noon or later. I had also become obese. Seth told me that my biggest problem was going to bed at 3:30 in the morning, when I was 47. None of the therapists I saw ever told me this was a problem.
At the age of 53, in early December of 2003, I finally started going to bed earlier, around midnight on average. Within a week or so I noticed a difference — the sensation of getting sleepy at night began to feel bodily pleasurable. My mood got better. I was in the habit of getting quite depressed on Christmas day. On December 25 of 2003, I was stunned by the fact that I felt fine — it was as if I had some magic protection. Soon after that, my love of music, which had been strong in my youth, returned in full force… I’d say on a scale of 100 my baseline mood went up 20 points at least. I was not on any anti-depressants.
Then in 2006, I decided to try another anti-depressant. My baseline mood stayed much better but I wanted to see if one might now work; it did (Effexor). I think altering my circadian rhythms lifted me up substantiall; from their the anti-depressant worked…
I’ve mostly stayed out of depression since, though I am vulnerable to stress. I am happier.
But the turning point was clear: finally following Seth’s advice to get up earlier. I repeat: No one of the 3 psychiatrists and 3 clinical psychologists ever suggested to me that getting up earlier would help my depression… So depressed night owls might consider changing their ways….
Timothy, I’ve often thought that many (perhaps most) depressed patients could benefit enormously by adopting common-sense measures, such as the following:
* Engaging in regular exercise, preferably exercise that is reasonably intense
* Going to bed earlier / getting enough sleep
* Adopting one or more pets
* Managing their finances better
* Learning how to get along better with their relatives
* Re-engaging in activities that they found enjoyable at one time
* De-cluttering their home environment and work environment
* Managing their time better (for example, spending less time on activities such as watching old sit-com re-runs)
* Improving their nutrition
* Taking care of long-neglected “to do” items
* If necessary, getting couples therapy (or perhaps breaking up)
* Starting some rewarding, long-term projects, like gardening or learning a musical instrument
Most mental-health practitioners would pooh-pooh such advice, though, as it doesn’t involve high-status interventions, such as altering neurotransmitter systems.
@ Timothy Beneke,
I’m surprised that you do not mention Seth’s discovery about faces in the morning. Did you try that?
Since my articles are being quoted, I thought I’d clairfy some of the issues being raised by those leaving comments.
I find SSRIs extremely helpful when used properly. My objection is to the notion that there is something wrong with serotonin in a particular diagnosis. While it is true that some people may be genetically predisposed to depression and a number of other troubles because of their serotonin utiliazation, so far the genetic contribution is relatively minor. (At least what we can show so far.) We do know that all kinds of environmental stressors can set off depression including experiences early in life. And as many pointed out above, we know that depression has physical effects that can be harmful in all kinds of diseases and may lead to some of them.
But that aside my article is objecting to over emphasis on biology, and the idea that a particular diagnosis, presumably “biological”, should be treated with a given medication because it is “evidence based” (ie when you group people by diagnosis and compare treatment with a medication to treatment with placebo it can be shown to be better than the placebo) This is not useless information but it leads to a cookbook mentality to treament that ignores the particulars of each patient. It leads to 15 minute once a month treatments since the patient’s problems reduce to symptoms of the “illness” and side effects.
My argument is that SSRIs and other meds have a particular PSYCHOGICAL effect which accounts for their usefulness. Increasing serotonin (whether or not the patient started with a deficit) seems to lessen the intensity of emotions. I call them the “well whatever drugs” Clearly when helplessness, or sadness, or panic, or anger, or doubt, or guilt, or any emotion is tearing you apart it is a great help to be able to get these emotions under control. And SSRIs can then be a god send. But I also have found them helpful in, for instance a thin skinned teenager who is getting picked on a lot. SSRIs can supply the needed “cool”. And so it goes for shyness (“social phobias” ) and other phobias. But as noted in the blog, the downside is illustrated in the patient who was distrubed by her lack of reaction to her baby being in a not great environment. (see my articles using the links above to find many other examples) The point is how is it helpful and how is it not helpful to decrease emoional intensity.
Psychiatry tries very hard to create an illusion of scientific treatment (by having readily cited statistics about various diagnoses) but the real facts are that we do not know enough about these diagnoses to pass off what we are doing as scientifically based. Most psychiatric illnesses are not analogous to say, strep throat, where we fully understand the etiology and have a treatment which will work 99.9% of the time. We are simply not there. More to the point, we are so uncertain about the value of various diagnostic categories that the DSM committee insisted on calling them “disorders” rather than actual diagnoses. The value of the various diagnosis are very controversial. Indeed, as the head of the DSM IV committee has recently written, DSM IV caused a pseudo epidemic of bipolar disorder, ADHD and autism (for more, link to my articles above)
Anyway, the point is not to be all for or against meds, it is trying to figure out what is going on and try to be as sensible as we can be given out limited hard knowledge
Timothy Beneke, thanks for telling your story.
Could you explain how you managed to get to sleep earlier? Was it sunlight in the morning as you mention in your guest post? Anything else?.
I am sure quality of sleep has an effect on mood. Many times I have nightmares or vivid dreams and I do not wake up refreshed.
Thanks.
@Alex Chernavsky, I’d imagine that most people who complete the tasks on your list aren’t depressed. And perhaps healthy minded people can keep such a list in mind to help guard against the potential of depression.
But once you fall into depression it’s hard to get out. Many depressed people have trouble accomplishing the simplest tasks (my roommate in college struggled to get out of bed).
They need some force outside of them to help them (whether it’s Seth theory of watching faces in the morning, or anti-depressants, or cognitive behavioral therapy, or hiring a life coach, etc…).
@thehova, people recovered spontaneously from depression long before antidepressants (or therapy, for that matter) were invented. In any case, I wasn’t necessarily suggesting that people simply pull themselves up by their bootstraps. Certainly, outside help may be beneficial. Perhaps what we need is some kind of para-professional that would be a cross between a life coach, a friend, and a parent.
I somehow stumbled on this website and am enjoying it. On the point of ssri’s and placebo, I’m a veterinarian and prescribe prozac often for separation anxiety in dogs and cats. In fact my own dog takes it. Without prozac she chews through a chain link fence trying to find her master. With it, she stays in the yard. Like acupuncture, there’s no placebo effect in animals. If the canine patient stops limping, it’s from the acupuncture treatment, not a placebo effect.
kevin
@Kevin,
The question in the relevant medical literature isn’t whether Prozac does something to one’s brain – of course it does something, which is why it has so many detractors.
The point here *isn’t* that placebos *aren’t* effective, it’s that they *are* effective at treating depression. That is, anti-depressant drugs are statistically effective, but not much more than a placebo, which in turn is also effective, with humans.
This isn’t to deny that anti-depressants can also change one’s biochemistry without a belief mechanism, as presumably it would do with dogs.
@OpenUri, while all of the incidents you are mentioning are compelling anecdotal evidence, again once cannot assume causation from correlation. Clearly there were extreme underlying struggles in all of the cases that you mentioned, which perhaps the anti-depressants failed to help, for whatever reason, but your post seems to imply that the anti-depressants caused the unconscionable behavior, an implication that I find difficult to support.
For a slight paradigm shift, there has been some mention to the possibility of “recovery over time” and recovery throughout history from depression, history that existed before the invention of SSRIs or any other mood stabilizing drug. I question the assertion that “people recovered spontaneously from depression long before antidepressants,” because it assumes an analogous relationship between experiences in the modern world, and experiences of some unstated time in the past. We do not live in a world (though I should say country) in which people are outdoors, active, maintaining strong familial bonds (both emotional and physical), living in non-toxic environments, interacting regularly, face to face with other human beings. I will not claim that these things are necessary to living mentally healthy lives (though they are necessary for ME to be healthy as an individual), all I am noting is that the world we are living in today is distinct from much of human history, even from that of our parents. Thus comparing peoples experience of and recovery from depression 50, 100, 500 years ago etc is not comparing like scenarios. What if we are living in a society and culture that while productive in many ways, does not conform with the psychological needs of human beings? In such an instance, short of changing our overall environment, the only treatment for depression would be treating the symptoms (medication being one route), and attempting to help the patient learn to cope in these psychologically unfavorable conditions.
The other idea I would posit is that we do not know how people recovered from depression, since there was no “clinical” diagnosis and treatment of depression specifically, no advocacy for the people suffering from it, and a strong possibility that a lot of long-term self medication occurred (alcohol consumption, reckless behavior etc). Furthermore, in a more survival oriented world, are our emotions put to better use (fight or flight) and thus not as prone to become problematic?
On a more personal note, I am diagnosed bipolar, and being put on Lamictal (anticonvulsant, not an SSRI) saved my life, and has helped when diet modulation, exercise, strict sleeping regimens and talk therapy failed–not so much failed, but couldn’t achieve functional stability. This being said, my ultimate goal is not to be on medication, a goal I am working towards cautiously but steadily.