The Serotonin Levels-Depression Link Is a 'Marketing Myth,' Psychiatrist Claims
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A few years ago, I started having incapacitating panic attacks. They were so pronounced that I'd end up in the hospital ER several times a month.
Eventually, I was prescribed an SSRI, and the anxiety attacks went away completely. Maybe it's placebo, but when I tried to stop taking them, the anxiety attacks came back. (reverse placebo?)
I'm not a big fan of big-pharma, but for me, SSRIs were a literal lifesaver. It's easy to criticize, but unless one has an alternative solution, it's best to let things be until better treatments come along.
I have not had a single panic attack since I've been on my SSRI.
*Edit: The reason I ask is because most SSRIs say do not drink alcohol while taking this medication. It could be discontinuation of alcohol that relieves depression.
http://www.nice.org.uk/guidance/cg115/chapter/Key-priorities...
> For people who misuse alcohol and have comorbid depression or anxiety disorders, treat the alcohol misuse first as this may lead to significant improvement in the depression and anxiety. If depression or anxiety continues after 3 to 4 weeks of abstinence from alcohol, undertake an assessment of the depression or anxiety and consider referral and treatment in line with the relevant NICE guideline for the particular disorder[3].
So, it's true for the general population. But it's a bit rude to ask one individual if they had problem drinking or to suggest their illness was problem drinking.
It's sort of a red herring to say "Depression isn't caused by a serotonin deficiency, therefore SSRIs are bunk", which is what this article seems to veer towards. SSRIs could affect a completely different body system as long as they wind up showing a statistically significant effect over placebo in a double blind study, then they are acceptable forms of treatment by our current scientific/medical standards. (Which apparently they do for most patients--so I wouldn't rule them out.).
[0] Cochrane Review: http://www.cochrane.org/CD007954/DEPRESSN_antidepressants-ve...
From the article:
"Most of the studies were supported by funds from pharmaceutical companies and were of short duration."
In other words, what they are saying is that the published research papers show efficacy for SSRIs, which is completely different from saying that the research shows that SSRIs are effective.
Isn't that true of MOST drugs?
Given that, I have a very hard time trusting any drug that does not show amazingly stellar clinical trial results. If you have the options of cherry picking what you publish, and your drug only "helps" 50% of the participants, I see that as random noise.
Ben Goldacre[1] is trying to shine a spotlight on this, and is doing a pretty good job. His Ted Talk[2] is well worth watching.
2. http://www.ted.com/talks/ben_goldacre_battling_bad_science
We've recently discovered genetic differences in medication efficiency - at some point in the future you'd have a genetic test that would tell you that meds A, B, and C probably aren't going to work for you. (Except by then we'll probably have better meds and better access to better talking therapies.) These genetic differences were not known at the time of the drug trials.
I totally agree with you about the problems of drug research and drug companies cherry picking which data to release. Goldacre's books are good.
Basically they give you a report of your genetic variations and how those relate to different medications or treatments.
First of all, not all these studies are funded by the producers themselves. And even when they are, it is still hard or next to impossible to outright cheat. There are standards in place, and thousands of people are involved, of which hundreds would need to collude.
Has this happened? Yes, it has. And when it came out it had a devastating effect.
But ruling all scientific studies were these stakeholders foot some of the bill invalid is just unfair and dangerous!
The idea is that depression could be a feedback loop in which negative life events cause the brain to become chronically flooded by stress hormones like cortisol and epinephrine.
These are pro-inflammatory factors whose chronic presence promote run-away inflammatory responses which kill glial cells, decrease neuroplasticity, retard neurogenesis, and also contribute to a whole constellation of other health problems like obesity, diabetes, and heart disease.
What closes the feedback loop is that this inflammation-mediated form of brain damage, particularly in the hippocampus and amygdala, directly compromise a person's cognitive ability to deal with life stressors constructively. The ability to process emotion, fear, and memory degrade.
Speaking a bit poetically, you could say that a severely depressed brain is one that has rewired itself to be a stress-processing circuit.
SSRIs no doubt work for some people, and the modern thinking is that they might be promoting neurogenesis through upregulating BDNF and other growth factors; there are multiple lines of evidence, one fun one is the fact that the maturation time of new neurons roughly matches the time it takes for SSRIs to start affecting depression (3-6 weeks).
Exercise also works, seemingly about as well as SSRIs for many people with moderate depression (Googling will provide examples of studies from the last few couple decades to that affect). I haven't read much about this but I would imagine that the metabolic and cellular stresses of a bout of heavy exercise (in which millions of cells die) promotes the production of growth factors all over the body, including in the brain.
Evidence is inconclusive for exercise; more research needed.
http://www.cochrane.org/CD004366/DEPRESSN_exercise-for-depre...
> When only high-quality trials were included, exercise had only a small effect on mood that was not statistically significant.
[...]
> Exercise is moderately more effective than no therapy for reducing symptoms of depression.
> Exercise is no more effective than antidepressants for reducing symptoms of depression, although this conclusion is based on a small number of studies.
> Exercise is no more effective than psychological therapies for reducing symptoms of depression, although this conclusion is based on small number of studies.
> The reviewers also note that when only high-quality studies were included, the difference between exercise and no therapy is less conclusive.
> Attendance rates for exercise treatments ranged from 50% to 100%.
> The evidence about whether exercise for depression improves quality of life is inconclusive.
So far a talking therapy, or a talking therapy combined with medication, are recommended for mild to moderate depression. That might change for some people with depression if we get better social interventions and lifestyle changes.
Actually, I think a lot of patients and researchers do care whether a drug "corrects a problem" or merely adjust brain chemistry some other way to allow a person to function. Something that merely someone "cope" might indeed be acceptable but it's not as highly valued as something that "returns you to normal".
They work ever so slightly, over Placebo, and only for severest cases of clinical depression. They made my anxiety worse, especially the heterocyclic drugs(Prozac).
There are many researchers who collated all the studies, and still can't find any improvement over Placebo.
I am so disgusted by this sham that was forced on Psychiatrists and patients by drug companies; I am too tired to cite links for my statements, but once you look into the efficacy of antidepressants, it is very depressing.
That said, if I was considering suicide I would see a Psychiatrist. Whatever treatment you are given, truly believe you will get better. Believe you will get better with Time.
The placebo effect is the little secret of all allopathic medicine, and alternative therapies. Most of you will get better if you just believe you will get better. In my world, the placebo effect is the only actual proof of a higher power(existence of God). I don't think there's a doctor out there who won't dissagree, with the fact that the placebo effect is the strongest healing modality they have in their arsenal?
I don't think I could find one Psychiatrist in the U.S. who honestly didn't feel most of their patients felt better because of the placebo effect, and time. If any MD wants to correct my statements; I would love to hear what you think.
(please stay off the internet medical sites because I just feel the mob can make you feel worse. See a good Psychiatrist(it's a crap shoot), and believe you will get better.
Antidotally--I have been very depressed' and anxious, and it does get better with time. I guarantee the stuff you worry about in your twenties; by the time you are in your forties, you will look back on those days and maybe--laugh. Oh yea, psychiatrists never tell young patients this; that debilitating fear of death some of you have--greatly dissipates later in life. Getting older sucks, but for some reason my anxiety and depression got better?
My only regret in seeing a psychiatrist was going on addictive drugs, but I had a complete breakdown. I went from being one of the better students in grad school--to a trembling mess. I came pretty close to being a shut in. I literally couldn't be around people without getting dizzy. The only drug that helped was klonopin, and alcohol to fight the panic attacks, and the placebo effect. I have been trying to get off the benzodiazepines, but I did stop drinking.
No. I'm pretty sure almost all doctors would rate.. Say.. Penicillin, or antibiotics, much much much higher than placebo....
I think I got this impression from reading Bad Science, which had references IIRC. Example column from the blog version:
http://www.badscience.net/2008/01/washing-the-numbers-sellin...
http://www.amazon.com/Bad-Science-Ben-Goldacre/dp/000728487X
https://scholar.google.co.uk/scholar?q=kirsch+antidepressant...
About 70-80% of the drug effect is replicated in the placebo arm. Other things to be worried about:
- Unpublished data was much less likely to show a benefit for SSRI than published data. - SSRIs have side effects which may increase expectation of benefit in patients - Numerous studies show unblinding is very common in trials of psychoactive drugs. These studies are not a 'gold standard' by any stretch of the imagination.
It also doesn't mean that these mood improvements are actually useful for treating depression. (For example some studies have shown an increased suicide risk - there is no firm consensus on the topic though: http://en.wikipedia.org/wiki/Antidepressants_and_suicide_ris...)
Drug dependency on SSRI's is a very real thing - I honestly don't see how its any better than an opiate addiction.
Also Big-Pharma funding has a strong and very much negative influence on the objectivity of our scientific body of knowledge. Very often studies/research that have been funded but do not support their conclusions will simply be shelved without publication.
Where are you getting this from? Withdrawal syndrome is a minor component in any real addition and is nothing without craving for the substance which is not present with SSRIs. As someone who has experienced both reasonably severe SSRI withdrawal and nicotine addiction I find your comparison ridiculous (no exp with opiates, but it seems safe to assume they aren't better than nicotine).
The issue is the way your body normalizes to the new default of higher Serotonin levels - when you suddenly return to normal the present state is worse than the it was before you started taking SSRI's (I read a few good papers on the topic a while ago, but I don't remember their titles now - wikipedia is probably a good place to start: http://en.wikipedia.org/wiki/Antidepressant_discontinuation_...).
Also lack of craving is a ridiculous justification for effectively prescribing substance abuse - for example aderol et. all are amphetamine salts - that people don't have a craving in the sense that they would for cocaine is just because the high lacks the euphoric effect -- they still can't function normally without dosing -- and it definitely doesn't mean it's fucking reasonable to prescribe to seven-year-olds.
Likewise people have cravings to watch their favorite tv-show or check their Facebook accounts - these cravings do not qualify these activities as substance abuse.
> Also lack of craving is a ridiculous justification for effectively prescribing substance abuse
What? The justification is improvement of patient's quality of life which is often unacceptably low without the treatment. Blinded by the anti-drug dogma you are unable to see that sometimes the only available alternative is endless suffering.
> these cravings do not qualify these activities as substance abuse.
Strawman. Substance abuse? No. Addictions? Absolutely.
That's simply not how addiction is defined e.g.:
"Addiction is a state characterized by compulsive engagement in rewarding stimuli, despite adverse consequences"
> Blinded by the anti-drug dogma you are unable to see that sometimes the only available alternative is endless suffering.
The ad-hominem is quite unnecessary,thank you. It's certainly not the only viable alternative. I'm not saying it doesn't help some people -- but religion also helps some people; I'm saying the number of people taking clinical prescriptions greatly out-number the people that actually benefit and/or are getting the optimal treatment.
> not in the last because I was experiencing it first hand.
First-hand experience isn't a good metric.
What this blog is saying is that when psychiatrists talk about a chemical imbalance, they are merely saying that brain chemicals are involved in depression in some way, rather than that a lack of serotonin causes depression. The latter has literally nothing to do with what Robert Whitaker is actually talking about. It's just nonsense pharma propaganda designed to trick people who haven't actually read the original book, which sadly is the vast majority of people.
> pharma companies and psychiatrists are selling drugs that haven't been proven to work by using the monoamine hypothesis
Where's your evidence here? SSRIs do work (I assume this is the class of drug we're talking about). For sure, they don't work for some people (or some types of depression; hard to say which is the issue at this point). But they still beat placebo on average.
In fact, the monoamine hypothesis was _based_ on the fact that SSRIs work. The cause/effect is the opposite of what it would have to be for your claim to make sense.
Did the Tylenol cure what was ailing me? Not at all. What it did is made me feel more comfortable while the root malady was being taken care of. If the pain persisted after one or two doses of Tylenol then I'd suspect something more serious than indigestion were at fault and I'd start looking for a reason. What I wouldn't do, and what I hope a doctor would be responsible enough not to do, is to keep taking Tylenol or a more serious pain medication to cover up the pain without considering the actual cause.
The serotonin hypothesis is probably wrong
There are problems with some of the studies used for SSRIs / SNRIs / etc, as with many drugs.
Studies show stronger effectiveness of meds for more severe depression
Fromt line treatment for depression and anxiety is not medication but is a talking therapy or a talking therapy and a medication combined.
None of this is particularly new. IAPT (Improved access to psychologicl therapy) is the UK national health service programme to help local health providers implement NICE guidance on depression and anxiety disorders. IAPT started in 2006.
The serotonin is one possible cause. It sounds like you are suggesting that SSRIs are incorrectly used as a universal treatment, which I'd agree with completely.
I think it's important to distinguish between depression and sadness. I've noticed a very sharp increase in the amount of people (especially youth) who claim to be depressed. They go to a doctor, get a SSRI prescription and next thing you know their brain has a dependency on SSRIs to maintain normal serotonin levels (they are now actually depressed). This is why this is important:
> talking therapy or a talking therapy and a medication combined.
I was clinically depressed for the longest time. Turns out it wasn't caused by serotonin but instead a genetic mutation[1] that something like 80% of human samples have. It can results in a condition is called homocystinuria. In layman terms your body is unable to activate (turn into usable form) one of the forms of Vitamin B. Unsurprisingly the symptoms 5-MTHF (the activated Vitamin B) deficiency can be strikingly similar to depression.
My fix for depression is to simply take a vitamin for the rest of my life. I'm just lucky that the doctors I went to cared enough to not default to the SSRI prescription.
http://www.bmj.com/content/350/bmj.h1771
Some of it I agree with, some I don't; I'm going to bed, but my primary objection relates to why the tricyclic antidepressants fell out of use. First of all, they're not gone; if you go to a psychiatrist and ask for amitryptyline or imipramine, you might just get it. But they're only used in depression which doesn't respond to SSRIs, because in some patients tricyclics can cause mania, hallucinations, and muscle twitching in addition to the infamous weight gain and sexual anhedonia seen on SSRIs. As such they were rarely prescribed even when they were the only drugs available.
Otherwise I agree, but the question "why don't we use tricyclics?" has a lot of excellent answers.
As a patient, if you feel the drugs aren't helping, you should be prepared to fire your doctor or even stop taking them. (I know that's a big medical no-no, but I never would have found someone competent if I didn't fire several psychiatrists and refuse to take drugs that had harsh side-effects. My first psychiatrist was so incompetent that I believed that they all were incompetent and all the drugs were harmful.)
Healy and Whittaker point out that the clinical studies initially used to justify the use of SSRIs cleverly took advantage of this effect. Patients on SSRIs were compared to those who had just been cut off the drug. Of course the latter group, perversely included as "placebo", fared worse than the ones taking the drug.
Your perception of their competence is mostly due to how much you like and get along with them. The next issue is the therapy they try initially, because different therapies work for differently well depending on your brain and your depression. But no doctor can know what works before trying it out.
Switching psychiatrists will most likely prolong your suffering, not shorten it.
Unfortunately it was banned by the DEA under very controversial circumstances, against the recommendation of doctors and scientists, (who wanted it to be schedule 3) so a promising avenue of research was shut down.
Of course it can be harmful, if abused, but if used correctly it's quite a benign substance.
We also know from decades of studies that SSRI's don't work very well, often not at all, and that they also have paradoxical effects such as suicidal feelings and depression.
I was on five to six different drugs to cure an odd social anxiety, that went away as I got older and grew more comfortable in my skin. How in the world can a drug cure an odd internal social behavior that leads one to feel anxious/uncomfortable? Answer for me is .. it can't.
Another example being my g/f. We started dating six years ago and up until a year ago she had been on 4 different anti-depressants each year. Her doctors would say oh that one isn't working lets try this one and so on. Finally she realized this stuff isn't helpful, what's the point?
For those it has helped that's good to hear, but for me, my g/f and many others I know... these drugs are just lining the pockets of the drug companies.
In his awesome book Bad Pharma, Ben Goldacre also hints that the link between depression and serotonin levels is not very well established. For those of you that don't know, Ben Goldacre is not some quack that pretends that science is wrong or something like that; in fact, what he asks for is precisely more rigorous science (specifically, more rigorous medical trials, all made public).
On the other hand, apparently there are a lot of people who have had a measurable level of benefit. My non-educated hypothesis is that there are several causes of depression and serotonin levels may be only one of them.
I'm sorry the drugs didn't help you, and I'm glad you got better regardless. Please don't talk like drugs helping with social anxiety is absurd on the face of it, because it isn't.
> up until a year ago she had been on 4 different anti-depressants each year. Her doctors would say oh that one isn't working lets try this one and so on.
What would you rather they do? Say "can't be fixed, tough shit?" Say "I don't care that it's not working, you have to keep taking it?"
As long as you keep asking a doctor for solutions, they will keep doing their best to provide one. For some people the first drug tried works; for some people it takes a few tries to find the right one; some people never find a solution. It's not simple and satisfying like we'd prefer, but it's how medicine works. It's how a lot of things work.
Then you need more and different medications.
It's true that some antidepressants tend to shoot a bit over the target, but that can be easily taken into account. One such "manic episode", which isn't really called as such because it is drug-induced, doesn't make a bipolar disorder.
I can't tell you how, but I can tell you that they do. A friend of mine went to the psychiatrist with a case of social anxiety and after the second or third drug they tried, the problem disappeared. Poof. Like that. With all the somatic effects he had.
So whatever he got in the end, eventually worked. But this is how it works with psychiatric mediation - people have a lot of different responses to drugs and doctors can't predict them in advance, so initially the therapy is mostly matching drug to patient.
Just an observation/data point.
For reason I won't outline here, someone strongly suggested, after having fought this unsuccessfully for quite some time and needlessly suffering, that I visit a psychiatrist because in his view, I had MDD. This is someone I truly trusted and he apparently dealt with his MDD in the past, so I was like, ok, I'm at the end of my rope so I'll give the MD a shot.
The best way to describe what happened few months down the road after a few trial/errors to see which SSRI fits me best (and that's how everyone finds out - trial/error, any doctor worth his salt will admit this- or they lie to your face if they say otherwise), is a persistent feeling developed, or I should say, resurrected only because I forgot how it felt to feel normal since I was a kid - of being lifted out of a deep hole that I seem to have been in for years, if not decades.
All the b.s. about sexual dysfunction they petrify guys with - for me was not true, in fact, it was quite the opposite as I regained control over that aspect of my life, rather than desensitizing myself with some activities which may have eventually led to ED, despite some "logic" that was telling me that I was doing the "right thing" ...
I could focus better at work, I was calmer in general with my wife, kids, and was more chipper and lit up overall. It's not a high or a dependency...to test it, I stopped, went through what one might call a "withdrawal", but then the MDD kicked back in in full force after a few months of being off it.
Since then, I went back on and decided it is much more important to be productive and focused on an SSRI, than a panic-induced, anxious, crying fits, lost mess without it.
So do SSRIs work? They worked for me - in conjunction with some therapy. Do they address the EXACT cause of depression? Unlikely. MDD is multi-causal, some nurtured by choice, some genetically inherited, no one really knows... but SSRIs treat it well enough in many cases.
Don't dismiss anything out of hand - would be my advice. Depression (clinical, not just depression cause you lost your job or gf/bf - which tends to go away) is real and it is sucks big time. Mine was classified as MDD of moderate to severe character...and I asked the doc, what's really severe - his response was, curling up into a ball on the couch and not being able to function. Some are worse and potentially self-destructive...(i.e. suicide). There is help...SSRIs are just one of many ways to treat this. Point is to reach out for help when someone points it out to you - if you trust them, and you've struggled w/it long enough to the point of unmanageabiility. Study upon study show high causality between SSRI therapy and major reduction of MDD symptoms...
good luck!
But that doesn't mean they were designed to only work under continous beatings. Same thing with serotonin: In depressed brains, SSRIs will "hit" the brain, and that works surprisingly often, but it doesn't mean the brain was supposed to only work with high serotonin levels.
Wanna hear something even trippier from my shrink's mouth? In cases where ECT failed - and not many at that - as an alternative, nicotine therapy broke the depression, restored feelings of normalcy. :)
Obviously, they didn't have the patient take up smoking, since there are other ways to administer nicotine only without the 4000 byproducts of smoke, but it made sense, since I believe most of my family is depressed and the whole lot of them have been decades long smokers, to this day.
Cool stuff huh? Grab that Camel pack now ;)