The debate over how antidepressants work is putting millions of people in danger

The debate over how antidepressants work is putting millions of people in danger

Nearly 10 percent of all Americans will experience symptoms of depression every year. One of the common forms of treatment includes a combination of therapy and antidepressants. According to the CDC, about 13% of Americans over the age of 18 were taking antidepressants between 2015 and 2018. The most commonly prescribed form of them is called selective serotonin reuptake inhibitors (SSRIs), designed to alter the flow of blood. serotonin in the brain.

I am one of the millions who take an SSRI – one called sertraline, to manage symptoms of anxiety, depression and obsessive-compulsive disorder. Before talking to a psychiatrist about using this medication, I dealt with feelings of impending doom and dread that came on a whim, as well as dozens of intrusive thoughts and emotions every minute. Basically, it’s like having your own troublemaker yelling at you all day. Taking the medication has been immensely helpful for me, as it has been for many others.

And that makes it even stranger to recognize that, as with many other complex diseases, researchers still don’t know exactly what causes depression and whether serotonin is a major culprit. In the 1960s, scientists discovered by chance that certain drugs used as sedatives helped relieve depression. How these drugs acted on the serotonin system, this led to “a very simplistic idea that low serotonin levels lead to depression,” Gerard Sanacora, a psychiatrist at Yale University and director of the Yale Depression Research Program, told The Daily Beast.

Most scientists now subscribe to the idea that there are many genetic, social, and biological factors that contribute to depression; and yet the idea of ​​a chemical or serotonin imbalance is stuck in the popular zeitgeist. It persisted in large part thanks to its prominent placement in ads for drugs like Prozac in the late 1980s — even as psychiatric research was already changing its perspective.

This brings us to the current debate around SSRIs. Most neuroscientists, psychiatrists, and physicians who study and treat depression agree: antidepressant drugs like SSRIs work just as well as cognitive therapy. With the right treatment, depression remission rates can range between 5 and 50 percent. There is no doubt that people like me are finding real relief thanks to these medications.

But if depression isn’t as linked to serotonin levels as we thought, then it raises the question that we really don’t know how SSRIs work and why they might help some depressed people. There are several promising theories suggesting that they play a role in mediating gut bacteria, to help the brain grow new cells, and to demand itself, to create larger and more complex physiological changes beyond simply increasing serotonin levels. But none of these theories has been proven yet.

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The ensuing discussion turned into a full-blown debate, pitting mainstream psychiatry against a minority of researchers who don’t think antidepressants really work.

Every few years, a new wave of studies emerges from the shadows, supposedly “debunking” the notion of the serotonin hypothesis. These studies suggest that depression is a result of social factors or caused by traumatic experiences, and that antidepressants do not work, dull emotions, or actively cause harm. Rather than medication, they believe depression is best treated through therapy alone.

The ensuing discussion turned into a full-blown debate, pitting mainstream psychiatry against a minority of researchers who don’t think antidepressants really work.

The fights between competing academics and researchers are as intense and vicious as any other fight that takes place on the internet – featuring fights on twitter, opinion articles for think tanks and the media themselves. The murky history of the pharmaceutical industry further fuels skepticism around the effectiveness of antidepressants. When clinical trials of antidepressants failed to confirm the expected results, pharmaceutical companies essentially buried the evidence and skewed the record in favor of antidepressants — which only exacerbated distrust of these drugs and their manufacturers.

Adding fuel to the fire, a recent review study published in the journal Molecular Psychiatry reassessed decades of previous data on serotonin levels in depression, finding no evidence of a link between the two and offering this as evidence that SSRIs don’t work or only work by blunting emotions. That conclusion has drawn criticism from many psychiatrists and doctors — the study didn’t even look at whether antidepressants work — but with the study authors’ support, the right-wing media got this message out anyway.

“If there are benefits, I would say they are due to this emotional numbing effect, and if not, what the evidence shows is these very small differences between the drugs and the placebo,” Joanna Moncrieff, a psychiatrist at University College London who led the study. study, told The Daily Beast. “Antidepressants are drugs that alter the normal state of your brain, it is generally not a good idea to do so. [that] long-term”.

Moncrieff herself is an influential figure in what is being called “critical psychiatry,” The Critical Psychiatry Network, which Moncrieff co-chairs, describes the movement on her website: The Effects of Psychiatric Interventions. Researchers associated with this movement advocate against drug use for mental health issues and have even promoted COVID-19 conspiracies.

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If depression is caused by the interaction of stressful events and biology, as some within the Critical Psychiatry Network argue, Sanacora doesn’t understand why this means antidepressants don’t work. “I just don’t follow logic,” he said.

Four other experts who spoke to The Daily Beast specifically rejected Moncrieff’s findings, primarily emphasizing that her and her team’s paper crudely merges two hypotheses under the serotonin theory. There is a well-known chemical imbalance hypothesis, which suggests that a deficit in the neurotransmitter serotonin in the body leads to depression. But according to Roger McIntyre, a professor of psychiatry and pharmacology at the University of Toronto, “the notion of chemical imbalance in your brain has never been presented as a coherent, comprehensive, evidence-based proposition.”

Rather, the most prevalent serotonin hypothesis that psychiatry takes seriously, and which McIntrye and others argue is supported by evidence, is that a dysregulation of the body’s entire serotonin system is what contributes to clinical depression. This includes problems with the amount of receptors available to bind serotonin, problems with the way cells fire, and various other disruptions at the biomolecular level. They argue that Moncrieff is wrong when it comes to making the grand claim that there is no evidence for serotonin’s involvement in depression.

The notion of chemical imbalance in your brain has never been presented as a coherent, comprehensive, evidence-based proposition.

Roger McIntyre, University of Toronto

Also, not knowing the mechanism of a drug is not a good enough reason to stop using it if it is proven to help people. “We are very confident that SSRIs work for depression,” Tyler Randall Black, a child and adolescent psychiatrist at Children’s Hospital of British Columbia, told The Daily Beast. “There are reams and reams of evidence showing us that they work, but not why they work.” McIntrye pointed to the fact that we also don’t fully know how Tylenol works – despite it being one of the most used pain relievers worldwide. Tylenol also affects the brain in unexpected ways – while it dulls social or psychological pain, it’s no reason to remove it from the market.

The defamation of these drugs can have unintended consequences because therapy is often not available, making SSRIs the only affordable option. “The demand for mental health care far outweighs the access available,” Sanacora said, adding that many Americans have to wait months to see a good cognitive-behavioral therapist. Also, abruptly deciding to stop taking SSRIs can be dangerous: one in five patients who do so will experience flu-like symptoms, insomnia, imbalance and other symptoms that can last for a year.

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While psychiatrists who spoke to The Daily Beast emphasized that the serotonin hypothesis was a way of simply explaining a complex disorder like depression, they highlighted that it promoted downsides over time. The story of a “‘chemical imbalance’ narrative negatively influenced patient decision-making and patient self-understanding,” Awais Aftaib, a psychiatrist at Case Western Reserve University in Cleveland, Ohio, told the Daily Beast.

The demand for mental health care far outweighs the available access.

Gerard Sanacora, Yale University

Phil Cowen, a psychopharmacologist at the University of Oxford in the UK, told The Daily Beast that socioeconomic status is a contributing factor to depression, leading those in the critical space of psychiatry to believe that it “empowers doctors and the industry.” about patients. Ironically, he ignores the millions of “experienced people” who have been helped through antidepressants.

Still, the million dollar question remains: how do SSRIs work? Aftaib explained that a new leading hypothesis is that they encourage the creation of new neurons and new connections between neurons within the brain. The hippocampus, a seahorse-shaped region of the brain important for memory and learning, shrinks and loses neurons when depression occurs. SSRIs appear to stimulate the production of neuronal stem cells, which integrate with the hippocampus to restore its function and structure. Other studies suggest that SSRIs help the brain rewire the connections that cause the clinical symptoms associated with depression.

He also added that SSRIs can work through different mechanisms in different individuals, so treatments may have to be more tailored on a case-by-case basis.

And more specifically, individual treatments may require psychiatrists to be more honest with their patients about what we know and don’t know about these drugs, rather than presenting an oversimplified (and wildly inaccurate) explanation.

Black already tries to do this with his patients: “I say we know for sure that it affects serotonin, but we don’t know how it changes your brain and we don’t know if you’re low on serotonin to begin with.” He found that these open discussions about what we know so far about therapy and medication pay off in the long run, and many of his patients will still choose to take the antidepressant as part of their quest to find what works best for them.

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