Why is it that % of American population on AD is highest of all countries? Is it something to do with U.S.? Is it underdiagnosed in other countries (I assume by "other countries" the author meant similar to the U.S.)? My experience with AD is very similar to the others who have mentioned here.
11
It seems my brother no longer has insight into how unwell SSRIs have made him, both mentally and physically. Furthermore, because he’s experienced withdrawal, which was torturous for him, having cold-turkeyed in the past (not recommended), we fear he will remain on these drugs forever. He is no longer the person we once knew. Sadly, his story is far from unique.
There is much greater awareness in the UK. Patients, academics and psychiatrists recently lodged a formal complaint, that the president of Royal College of Psychiatrists has misled the public over antidepressant safety: http://cepuk.org/2018/03/09/patients-academics-psychiatrists-formally-co...
Public Health England is launching a government review into the "growing problem" of prescription drug dependence: http://www.bbc.com/news/health-42787958
12
In the UK, patients, academics and psychiatrists recently lodged a formal complaint that the president of Royal College of Psychiatrists has misled the public over antidepressant safety: http://cepuk.org/2018/03/09/patients-academics-psychiatrists-formally-co...
The formal complaint: http://cepuk.org/wp-content/uploads/2018/03/Complaint-to-RCPsych.pdf
The UK is much more aware of the problem than we are here in North America. Public Health England is launching a government review into the "growing problem" of prescription drug dependence: http://www.bbc.com/news/health-42787958
I have an interest in this because two members of family’s lives have been devastated by these drugs- one is still on them. We believe he no longer has the insight into how unwell they have made him, both mentally and physically, due to the damaging and spellbinding effects of the drugs. Also he knows the torture of the withdrawal from psychotropics, having cold-turkeyed in the past (not recommended). The other family member is in a protracted withdrawal, going on 7 years. Sadly, their stories are far from unique.
6
Many people who are prescribed anti-depressants have underlying personality disorders that the drugs don't treat.
11
They definitely work. I can vouch for that.
However they affect you in a certain je ne sais quoi that makes many quit the drugs.
9
Early in the article, it suggests effects only for those with moderate depression.
Then later, it suggests benefits were for only those with major depression.
Am I misreading this?
10
The second time that's mentioned they only specify that the drugs work better than a placebo. The drugs did have more of an impact on mild depression. Nonetheless, the antidepressants had some positive affect on severe depression compared to placebo.
2
Personal experience is that this study is flawed. Some antidepressants work wonders, though each uses different mechanisms and each are not equally effective on all patients. Also, perhaps the patients where the medicine did not work didn't have clinical depression to begin with? Depression is not the blues, but a chemical imbalance in the brain. Without an imbalance, these drugs would be ineffective.
8
This "chemical imbalance in the brain" stuff is a fairytale invented by doctors and Big Pharma. No one knows what "balanced chemicals" in a "normal" brain are. It's not known how these SSRIs 'work'. There was a fairytale about increasing seratonin levels, then a fairytale about decreasing seratonin levels, and now not even the doctors tell fairy tales about seratonin levels.
If SSRIs worked for you, that's good for you, but it does not mean the study is flawed. You are just one person. Do you really think the studies would all be full of patients who "didn't have clinical depression to begin with"?
21
I think chronic use of depressants is a mistake even though pharma would prefer chronic lifelong dosing.
"The bad news is that even though there were statistically significant differences, the effect sizes were still mostly modest. The benefits also applied only to people who were suffering from major depression, specifically in the short term. In other words, this study provides evidence that when people are found to have acute major depression, treatment with antidepressants works to improve outcomes in the first two months of therapy." the what happens? How about a study that asks about symptom recurrence after cessation and rates of weaning; from as little as 2 months therapy.
4
I wonder what would happen if the same kind of study were used for cancer drugs. I doubt the results would be any better (probably worse, considering the parameters of this study), and the side effects are much worse for cancer drugs. For the many people who suffer depression and can live normal, productive lives thanks to these drugs, this kind of reporting is not only sloppy, but also devastating. With depression, as with cancer, our knowledge is still on its infancy, so a lot of trial and error goes into finding cures. When the title of your article states that antidepressants--as a whole--show "mostly modest effects" you are perpetuating the stereotype that the illness is "all in one's head", and people just "don't try hard enough", or that there is some other fault in the character of depression sufferers. Again, just imagine an article covering cancer drugs in the same manner.
24
No, that's not true, MR. Saying the drugs don't work is not saying the depression doesn't exist. It's saying better treatment options are needed. You mention cancer. It's like saying someone has Stage 4 terminal cancer. No one thinks that means the cancer doesn't exist. It means the doctors are unable to cure it.
7
This was an interesting article and as a scientist, I know all too well the publication bias there is for positive results over negative ones. I do wish, however, that the article talked more about how the article started off--that more Americans, percent wise, are on antidepressants than individuals in other countries. I wonder if it has something to do with American culture or society (or maybe that doctors are more prescription happy here in the US--I'm actually not sure if this is true) and if so, I would find it way more interesting to know what part of our society/culture/etc. makes people more depressed than those in other countries.
16
As a pharmacist of 48 years, it is my opinion that these drugs change lives for the better in the vast majority of people. Therapy may need to be adjusted by dose or drug to get optimal results. One wonders how many people will stop their meds after reading this nonsense and suffer needlessly.
44
This is not Tom Cruise, and I didn't stay at a Holiday Inn Express last night, but you'd be surprised what homeopathic/herbal medicine can do. There have been studies showing things like tryptophan are just as effective as drugs like Zoloft, with zero side effects. The problem with things like this are that they take a while to build up in your system and become effective. I can't recommend "The Edge Effect" enough. Read it, learn about your brain chemistry, and try something different. It may work for you...
10
Perhaps once patients can be sorted by their pharmacogenetic results, we might see a different distribution of "what works". That is, for a given drug and known pharmacogenetic profile (e.g. rapid metabolizer, slow metabolizer, MTHFR variants, genotypes known to predispose to side effects or low efficacy) who is helped? Without this everyone is lumped together so effect size may be artifactually low.
16
Antidepressants saved my life. It's that simple. But it wasn't easy to find one that worked for me and continued to work. I still end up changing medications every few years because they become less effective for me. Early in the 1970s, there were no effective antidepressants but a tranquilizer helped a little. In the 1980's, I endured one failed medication after another until very high, off-the-charts doses of one finally helped a little. It was only with the advent of SSRIs in the 1990s and later, SNRIs, that I was able to find a medication that helped stabilize my mood. By that time, it was clear that I suffered not only from depression but also from post-traumatic stress disorder. There is no specific pharmaceutical treatment for PTSD. But a combination of intensive therapy over many years, good psychiatrists and experience have finally worked with my current antidepressant, so that now I function fairly well in retirement. Until we have a way to figure out which medication will work best for which patient, we will continue with difficult trial and error and hope for the best. Thank goodness, sometimes the best happens.
25
Barbara, how was it finally realized that you had PTSD when for so long it wasn't?
1
I am a mental health professional. I realized over time that I had the symptoms of PTSD. My doctor was initially resistant ("how would I treat you differently?"--1999), but I joined a Yale study on PTSD which confirmed my diagnosis. Understanding the diagnosis did not make the depression go away but it did somehow put it in perspective.
4
I've had depression issues since I was 10, and PTSD was not diagnosed until I was almost 50. If you didn't go to war, it was not even considered in most cases.
1
Because there are many varieties of depression yet to be identified (due to glandular or endocrine imbalance, immune system dysfunction, etc) and some varieties we know are underdiagnosed, there is not the range of antidepressant --or other treatment-- available to troubled public as needed. Just one example, fluctuations in levels of a body's estrogens changes mood pretty drastically for some but ER docs are not trained to inquire of the female suicidal patient whether she has irregular or other trouble with her periods, had recent abortion, romantic tangle, etc. This well-intentioned behavior was part of a feminist political wave that wished to avoid any implication of hysteria. But each gender can present psychiatric symptoms as differently as they do cardiac! Yes, sadly, the problemS of depression have not yet been solved by medicine with pills but we need to be reminded that medicine still remains a practice and that good health, like good fortune, is a gift not fully understood....
5
The fact is if you accepted the same results in other areas of medicine, we'd all be dead, or pretty close to it. Imagine a polio vaccine that had some "modest" results. For a short time! Even for an incredibly long time! Or an HIV drug with modest results for two months. or an antibiotic that had modest results for whatever time. Sure, better than nothing if that were the choice. But to accept that as the choice in any other area would be unacceptable. I can only call this disastrous.
9
According to this reasoning, we should not use antibiotics. How many times doesn't an antibiotic fail and another one has to be used to cure and infection? The problem is not with the antibiotic, but with the diagnosis. And how are we going to learn more and develop better medicines and better diagnoses if we just give up and don't use the medications? Regarding the short periods, that's in many cases what is needed. It is quite well known that if you overuse an antibiotic, you end up getting antibiotic-resistant bacteria. If you had a debilitating disease that was preventing you from getting to work, wouldn't you like to have the option to try different medications if you knew one of them might be what will allow you to keep your job, your friends, and/or your marriage?
12
They work. I was in a really bad place, went to a psychiatrist for 3 months and when changing behavioral habits wasn't that effective she recommended getting a prescription. It took 4 weeks to see the affects but it was well worth it. I am a guy and too often we don't do anything about it for fear of being seen as weak. Go get help!
29
A big problem with these studies is that just because a person says they are "better", does not necessarily mean that really are. The studies rely on subjective, anecdotal data from people eager to see improvement. They don't take into account those not in studies who took antidepressants and then took their own lives. These meds are highly unpredictable, often very dangerous. When my son was 8, his soccer coach was put on Prozac, and a couple of weeks later brutally killed his wife and children. (Years ago I tried them, felt little change in mood, but did notice that I was starting to buy loud colored shirts!) They do however, make a lot of people rich, not by taking them but by manufacturing and selling them.
11
I am a primary care MD and I have a major interest in brain chemistry in mental health. I prescribe SSRIs initially but I also try to get patients well enough with nutrients to get them off medication. Research in this field has been done mostly in America. A useful introduction is Nutrient Power by Dr William Walsh PhD and who has a website at www.walshinstitute.org. I analyse blood and urine tests for zinc, copper, histamine, Vit D and Vit B6 for example. I can then put a program together to normalise the brain chemistry. I use DHA lab in Illinois and the overall result in most cases enables me to reduce medication or even stop it. An interesting drug called lowdosenaltrexone (LDN) is useful and cheap. A Harvard research article shows it is a mild antidepressant with minimal side effects. See www.ldnscience.org. LDN works for over 100 physical conditions too! The American website is www.lowdosenaltrexone.org. The front page mentions that the Norwegian TV program is in it and I was in that program. 70% of Norwegian GPs now prescribe LDN. Using drugs, nutrients and LDN gives me a great deal of satisfaction. Incidentally depressed patients who are in in hospital often tend to have low zinc and low Vit D in particular. It amazes me that so much can be done for mental health patients when a little more knowledge can utterly change lives.
13
Just be careful if you're in the market for life insurance, long-term care, disability, etc. The indication (what the insurance company sees) for this drug is for opioid and alcohol dependence. Depression is an "off label" condition for this and the insurance company will assume you have an opioid or alcohol problem, which makes you a bad risk and you could be denied coverage. You can appeal the decision but it is the insurance companies duty to underwrite for the worst case scenario. Proceed with caution, at any dosage.
3
What is all this research about? Most "new" antidepressants are combinations of old drugs. There hasn't been a significant breakthrough in 30 years. The SSRI, SNRI route has hit a wall. New findings on Ketamine suggest neurotransmitters aren't even the answer. Big Pharma tells us we need to pay high drug costs to pay for huge R&D costs and now you tell us it's junk science meant more for finding investors than finding cures? How depressing.
6
I think these drugs are very addictive and sometimes if a person goes off of these drugs abruptly, psychotic episodes can result. It is scary how many people are on these drugs in this country. I don't think it's a coincidence that a great many mass murders have been on these drugs.
8
Antidepressants are NOT addictive, but the body can become dependent on their effects. I'd like to see your evidence that mass murderers are associated with depression, let alone medication. Please don't say things you can't back up.
20
Barbara: dependency is the basis of "addiction", since the brain adjusts what it produces/does once it gets used to the new intake. IMO brains differ in their flexibility to adjust. Perhaps they respond best to what they lack, who knows. When the response is a great feeling (joy? "high"? calm and content?), usage is often going to be slandered as addiction if the dose is not MD approved. When the dose stops coming, the brain has to readjust: withdrawal. If the drug was filling in a biological defect, it seems good to continue, but what returns after withdrawal may or may not be what was the pre-drug situation. Similarly, it appears that some antidepressants lose their effects over time -- the brain must have adjusted its actions, maybe building up opposing neurotransmission. If so, stopping will trigger unpredictable readjustments. It truly seems that long-term meds that alter neurological action are "addictive" just like anything else that, over time, physiologically alters brain chemistry. Same as alcohol or opioids or coffee. (Our society tends to call it addiction if the user appears to be seeking an unacceptable feeling.) Overly high long-term intake of alcohol or opioids causes quite a number of health problems plus other dangers. For coffee, it's less of a problem. For antidepressants, well, we don't really know yet. They may cause permanent changes in brain function. It would be best to know exactly how they work, and to understand their risks.
I agree. Antidepressants and my M.D. sent me right into a serious addiction to benzos, for which I sought inpatient treatment. I will never again put another mood altering drug in my system. Ever.
5
An excellent critique of this study by Robert Whitaker, author of Anatomy of an Epidemic. https://www.madinamerica.com/2018/03/do-antidepressants-work-a-peoples-r...
7
This article, among other things, doesn't consider the difference between correlation and causation. Still, I would point out, that he talks about how antidepressants are used now. I also would note that he mentions primary physicians being the ones who diagnose and prescribe. With a few exceptions of primary doctors who really know what they are doing (but they bothered to learn and also do listen carefully to their patients), primary doctors are not trained and should not be prescribing these medications.
4
The author must not suffer from depression or other mental illness. Otherwise his article might be more positive. The headline should be just that they work without the qualification of “modest.” Who cares? Something is better than nothing when everything you feel is bad.
15
But for many, there's no improvement at all and terrible side-effects. Just read through all the comments here to see.
2
watch out buddy! big Pharma coming to get you
3
If a "negative" study was sponsored by the drug manufacturer, you can bet your bottom dollar it wasn't published.
5
Next week in the NY Times: Vaccines offer no health benefits.
7
I was very against medications and resisted them until age 53. I used diet, yoga, meditation, therapy. I was depressed starting about age 15-16 and my life was severely impacted, my ability to work especially. It's hard to succeed when so much energy goes into just trying to feel OK. Taking anti-depressants was life changing for me, and I regret not giving them a chance earlier. Yes, there are side-effects, but not as bad as what I suffered before. I do think a holistic approach is needed- medication, nutrition, therapy, mindfulness- it's a mind/body/spirit affliction. Need to address the whole person.
29
Thank you for sharing. I completely agree with your sentiment!
7
Does this include mood stabilizers and anti psychotics for those with bipolar depression? Anti depressants did nothing for me (or made symptoms worse), but mood stabilizers and anti psychotics changed my life. They absolutely pulled me out of severe depression that therapy and lifestyle changes could not change. The few times I tried to go off of these meds, I had terrible relapses in mood instability and depression. Yes, side effects to these meds can be bad and do require trial and error, but I cannot function without them. So, for those desperate for a solution, don't disregard all medications before trying them for yourself.
11
I can say that for some people they are life-changing, in a good way. I have an anxiety disorder and mild depression. I've been taking antidepressants for many years. I still feel a huge sense of relief that I'm able to get out of my own way and think about something besides the worries that used to engulf my consciousness. I appreciate being alive now and am able to learn and grow.
27
Everybody has a story about their experience with one or more ADs. Mine is that it is not a panacea, a "miracle drug" that brings you peace and joy out of hopeless despair. But it gives you a "safe zone" where you can look at aspects of your life that need changing, habits of thinking and health that are hurting you and others, and the courage to seek help in other ways, whether from a professional therapist, a support group or a spiritual practice. Without the AD, I don't think I would have taken those next steps which finally brought me to a spiritual awakening and supportive community. Please do not discourage readers who are suffering depression from trying medication as a first step out of the dark pit they live in.
25
Thank you, Abigail. Very well put.
7
Did these studies include people who took anti-depressant medication and participated in some type of counseling/therapy? Did they look at the results for those 2 groups? My experience and observation has been that anti-depressants (addressing the immediate symptoms) along with counseling (addressing the long term behaviours, coping mechanisms, whatever) is very effective but most studies seem to focus on the medication(s).
10
I'm 62. Suffered from clinical depression from age five until I began taking Venlafaxine in 1994. For me, the life change was like insulin for a diabetic. Just one example, but anti-depressents saved, changed, and re-ignited my true positive life.
24
Please, people who have never suffered from crushing depression where you cannot function and suicide becomes a viable option keep your ignorant comments to yourself. If you have never experienced crippling depression, you have no idea. It's not the blues, it's not being sad.
49
Amen to that!!!
7
Agreed!
4
As a life long clinical chronic depressed person I would say the anti depressants I have been prescribed have not worked . I go all the way back to the Paxil days. I find that the most effective drug I've been on is oxycodone which I take for chronic back pain.
Anti oxy people please keep your comments to yourself, my life without oxy would be a painful, unpreductive hell. Also comments about my being out of it are not welcome, I don't notice any effect of the oxy besides keeping the pain in abatement, and the side benefit of suppressing depression.
16
A shortcoming of nearly every study of SSRIs and SNRIs is the relative poverty of information they uncover regarding negative effects.
I experienced quite a few, and searched high and low for research that looked for or reported on any of the bad experiences I had. I found almost no research that did in detail.
One very severe problem is known as serotonin syndrome. Unfortunately, almost all of the symptoms that are listed for it - tremors, fever, sweating - are biophysical, not psychological. Very few survey questions - in clinical settings or in research - track down less but still severe effects: being panicky, cognitively impaired, foggy, and so on. No follow-up questions were ever asked of me in that regard - I had to force the issue. I experienced a week of meltdown - a panic attack-like state, like having the mental delusions of a fever, but without the actual fever - that lasted nearly four days.
No studies look for those not-uncommon reports of experiencing zaps to the head - like electric jolts - after loud abrupt sounds or being startled, a negative symptom I developed - and still have - after being prescribed an SNRI.
I can see how teenagers would want to commit suicide.
Because these and many other serious problems have not yet been seriously explored, meta-analyses do not track them very well either - the stats on efficacy (probable benefit weighed against probable harm) continue to be deeply skewed. You don't get numbers for what you aren't looking for.
12
Thank you M. Peirce. It's important that such testimony is heard. I'm glad you "forced the issue". They don't look and then don't record when people like you tell them, because they don't want to know the truth.
5
I believe many patients take these drugs for there mood/personality altering effects and less for depression than is recognized. These meds can have effects on a patient's OCD behavior, anxiety, defensiveness, etc. They seem to have significant effects on one's socializing behavior. I have had a hard time seeing much attention given to these effects and how many people may actually take them for these benefits instead of relieving depression.
4
I took them for depression. it helped me significantly, I can function way better and don't spend all my free time sleeping and watching TV in a dark room thinking about killing myself.
18
They work for me. They work for other members of my nuclear family. They have helped me be comfortable in my life, reduce life-long anxiety and episodes of suicidal thoughts. They don’t work for everyone I know. Some I know have tried a few to find the right one. Some have given up after one bad experience. Anecdotal? Absolutely. The take away? It is not a one-size-fits-all solution but when it works, it is transformative. I hope it works for you.
29
There is a difference between depression and disappointment. Many who think they are depressed are disappointed. Life is mostly grind, with rare highs and lows. This reality is deeply disappointing for a lot of people who expected otherwise. But it is not depression.
13
Yes, and I think this is largely why the US has so many more people on antidepressants than any other country. In other Western countries, they're more likely to be prescribed only for severe cases of depression. But here in the US, where prescription drugs can be advertised on TV, the drug makers can craft their pitches to appeal to almost anyone.
7
What we don't have and need is a better understanding of the interaction between the brain and antidepressants and the secondary harms. The benefits to many are well documented but the side effects and withdrawal symptoms are not minor. Many patients want to use these drugs for a short time to cope with a brief period of sadness often have to increase their dose or often relapse soon after the drug has left the body. Is that because the depression is a chronic illness requiring long-term treatment or because the brain has become dependent on the drug? For example, how many people have gone off the antidepressant that was used to cope with a major loss (death, divorce) and remained off? As long as their are benefits to a drug, it appears that Big Pharma and physicians prefer to overlook the long-term harms.
7
No mention was made of studies comparing antidepressants with cognitive therapy. Cognitive therapy has been shown to be effective for depression and other conditions. And there are no side effects as there are with drugs. Too few people are treated with it.
9
You have a valid point. Perhaps because a. It's hard to find well-trained therapists, and b. Most people suffering from depression (I'm referring to the functioning ones like myself who hold down jobs and lack a support network) don't have the money and/or sick leave required to participate in CBT. Hence, the over-reliance on pills. Thank God for Wellbutrin, for without it, I would be a hot mess.
10
If you are really depressed, you need both.
3
From personal experience with SSRI medications, namely Paxil & Wellbutrin, these drugs do work long-term for a person who had had a major depression. I have been on both of these medications for about 25 years, & am certain that stopping them would lead to to swift & certain relapse. They not only work, they saved my life & gave me a far better one than I previously had.
25
Hear, hear! Wellbutrin has enabled me to live my life to the fullest.
9
You'd relapse because you'd have the published side effect of: withdrawal symptoms include deeper depression. Like any powerful schedule 2 narcotic you can't just stop taking them and that's what the drug companies count on.
4
Sometimes depression may not be a disorder. It may be a rational reaction to the predicament you are in.
I have a friend who almost died in an accident in 1998, whose three year old daughter died of leukemia in 2000 and whose wife died of metastatic melanoma in 2005. Who would fell cheery in that circumstance?
16
That's terrible situations to be in. But a lot of people are depressed legitimately and it's due to a chemical imbalance, not situational. By comparing the two, you're delegitimizing both situations.
14
True.
But there is a contiuum of possibilities.
People in her situation will cope differently depending on many factors.
I have heard stories of many people who lie rally can’t cope to people who rise above unbelievable tragedies.
A lot of the difference may well be genetic as well as other life experiences.
4
And that is called "reactive depression". It does not apply to clinical major depression requiring long term use of anti-depressants.
Apples & oranges, as any good clinician knows.
5
This article is noteworthy for one major point. First, that antidepressants have a definite place in the treatment of more acute severe depressive disorders while their efficacy is less proven in cases of chronic moderate and severe depression. What the article fails to mention or acknowledge is the fact that in cases of mild and moderate depressive disorders psychological therapies are at least as effective if not more so than antidepressants and there area host of articles in peer-reviewed journal attesting to this fact. Also there is no mention of the adverse effects of some SSRI antidepressants, i.e., increased suicide risk, without careful monitoring. The article also fails to acknowledge the wide spread and often inappropriate use of antidepressant medications in children and adolescents when psychological and environmental therapies should be the first intervention choice. The pharmaceutical and medical communities, as well as insurance providers, are in too many instances reluctant to acknowledge these facts and findings for a variety of reasons not the least of which involves financial issues.
6
No mention was made of the use and efficacy of antidepressants in the treatment of other disorders besides depression. The SNRI antidepressants or the old tricyclic antidepressants such as amitriptyline, which raise the levels of nor-epinephrine in addition to serotonin, have been used in the treatment of chronic migraine and pain management. And since the gut has loads of serotonin receptors, SSRI antidepressants are used for the treatment of IBS and functional dyspepsia.
I developed chronic migraine several years ago that manifested itself as constant pain behind the eyes 24/7 when I wasn't actually experiencing severe headaches. I was put on Cymbalta and started to achieve real relief until I experienced urinary retention (one of the possible side effects of increased nor-epinephrine) and had to go off it.
8
As a psychiatrist, there is more to prescribing antidepressants than just picking one. First of all, its diagnosing if someone is what i call biologically depressed. Do they have a sleep disturbance, fatigue, loss of concentration, nihilistic thinking? Is there a medical cause such as low thyroid, Lymes disease, low vitamin D, etc.
Finally, asking if there Is a first degree relative that had a good response to an antidepressant. Is there another diagnosis that needs to be treated such as panic disorder. What type of depression is it ? Someone who is a couch potato may get a more stimulating ant depressant. Dosing itself is the final factor. A lot of studies limit the dose used and psychiatrists exceed it. Most psychiatrists can discern whether someone is a slow or rapid metabolizer by a good history or treatment. Finally, compliance. A lot of patients do not take their antidepressants every day. Patient education is needed all the time.
Above is just a brief synopsis. Its even more complicated than that. And this is just the medication aspect.
29
I think that the issue is a rather indiscriminate diagnostic procedure that over diagnose depression. In our increasingly syndromized society we tend to diagnose every feeling of despondency as depression and want to eradicate every notion of emotional discomfort. Anti- depressants appear to be effective for people with endogenous depressions either major or milder but more chronic symptoms. Generally its effectiveness is enhanced by participating in talk therapy in conjunction with life style changes. It is not meant to alleviate every symptom of emotional discomfort.
4
How many millions of Americans are prescribed anti-depressants when you are supposed to be depressed? Unexpected loss of a loved one. Long-term unemployment. Other major life setback. When things like this happen, you are supposed to be depressed.
Sometimes, a walk in the woods or quality time with a loved one or friends, can do the trick. And no nasty side effects, no trial and error, and no addiction.
13
1. Depression is different from reactive sadness.
2. Antidepressants are not addictive. You may be thinking of anxiolytics.
29
L: "Antidepressants are not addictive." Antidepressants may not technically be addictive, but many, many people find them next to impossible to get off and find that they are trapped with them without having been warned about this before they started. Just read the comments here and you can see that.
1
And sometimes those terrible event you describe can trigger depression and anxiety that can be treated with medication.
If overwhelming fear or sadness lasts, it's a good idea to consult one's doctor.
15
If our brains were all alike we would all think the same thoughts. Responses vary. For some they are robust but in a pool of test subjects the robust responses are in part canceled by the negative ones.
4
Psychiatrists will tell you, whether the drugs will work varies from patient to patient. What they don't tell you is that the patient to patient variation is attributable in large part to the extent to which patients have differing abilities to metabolize the drugs. These differing abilities are attributable in large part to the differences in liver enzymes. So, for example, if you need Enzyme A successfully to metabolize Medication A, but you lack that enzyme, then Medication A will not work for you. Unfortunately, physicians rarely attempt to discern whether a patient has the enzymes necessary to metabolize the medications. Doctors have the tools at hand to make those determinations, but rarely use them at all and almost never use them before a patient fails to respond to a medication (due to insurance reimbursement guidance). These tools involve gene testing, which broadly predict whether patients have the enzymes necessary to metabolize psychotropics and, if they do, what dosages may be appropriate.
What does all this mean? If you are prescribed a psychotropic medication, ask for genesight or other, similar testing. The testing may indicate that your liver enzymes are such that you need a higher than normal dose (or a lower than normal dose). The testing may indicate that you will not respond favorably to any dosage of some medications--you're just wasting your time with them. P.S.-Consider what it means to omit these tests from drug trials!
17
To address NotReallyaDoctor's quite valid point about gene testing--as a practicing psychiatrist I am not against gene-testing, but as a practical matter, the question to my patient is "Do you want to spend $2000 of your own money and wait several weeks for results to get a better idea of what might definitely help, or do you want to take $4 worth of Prozac which has a better than even chance of helping you feel better in the coming week?" What would you choose?
29
The results of gene testing can typically be had in less than a week. Dr. Price has a good point re the money. Maybe a better question for the patient might be, "You are depressed. Your depression may impair your ability to assess your own mental condition and your risk of harming yourself. I am going to start you on a course of Prozac, which may or may not do you any good, depending on whether you have the necessary enzymes. If you have the money, you may wish to determine whether your body will respond to Prozac at the dosage I'm prescribing. Or, if you prefer otherwise and don't have the money, we can just wait to see how you do. While we wait, your mental, social, and emotional states may degrade to the point that you kill yourself." Of course, most patients never hear about genetic testing at all until they have failed at least one or more drugs--that's when insurance may pick up the bill. A point here is that depression is, of course, isn't merely a matter of sadness: it impairs cognition in the patient. I think there is a much larger point here insofar as drug trials are concerned. When genetics are ignored, trial outcomes pertaining to efficacy and dosage levels are just goobledy gook.
1
What would be really interesting is to see ceilings and floors of different therapies for each of these conditions.
SSRIs are an option.
But they're prescribed almost reflexively and exclusively without a scientific comparison to other methodologies that may have promise but not the billion-dollar backing of the pharmacos (i.e., exercise, acupuncture, life changes, meditation, etc). Would love to get that data and move to a more thoughtful and personalized set of scientifically-vetted options for patients in need.
1
Meditation and life changes do not and never will work for anyone who has a true mental/neurological illness. We are unable to change the brain action that likely was developed during gestation. Depression, bipolar and schizotypal disorders, anxiety, are all related to epilepsy, autism, Parkinson's and a host of other neurological disorders. They cannot be meditated away.
There is a world of difference between mental disorders and temporary setbacks from traumatic events. However, some events are so severe that the brain chemistry can change to disable a person for the rest of his/her life. That rarely occurs, and talk therapy is the best way to ease the pain of grief or near-death experiences, and post-traumatic stress syndrome.
33
=UltimateLiberal, I have never heard about the depression/bipolar, etc. equation with epilepsy/autism, etc. I have an acute case of Seasonal Affective Disorder and take a relatively low dose (50 mg) to keep it in check. My sister’s youngest son has a history of epilepsy/seizures and takes an anti-convulsant for it. We’ve all assumed it’s related to his being developmentally disabled, but perhaps not. I know that what he’s on works, just as my drug works for me, so nothing’s going to change there, but it’s an interesting bit of information to ponder.
My 21 year old son died by suicide 18 days after starting an antidepressant, Lexapro, an SSRI, for major depression (first time treated, first time depressed that bad with a lot of new transitions in his life). I found from his records he actually formulated a plan to kill himself within 4 days of starting this drug and was going to do it then, but was interrupted.
The FDA Black box warnings were not followed. I only learned of the seriousness of these drugs afterward.
26
Sometimes a patient who intends to commit suicide will experience increased energy a few days after starting meds. They have then the energy they needed to complete their plan. I blame Congress for dismembering our mental health system. Patients used to go into a facility for observation while they adjusted to their meds. For someone who has a history of psychosis or bipolar disorder with past discussion or obsession with suicide, being in a safe pace is very important. The patient and their family can meet with the patient's doc or counselor and be coached through the adjustment to the meds. When the brain starts getting what is missing for so long, the patient can sometimes experience a downgoing for several hours up to a few days. When it passes, they begin to feel really good. I have seen many, many people benefit and be able to change their life in positive ways, after going on meds.
19
lizzygirl168, Congress may be dismembering the mental health system, but it never was good. Those facilities you mention have always been horrible places. You are wildly speculating about "When the brain starts getting what is missing for so long", while pretending that the suicidal ideation is actually the patient's fault, not the drug's fault. You say you've seen many, many people benefit, but you ignore the many, many people with no history of violence who have been made violent by SSRIs.
i am old enough to remember when we used to hospitalize someone who was severely depressed for 2 or 3 weeks especially if they were suicidal. now insurance will only cover 5 or 6 days.
5
Many cases of depression are psychologic
[rather than neurobiologic] in origin. You're not going to expect a lasting improvement if you treat such a depression with an antidepressant.
On the other hand, some placebo effect can occur even with psychologic depressions. It may not persist however.
Many [drug] treatment refractory depressions are primarily psychologic.
You would expect that placebo effect to be higher if the doctor strongly endorses the antidepressant - which tends to be more likely when a drug is new on the market.
3
The late biostatistician, Dr. Donald Mainland, formulated what was known for a while as Mainland's dictum, upon examining the results of a study of arthritis medications. He noted that "The efficacy of a drug is inversely proportional to the quality of the study." Good studies tend, therefore, to show modest benefits, except for a few sensational breakthrough medications.
3
Only anecdotal but the drugs changed my life. Mine was late onset but I had been drifting in a haze for several years and immediately, after taking the med, the fog lifted - and I was able to get on with my life.
A broad study, as they hinted at, doesn't separate better targeted modern meds vs old meds that numb you and have lots of side effects. But even new meds aren't perfect. Their effectiveness can diminish over time (as for me). Does this diminish their viability? Not really, we just need more research to find something better.
20
As a psychologist of 40 years experience in private practice and in Psychiatry at a university- I agree with Henry’s comments and a few others: sometimes with depression/anxiety these drugs help for a period of time long enough to make changes or see why life has been so trying. Remember some people try very hard but/ and are genetically endowed ( see mom, dad, aunt, cousins) with an outlook that needs more than therapy for awhile . Henry is correct .
11
Yes, but if mom, dad and aunts are depressed, that does not necessarily mean that baby sister has a genetic endowment. It could be dysfunction in the family. If twin sibling, separated at birth and growing up in a healthy environment, is also depressed, that would be different.
Your point about drugs for awhile or in combination with something else is well taken. But let that not be buried under the reality that these medications are way over-prescribed and often as a first line of defense.
The genetic argument rationalizes an illness narrative that takes agency out of the hands of the individual. Yet we know that people are more likely to get better when they believe that they will do. This should be factored into meta-narratives about the possibilities that people harbour for making change.
Bernard Lown says: "Optimism, although a subjective emotion, becomes an objective factor essential for unleashing the energy needed to shape one's health."
3
Erin commented:
"The genetic argument rationalizes an illness narrative that takes agency out of the hands of the individual."
It's not an "illness narrative", it's factual that genetics play a role in the depression of some people.
one need only examine the reduced incidence of suicide following the introduction of antidepressants. also, recognize the difficulty of overcoming the placebo effect.
6
These comments make me sad. I think doctors are very well-meaning, but drugs are not the answer. If you are depressed you need to ask yourself why, and take action on the basis of the answer. Are you happy in your job? Are there things you can do to change it? Are you progressing towards your goals? Are you happy in your relationships?
I read some interesting things about the relationship between meditation and taking meaningful action in one's life. We become empowered to create change in our lives when we come in touch with our basic processes. That can mean some difficult decisions in order to create the space we need to listen to ourselves. Other people do not often surrender their hold easily when a person decides, for the first time, to begin honouring themselves. That doesn't not change the basic task.
9
I always thought I wouldn't wish depression on anyone, but lately I am changing my mind. I think all the people that keep telling me and other people with depression that we just need to change our outlook on the world and make an effort to change our lives deserve one year of real depression. Then you would reconsider your opinions. Telling a person with depression to make a difficult decision and change their life is similar to asking someone with a fever of 102 to just make a real effort and get up and go to work. If they faint on the way it's because they didn't try hard enough.
113
This comment implies that everyone suffering from mental illness is making a choice to be mentally ill. That is far from the case.
4
Thank you MR ... you read my mind.
Some of documented but rare side effects are scary: at least nine cases of documented parkinsonism from Bupropion/Wellbutrin?
Though watchdog sites don't always get things right, it's worth checking out the worstpills.org site for anything new you're prescribed. Or the People's Pharmacy. Or any other organization trying to care for people instead of Big Pharma profits.
8
What is Bupropion/Wellbutrin and what is it prescribed for?
Note to author of this article -- you have talked about "effectiveness" your article as the key measure of whether these drugs work, yet there is no definition of what that means.
Does this mean that 51% of people who take the drugs show "improvement" and 49% don't?
Also, no discussion of common, non-pharmaceutical alternatives, like, for instance...regular exercise.
Knowledgeable clinicians, etc., I've spoken to in the past have said that the proven statistical benefits to depression of simple regular exercise vastly outway anything drugs accomplish.
8
For those that can make it to the gym.
3
The SSRIs-- the main drug class used for depression--works on the serotonin system and if you read the medication information further it states we do not know exactly how it works for depression. There are likely numerous mechanisms and neurologic pathways that cause " depression" and so we are not treating the same illnesses in all patients but we use the same class of medication for most patients. Not surprisingly they don't work for everyone and until we elucidate the causes of depression further it will be difficult to help many patients. I started practicing just before these drugs were on the market and I can confirm that these medications are far more effective and with a lower side effect profile than the medications that were available in the past. Mental health is one of the areas where we have made some progress, but much work needs to be done. The biggest issue is access to mental health providers. The benefit of these medications has been primary care doctors like myself, have become more comfortable using medications to treat depression because of their relative safety and efficacy. It can take 6 months to 1yr to get in to see a psychiatrist in some areas and the ability for primary care doctors to try and help treat patients with major depression has been enhanced by these less than perfect drugs.
12
Unfortunately, what is classed as "depression" may be a misdiagnosis. It may be one of the forms of bipolar depression, which responds to different medications. Severe depression may respond better to ECT. And medication alond, IMHO, is never the answer without concomitant therapy.
2
EPMD, yes there are societal problems, as well as socio-economic problems. But trying to solve one problem with another problem is dangerous. Have you been referring your patients to good clinical psychologists as well? I guess you'll say they wait a long time for those too.
Just because you "have become more comfortable using medications" you admit no one knows how they work or if they'll work, doesn't mean that you should be doing it.
2
If one believes in the process of natural selection, then there are too many people who are in need of psychotropic medication, anti-depressants included.
Over time, those whose nervous systems were dysfunctional would have been weeded out by natural selection.
Conclusion: We are not talking about a biological disorder for most people who take anti-depressants but, instead, are dealing with something more like opioids---a substance that makes peoples' lives more pleasurable, or that distracts people from the underlying emptiness of their lives.
3
According to you, also diabetics would have been weeded out through natural selection, as people with many other ailments. Regarding the emptiness of people's lives, why are you assuming that depressives have empty lives? Many famous artists, scientist and entrepreneurs have suffered from depression. I guess the stigma of mental illness is alive and well.
38
There are so many ways in which we are currently, as a species, subverting natural selection. Too much thoughtless breeding and too many drugs masking conditions that should not be reproduced.
Gustav Mahler, one of my favorite composers, had Seasonal Affective Disorder, as do I. Alas, I am no Gustav Mahler, but I am now grateful that thanks to Sertroline, I am alive to listen to him.
1
I have both taken antidepressants, and prescribed them rather extensively as a mental health professional.
Despite that, my comments are entirely anecdotal.
I agree that the effects overall are rather modest, although there seems to be no way to know who will respond, and to what drug.
I do spend considerable time educating my patients to have realistic expectations about what antidepressant medications can do. And what they will not do.
Keep in mind the SSRI's and other antidepressant drugs are also used for anxiety, which may be easier to treat, and is usually co-morbid. And they are much safer than the benzodiazepenes.
I have seen the occasional dramatic and unexpected recovery with the use of these medicines.
However, in general, the effect is subtle enough that it can be difficult to tell if they are helping, or if it is wishful thinking.
Aside from sexual dysfunction, rarely have I seen significant long adverse term effects.
And yes, sexual dysfunction can be quite a big deal.
Anecdotally, an SSRI was greatly helpful to me some 15 years ago, after finishing graduate school and entering the job market. The pressure, and anxiety, was intense.
In combination with cognitive and behavioral therapy, I eventually saw through the facade, and I was able to get off the medicine with no issue.
There is no question they do greatly help some people. We just don't know exactly who.
16
I am a psychiatrist. I agree that the medications labelled "antidepressants" do that job pretty good for some people and not much for other people. The vast majority of them work on the serotonin system, and thereby are much more effective for anxiety than depression. Accordingly, I consider them mis-labelled.
Then there is the whole question of "what is depression?" On the whole it seems to me to be more of a symptom than an illness (except for people with bipolar depression). So again, there's a lot of mis-understanding, in both the medical and general communities, about what it is reasonable to expect these molecules to do for people.
On the whole I'd say they are "pretty OK" for a lot of people. There's a lot of hype and overgeneralization around the idea of psychotropic medication in general, and its best to ignore they hype and consider each person individually.
20
Henry, apart from damping the hype, you need to think about the possibly serious side-effects, both those officially recognized by your profession and those denied but reported by patients e.g. in reader comments here.
2
I was an adult when most of these products were introduced and I read quite a lot about them. Shortly after this I experienced several life changing events in a short period of time that completely knocked me off my center. I finally had to admit to myself that I could not get through the inner trauma without real help.
I started seeing a psychiatrist for therapy but that was difficult because of the mental and emotional chaos I was in. After a few visits I was feeling hopeless about the therapy working for me and I discussed this with her. She told me that I was not yet at, what she called, a therapeutic level; basically I could not respond because of the inner chaos. She put me on the new leading antidepressant to help me to get to that level and I soon started responding, gained inner stability and gained an incredible amount of insight into the problem areas in my life. I was not on that medication for long after the therapy started to really work for me once my center was stable.
That was how these product were first used: as a aid to therapy and usually prescribed from a psychiatrist. Within a few years that was no longer true. Doctors of all disciplines were writing scripts for them with no reference to therapy or other programs that address the underlying genesis of the depression and anxiety.
Based on my personal experience, I believe that the medication itself cannot cure but merely mask the causes and will, after time, not even do that.
9
I don't understand your comment - you say the medication will merely mask the causes, but before that you said that for you the medication helped you understand the causes and deal with them.
Take my anti-depressants away, and I can't function. My recommendation for untreated depressed people is to try and let go of the unfortunate stigma about mental illness, and ask for help.
I've been on anti-depressants since the late 1980s. Tried three times to wean off them. For a very short period of time felt even better, but within two weeks crashed. They make my life possible.
Some don't work and some stop being effective after a while. But, working with a good psychiatrist can usually help find the right combination and dose of anti-depressants. I'm on a finely tuned combination of three anti-depressants, which took a while to figure out.
Side effects, yes. Some where intolerable and I had to switch. Others I've been able to live with, and will gladly accept over being depressed, any day I am on Earth.
They work for many. I'm so very grateful they work for me.
85
Doug, may I ask what were the intolerable side-effects?
1
I was on Effexor for three years and know how it feels to be afraid to come off. I failed a major exam due to not being able to concentrate or sleep on this drug; got off the drug, re-did exam, and proceeded from there.
The first thing to say is: kefir. It's a probiotic bacteria/yogurt. Apparently, most serotonin is produced in the gut. I can't speak to whether it works for major depression, but it works well for me and the one time I stopped taking it (as my grains died) I started to get pretty depressed after a couple of weeks.
Also: when I went off the Effexor I never got the awful withdrawal symptoms that everyone talks about. I ascribe this to the fact that I switched from the drug to taking liberal amounts of fish oil supplement and 5HTP. 5HTP or tryptophan is a serotonin precursor. You can get both of these supplements in the drug store. I have headed off a looming depression with 5HTP. I find it starts working almost immediately. (Your mileage may vary.)
For me, these supplements work as well as the anti-depressant ever did and they have no side effects. (Be careful with overdoing the 5HTP though as it has been reported that this can do something with the heart valves)
Just my two cents.
Good luck!
11
Erin, what does of tryptophan did you / do you use? Just what it says on the bottle??
1
I never tried effexor because of the horror stories.
3
I believe that this article is avoiding the evidence of actual brain damage that long term use of phototrophic drugs cause plus the serious side effects they cause and need for multiple drugs to control those.
This is a serious scandal in American medicine.
10
Then please post the evidence of long term brain damage here, so we'll all know.
4
Yes. That's why the attitude psychiatrists have of keeping on randomly trying different drugs and combinations of drugs like someone sampling candy at a candy store is so flawed. They ignore the potential serious harm the drugs can cause.
So many terrible side-effects are mentioned in readers' comments below that are not officially recognized side-effects.
3
I looked at the article and didn’t see what fraction of patients responded and what fraction had a major improvement.
This Is a critical statistic in considering the value and use of a drug.
Stephen Rinsler, MD
12
I know many people who were put on some of these drugs and found it almost impossible to get off them because of the withdrawal symptoms. Something to consider. And most doctors who do prescribe them have no idea how horrible the physical side effects are when they try to get off the drugs. It is far worse than the doctors (and the manufacturers) would lead you to believe.
18
It can also be difficult to get started.
Another overlooked hurdle.
2
I took Zoloft for six months at a low dose for anxiety and when I came off of it I was getting brain shivers. Very unpleasant.
3
This is ignoring the report from the UK very recently (2017-18) which listed the most effective.
4
We shouldn't underestimate the connection between widespread obesity, widespread erectile dysfunction in men, widespread sexual disinterest in women, and widespread use of anti-depressants.
7
I would not be alive today without antidepressants.
51
It sounds like the evidence supporting SSRIs for depression are not much better than the evidence for CBD (cannabidiol): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202504/.
3
Someone was bound to start talking about marijuana ...
2
that's why I take Effexor and smoke pot.
1
Oh no!
Now there are so many people to tell that they don't feel better after all!
More importantly, most of the studies are flawed because they don't pay attention to different kinds of depression, to other diagnoses that mimic depression, to other psychiatric conditions that often accompany depression, and to the important role of psychotherapy.
Alas, many people will suffer because of this flawed piece of research.
18
I have a degree in neurophysiology. I also have experience with prescribed antidepressants. Here's what people fail to understand about anti-depressants.
Habituation.
Our nervous system gradually becomes less and less responsive to a stimulus. Unlike other drugs which keep our blood pressure low or kill cancer cells, a psychoactive drug will diminish in effectiveness over time. Most people I know on antidepressants have been through this process; increase the dose, add another anti-depressant, change to a different anti-depressant, increase the dose.
I had a brilliant doctor who told me, when the drug "stopped working" to go off it for a day, or two, and then take it again.
What prevents most doctors from recognizing habituation is the placebo effect. When you are depressed, there is a terror of returning into the darkness, the loss of meaningful connection with others.
So the pill becomes this tiny island where one knows one feel safe.
I discovered in taking a tolerance break, I did not fall back into depression, and I could resume taking it when I needed it again.
I've come to doubt the regime where you have to take an antidepressant every day for the rest of your lives.
If I feel depressed now, I mostly go to nutritional sources to solve it. I nurture myself. I talk to someone. Yes, I have childhood trauma, I've had severe depression, and yes, the body is resilient, you can recover.
23
It is great that this works for you, but I’m not sure that this is relevant to someone with a genetic predisposition.
Part of the trick of treating depression is recognizing that each situation is unique. While there may be similarities, it can be a balancing act.
I agree that taking a “break” can be valuable, it seems that recurring depression can be unnoticed by the depressed person and result in a crisis situation.
It can be very complex.
2
But you would take insulin if you needed it, correct? Would you consider the symptoms of being off insulin to be symptoms of "withdrawal"?
1
Deb,
It's impossible to stop taking certain anti-depressants, even for a couple days, without suffering mental repercussions.
One that comes to mind is Effexor (venlafaxine), even missing a small dose, say 50 mg, will cause what feels like mental short circuiting and leave one out of sorts.
I can't imagine any psychiatrist agreeing with your general recommendation regarding anti-depressants.
2
More anecdotal evidence: two weeks ago I ran out of my regular antidepressant dose, so pulled out an older supply (not that old) at a lower dosage to take until I picked up my refill. Then I got busy and forgot about the refill. On the third or fourth day I started feeling more than a little depressed, for no apparent reason, and wondered why. It took me another day to put two and two together, and several days with the correct dosage before I was back to normal. Make of it what you will.
15
I didn't get better until I faithfully practiced yoga the times a week. Quit my antidepressants and my therapist!
2
Fantastic.
But it doesn’t work for everyone.
6
Is there a pill for being economically challenged?
There is a direct correlation between having enough money and our general happiness. Being poor, long term, is a drain on one's mental and physical well being.
11
In many cases it’s a chicken or egg conundrum.
Either one can possibly lead to the other.
2
Yes, they worked for me while I took them.
2
My experience with Zoloft was a horrible nightmare for years. I finally freed myself from this addiction and now I have my zest for life and love back. Anti-depressives make you fat, stupid and lethargic.
16
They also kill your sex drive which was why I quit taking Zoloft after 6 months. I was only on 25 milligrams. It didn't take a high dose to mess things up.
2
Your comment isn't helpful for those who truly need anti-depressants. Just because zoloft made you fat, stupid and lethargic doesn't mean all anti-depressants are useless across the board.
Zoloft may not have been compatible with your particular chemistry but it may work wonders for others.
3
And for some, antidepressants work.
If only there was an easy way to tell beforehand.
prescriptions by general practitioners and specialists
lacking pharmaceutical knowledge ...
:to be conscious about harmful effects on short and long run
of paramount necessity by respect for Life...,the well-being of a patient and relatives.
And to acknowledge also if not knowing at all!
1
Full disclosure: I speed read this article. I think the question that needs to be asked is how well do antidepressants work on the different categories of depression? Mild to moderate episodic depression is a totally different ballgame than moderate to severe chronic depression. Just looking around at my family, I'd say they work great for the first category. As for the second, not so much. All anecdotal I know.
7
The article is saying they work for severe depression.
The first point that was not considered in this article (and maybe in the study it is based on?) is that there is a lot that we still don't know about the brain and mental illness, and the fact that an antidepressant was prescribe doesn't mean that patient was depressed or that the medication was the right one. I was lucky enough to participate in a study that checked some liver genetic markers that indicated how your body processed the medications. I cannot tell you how the study worked for others, but I feel a lot better since I stopped taking a medication that according to their analysis was very wrong for me. This is only one genetic marker, who knows how many more will be found? When we are at this stage of research, is no wonder that any meta-study including decades of studies with different parameters is going to have different results.
I cannot talk about medical studies, but in my case medication works. In fact, without it I couldn't be a productive member of society. I've seen the same change in other people. I believe the data is more than anecdotal. The fact that they don't work for everyone should be expected, when finding the right medication for someone is more an art than a science.
5
Aaron Carroll:" Even with so much research on antidepressants, there are still many unanswered questions. It’s unclear if drug companies would be interested in the results, or indeed why they would be. The drugs are already being widely used, and no regulatory agency is requiring more data. If patients want answers, they will need to demand the research themselves. "
Readers, all of us as a society need to demand the research, including into dangerous side-effects, such as are described by people in this comments section.
12
A low dose of Fluoxetine puts a floor under my depression but does not leave much room for joy. Several experiments with other options or quitting, however, did reveal how miserable I could be without it. Vitamin D is also helpful in keeping stress related emotional turmoil at bay.
Is depression a Western-Civilization related disorder? Do hunter-gatherers get depressed? Did cave-people have days when they just could not leave the cave? There is simply too much we need to know these days. It's impossible to keep the dark stuff out.
16
I had the same problem. there are better medications out now.
2
"Is depression a Western-Civilization related disorder? Do hunter-gatherers get depressed? Did cave-people have days when they just could not leave the cave? There is simply too much we need to know these days."
Well, it might be difficult to know for sure. But suicide has certainly existed as a phenomenon for all of recorded human history, and I would wager that over that period some (possibly a large portion of) suicides suffered from depression.
2
Strange study. They include a lot of older tricyclic medications and other, newer, novel medications. it muddies the waters for the majority who are prescribed SSRIs.
Also, as someone else pointed out, medications are prescribed for many more reasons beyond depression--OCD, anxiety, etc.
9
The best antidepressant for me would be a world that still considered me employable despite my older age. There is a direct correlation (r² = .94) between my depressive state and the loss of my corporate job 11 years ago.
31
Indeed. We all need stability, which seems to be in short supply not just for the over 40 crowd but for everyone caught in the gig economy. It's more difficult for older workers though since medical insurance is cost prohibitive unless offered by employers (increasingly rare).
12
EXCELLENT ARTICLE. Informative and well written for both the average reader and those with more understanding of these matters. This information is easily applicable to so many drugs on the market, I hope people do see the correlations. We are living in a brave new world. It wasn't until the 1960's that there were all these medications on the market for whatever "ails" you. I remember in the 60's being aware and surprised that my elders were suddenly going to the doctor all the time and taking pills for weight, sleep, lack of sleep, injections for energy, pep pills and so forth. Why must one click on the bubble to see the comments? They should be displayed on the right margin like other NYT articles.
At any rate, caveat emptor! And more from this author, please.
3
Antidepressants do work, better for some than others. And side effects are not always a small aspect to figure into the mix.
One of the problems that is of major concern is the money monetization of treatment. Treatment can be expensive, and presents a sometimes roadblock for persons suffering from depression.
The latest and greatest possibility is treatment with low doses of Ketamine, a cheap but often extremely effective treatment that is almost exclusively available to the rich, at $500 to $1500+ per infusion.
I can almost guarantee that this will be stalled, as greedy people find optimum profitability.
8
Absolutely awful, yet predictable coverage regarding antidepressant use.
No mention of efficacy differences between conditions. It's not just about depression, many people take antidepressants for anxiety, OCD etc.
Can future coverage expand the analysis beyond just depression, with actual numbers & less editorializing ?
14
The hardest part for people who have come from families that either were emotionally repressive or that their emotions didn't match the situations that those people were in. The children of those families don't know what their own feelings are telling them. Repression of ANY emotion can cause depression. Depression is not an emotion it is a state of being. It is a state of not allowing emotions related to a certain event or events not to come to the surface to be felt. Emotions are not positive or negative. They're not good or bad. They are comfortable or uncomfortable. All emotions are just an indicator of how you are being treated. Example: anger is an indicator that you are being abused and the energy of anger is such that it would move you to change your circumstance. Unfortunately we are taught that anger is "only" about hitting and screaming. Not that such circumstance isn't needed at times, but usually anger should be a motivator to get you to change your environment. Also, is the anger being felt of this time or past that is being relived in an attempt to heal? I would suggest going to " OurPsychicLives "a story there that will help you to get to those memories and feelings and will help you to heal. The story is called " God Enhanced Music". It is about saying a simple prayer and asking God to put something into some music to help you to heal. Your choose music, time, place and you say the prayer. Best if done sitting down comfortably at home.
2
Sometimes people feel inappropriate emotions. For example they may feel anger and interpret that as anger because they are being mistreated when in reality most people would not consider them mistreated in the given situation. Ever raise teenagers, for example? However I do agree with you that depression is about repression. Sometimes that repression is self-imposed and sometimes it is externally imposed. Thanks for your interesting comment. As for your suggested remedy, I agree it is possible to be open to healing. I call it radical acceptance of reality because we suffer a lot from what we are hiding from ourselves and hiding from the world, esp. in terms of *abuse*. The truth will set you free if you allow yourself to see it and then take the leap to accepting it. So hard to do. Best wishes.
5
Let us put this plainly and simply. Antidepressants work very well for those who need them. For temporary issues, why would anyone want them?
I say this as a parent who saw both children change into real humans after being medicated. I, myself, did not realize how broken I was until the next episode. I asked my physician to consider a certain medication that had worked a miracle on one of my children.
I have never been happier, the past 20 years, and will never stop taking this drug. It has totally changed my life; it totally changed my child's life. Both adult children are on two SSRIs/other drugs--they need them for their lifetimes and cannot function without them.
My hypothesis is that too many "well" people are abusing life-altering medications that they believe can work for temporary crises. Mental illness is not temporary, and is all too real and disabling. Temporary grief, anger, loss of job or spouse do not cause mental illness and should never be treated by psychotropic medication.
No wonder some people think the meds aren't working for them. When we truly need a certain medication, it is a godsend, and must be taken for life. Mental illness cannot be cured; it can only be controlled and masked so that the individual can function as a normal person.
If you weren't born with scrambled brain waves, you don't need drugs when you have temporary anxiety or fears after a loss of job, loss of fortune, loss of child or spouse. You are NOT mentally ill.
38
I agree with you mostly, but I believe that most people are born with a predisposition to depression and the events in their life will determine what happens with that predisposition. There are people that will need medication for life (like me), but there are people that have maybe one or two episodes in their life and don't need to be on medication permanently.
8
I think sometimes life experiences can interact with our genes to create a mental illness. I managed without SSRI's until my mid-adulthood, when I had a time with several years of trying to get and stay pregnant, then I had my first episode of major depression. I tried to get off of SSRIs several times, but have found I always drifted back into depression without them. I have accepted it's a lifelong medication for me now. Maybe without those experiences I wouldn't need my medication, or maybe I just had to hit a certain age, like schizophrenia often hides until early adolescence.
9
I believe in some instances our life experiences might be so traumatic that brain chemistry may be affected so as to cause permanent damage. That would need lifetime treatment. Talk therapy is usually part of bouncing back from PTSD and grief from the death of a family member, particularly a young, violent death. Temporary talk therapy plus medication for a limited period of time is not an indicator of mental illness; it relieves temporary sadness or confusion.
Schizophrenia has always been present in the disordered brain--it manifests itself as the brain matures to its adult stage between 15 and 35 yrs of age. Certain synapses fail to connect messages in a normal pattern. Depression and social anxiety are usually noticed between age 3 and 15, but not always recognized (as in bipolar disorder) until age 20-25, when episodes can be charted and tentative diagnoses can be made for beginning a drug regimen.
I am not a physician; we have several family members with various types of illnesses, including myself, two children, a parent, siblings, cousins, in-laws.
The efficacy of antidepressants is sisgnificantly enhanced by the addition of evidenced based psychotherapy for depression, such as Cognitive behavior therapy , and interpersonal therapy. In fact it decreases the number needed to treat for antdepresssant tpefficacy from 4.85 to 2.5 in one study. So let us use this combination approach
9
Many psychiatrists believe that antidepressants generally work for severely depressed people and are of less benefit to the mildly or moderately depressed. There are factors in play besides severity, such as chronicity, age of onset, and type of depression, to name just a few. People with serious, long-lasting depressive mood disorders benefit most from antidepressants in conjunction with psychotherapy, which some insurance companies decline to cover for the long term. As a person who formerly worked in depression research, I have seen, both scientifically and anecdotally, miraculous recoveries, whether placebo related or due to the real drug. Recovery and/or great improvement is possible but never guaranteed, similar to results in treatments of other chronic diseases.
12
Barbara, by " miraculous recoveries... placebo related", do you mean placebo and nothing else?
1
Cue the people who know nothing about the subject, but will happily offer their opinions!
20
And who prescribe kefir and yoga--three times a week!
1
Let's not forget the primary objective of Big Pharma: $. Once you accept that, and the FDAs complicity in approving scores of suspect antidepressants, the rest is clear.
50 years from now hopefully, society will think about Big Pharm much in the same way as Big Tobacco and cigarettes...
8
I hope that you are right.
Big Pharma (to a great extent) wants customers, not cures.
Greed is the root of evil.
1
Antidepressants stole almost a decade of my life and in the end made me more socially isolated, paranoid, and hostile. I weaned myself off of them and got my life back. Found out later that I am a poor metabolizer and that these drugs build up to toxic levels in my body. But without for the last five years, I feel so much better. I find the renewed push to encourage people to take them very disturbing.
15
Just curious: if you were doing so well why did you take thew antidepressant in the first place?
9
And I quote: "He’s also hopeful that future studies will be even better at informing individual-level responses, which might help to see if some patients benefit substantially even when others don’t seem to benefit at all." It seems to me that simply asking the patient to weigh in on whether they have benefitted would be sufficient. There is no question in my mind that I am alive (very much so!) today because anti-depressants benefit me. I have a lot of data to inform my response: my own experience, my mother's experience, her mother's experience .... I lived about 50 years without medication, gritting my teeth as the tidal wave of blackness attempted regularly to wash me out to sea beyond where I could swim back to my life. I have lived a further 15 years so far, safe and sound in mind and body. The question of whether all patients benefit equally seems, ultimately, pointless. Unless perhaps you are seeking to justify ... what?
14
But for others, drugs take their lives. You are ignoring negative side-effects including suicide etc. for some patients.
4
No, John. I'm advocating recognition that there is no universal experience. Your mileage really does vary. And I question the point of analyzing for a universal value. What helps some people may harm others.
Yes, there are risks, and people should not take antidepressants if they are not needed. The correlation between starting a drug and committing suicide needs more studying, and someone who is having suicidal ideations should be monitored closely when they start to take an antidepressant. What you are not considering is the number of suicides that are avoided thanks to the medication.
Personally, for me, they've been working for decades. I started taking them prior to 9/11/01, when, as one can imagine, there was a major increase in their use. Obviously that was not a factor for me.
I can't pinpoint any particular event or incident which prompted the anxiety. Let's just say anyone who has lived in this densely populated, hyper-kinetic burgh of ours, for any considerable amount of time, can attest to the propensity for one attaining high-stress levels.
On occasion, when people speak to me of stress, I will recall vividly the day I first took what for me was a magic potion. Leaving my doctor's office, located across from Roosevelt Hospital, with script in hand, I turned the corner of 59th and Ninth, and headed to my pharmacy. The script filled, I then returned to my apartment, another block away. I opened the bottle and took the pill immediately. And, I swear, withing hours, I thought I could feel its effects. When my wife arrived home, around dinner hour, I was buoyant, and told her so. She gave me that look. She had her doubts. But by the next day and the ones that followed, she became convinced.
Two weeks later, I returned to my doctor's for a follow-up. He was somewhat skeptical. He told me it usually more than a day, but it varies with each individual. He dubbed me, "a model of the miracle of modern pharmacology". As you see, I haven't forgotten that day, his quote, and all the good days that have followed.
DD
Manhattan
21
When I have come debilitated by depression, I have also found almost immediate relief when beginning antidepressants.
2
Dear Raye:
As my doctor said to me, its effects vary with each individual. Your situation sounds similar to mine.
How did that saying go? I believe it was a commercial for Alka-Seltzer? Plop, plop, fizz, fizz, oh what a relief it is?
There was no plop or fizz for me, but, oh my, what a relief. And I have not had to increase my dosage over the years. Glad to hear it did the same for you. Good luck and Godspeed.
DD
Manhattan
Really excellent writing by Aaron Carroll. I'm interested in the construction of the studies, and it appears that John Ioannidis's work is groundbreaking.
It seems that there is too much bias, of whatever kind, in the studies. These are all driven by a philosophy, that human dysfunction is correctable by pharmaceuticals. In some cases it's true (e.g. insulin, aspirin), in others not so true. If a study has to split hairs to show a result, maybe there's a problem with the study.
Another issue with antidepressants is that the mechanism by which they work appears to be poorly known, or unknown. Were there a known chemical process, we could just look to see if the drug behaves according to the process to see if it worked.
Statistical analysis ignores the underlying mechanism, which is viewed as a black box, and looks for statistical significance. If the significance is arguable, maybe there is more work to be done.
Severe depression is horrible, and desperation can lead to medication as a last resort. These studies indicate that antidepressants might be like the old joke about taking chicken soup for a malady: it won't help, but it won't hurt.
1
Most interesting part of this article is the trials the researchers endured to get the trials. I'd always suspected that lots of data gets buried because of adverse results (to say nothing of the data that never gets collected because it's not economic to do so). It's human nature, and income enhancing, to hide bad news, but it's very bad for learning. Maybe one day the world will demand a database of results that captures all we need to know to make good decisions.
8
They kept me alive until I could leave the trauma behind. That took decades, I’m only just now able to cope with fewer meds. It depends on who’s taking them, what they’re taking, and why they need them.
51
Agree completely, Sloper. I couldn't have worked for my whole career without psychopharmacological meds for anxiety and depression. Had done yrs of talking therapy to no good end. Only meds helped. Now that I am retired, I've reduced the meds to very low doses (supposedly non-therapeutic ones) of three.
6
I've taken several different anti-depressants at various times in my adult life. They were mainly prescribed to alleviate significant panic attacks. The medicines alleviated both my depression and panic attacks. The hardest part was stopping the medicine after my symptoms were solidly under control, usually one year. I suffered from withdrawal which is rarely attributed as a side effect of anti-depressants. Withdrawal for me was zapping noises and feelings in my head which took about a month to go away.
14
We've medicalized depression when it is mostly a political issue I've come to believe. Although there is some room for interpreting depression as merely a chemical imbalance, something that can be adjusted with drugs, this is an escape from reality for those confronting a depressed person. The "drug" narrative allows people to escape responsiblity for a depressed person's misery, the role they play in it. Depression is situational more often than not. People are depressed for a reason, more often than not because their idenitity, the person they are, is not acceptable to the people around them. Depression is a result of the politics of experience, how we experience ourselves in a community of people. Depressed people are often expressing the shadow side of the community, an aspect everyone shares, but cannot accept in themseles. And so they sacrifice others to maintain their own belonging in the community. That's why people are depressed, and why the notions that drugs can save the afflicted is so comforting.
2
Major depression is not "political"! It is neurological, possibly genetic, which makes managing life trauma difficult to impossible.
Example: within a given family, three children were subjected to the same level of childhood trauma, yet only one developed major depression. As adults, all three experienced varying levels of trauma, yet the one who has the most egregious experiences never developed major depression.
The one who was ultimately diagnosed with major depression as an adult seriously pursued talk therapy for a decade, only giving in to taking medicine when the psychologist insisted he see a doctor. But "a doctor" was insufficient; it is for anyone. M.D.s aren't trained in how to use these medicines, and probably accounts for their marginal effectiveness with most patients.
It's only when the patient in this example stumbled upon a psychiatrist also trained as a psychopharmacologist that he got real relief. This doctor, among other things, understood how each neurotransmitter involved in major depression is affected by which medicine, and how those medicines work together. Rather than large doses of a single medicine, which had had awful side effects on the patient, this psychiatrist slowly and carefully constructed a regime of several low-dose medicines which collectively, and at last effectively, addressed the neurological foundation of the patient's major depression. Psychotherapy of course continued.
14
I used to believe much as you do, Wade, until I worked with severely depressed peo89wśGQ@#Fple. Sometimes the same life circumstances chana undergird both happy attitudes or deep depression. It isn't what's happening but rather the perceptions, withdrawal from, over-reaction and/or feelings surrounding those circumstances. People react differently to even the same things at different times. Sometimes drugs are a catalyst to recovery and can be eventually withdrawn as people get better. Severe depression is massively debilitating and must be addressed at the individual level. While remaining sensitive to community influences, most of those are either intractable and/or misperceived by the sufferer.
2
The article does not address post-partum depression. For me, a small dose of zoloft along with therapy worked miracles. I started to feel better almost immediately, and I was fully recovered within a few months.
Many women don't receive treatment for post-partum depression, and I urge researchers both to study how well drugs address it and work with doctors to screen women more often, so it's easier to get treated.
Had I known what I was facing sooner, had I known treatment could work, I would have gotten help sooner.
17
I can't vouch for all anti-depressants and anti-anxiety meds, but based on my wife's experience, some do work. When first diagnosed, (that in itself was a long and frightening process) she was given a med which worked. Per standard procedures, she was gradually weaned off it, and she was fine for about two years when the symptoms returned. This time, the original medication was ineffective. Over several years and several doctors, we found a mix of meds which helped but did not relieve the depression. Finally, a new doctor found the right combination and we got requests from our insurance to try other less costly meds. We had tried nearly everything their list, both cheaper and more expensive. But this combination restored her life. She remained on a maintenance dose for the rest of her life except when she was hospitalized for cancer treatment. Without informing us, one of her doctors stopped the anti-depressants. Her symptoms returned, and we questioned the meds. When we learned that the anti-depressants were halted due a possible conflict with the cancer treatments (when we investigated that, there were none known), with the help of the hospital psychiatric staff, her anti-depressant meds were re-prescribed. As usual, it took time, but they were again effective. In case anyone wonders about how depression affects people, my wife's request was that if she could be treated either for depression, or cancer, treat the depression. At least then she would still be herself.
51
Anti depressants, ( I have taken, prozac, lexapro, celexa ) all worked at alleviating the episodic or cyclic symptoms associated with moderate depression I was experiencing. Since I have never suffered from severe depression ( suicidal, immobile, non functional) I cannot speak to that. Moderate depression and anxiety, in and of itself, is unpleasant, tedious and distracting. But it isn't life threatening. So, any studies need to focus on the explicit symptoms that the anti depressants are seeking to relieve...and report the results or findings from there.
13
My own n-of-1 study tells me that antidepressants work. That doesn't mean they work for everyone. But for me, I have had periods when I have gone off the meds, and the difference is dramatic. Without going into a full-blown major episode, the person I am without antidepressants is full of poorly controlled rage, highly anxious, and moderately functional. On them, I am the best me that I can be. I have been on and off drugs (and talk therapy) for 30 years now - beginning as a pre-teen. It may well be that kids with these problems are different than people who don't have symptoms until they are adults. I will never relinquish my antidepressants again.
35
No where in the article is any mention of comparing antidepressants to 'active' placebos. Studies typically compare a drug with an inert substance (sugar pill) that has no discernible effect. Since most medications have side effects, it is obvious to the subject whether they are taking the drug or a placebo. A very small number of studies have been done using 'active' placebos-substances which have no clinical benefit but do produce side effects. Think of using Benadryl as an active placebo. It will have side effects (dry mouth, sedation) but no effect on depression. When such studies are carried out, the benefit of antidepressants disappears. That is why such studies-nearly always paid for by drug companies-are almost never conducted.
5
Such studies are a good idea, but your reasoning seems a bit flawed. Antidepressants do not cause side effects in everyone by any means, so it is not the case that all subjects can tell whether they are taking a drug or a placebo. You state, "When such studies are carried out, the benefit of antidepressants disappears." That's a pretty strong statement. This is the case with ALL such studies? Every single one of them shows no benefit of antidepressants? I doubt that.
6
If you use Benadryl as a placebo, the effect of the antidepressant would be greater, since the sleepiness produced by the Benadryl would increase the depressive symptoms. Most people don't get side effects or they are very minor.
I have taken antidepressants for many years. A while ago, I decided to wean myself off to see what my (new?) baseline condition was. Turns out I am still prone to serious depression, as I discovered when I bottomed out several weeks later. I agree with Dr Carroll that more data is needed on individual responses and susceptibilities. Clearly, I am in a category where chronic treatment is needed, but the prevalence of my situation isn't well understood.
20
"Modest results," for many, is enough to function, which matters to the victims of depression.
63
Agree - you may not be "happy" but you can get up in the morning and go to work. So you are "functional". On the other hand, I agree the meds loose their efficacy after a while.
2
When I was desperate for an answer to my depression and anxiety twenty years ago, my doctor put me on Effexor. For a few years, the drug helped to allow me to live without too many upsets. But it also completely stifled my creativity. I went from creating two to three paintings a month to none. I have not painted, drawn or crafted for twenty years. The psychic pain this causes is equal to, even outweighs, the original problems.
In addition, no mention was ever made to me of these side effects (apparently well known) nor the incredibly difficult process of stopping this type of drug. I still hear and read that patients are not informed of the full nature of these drugs.
I am afraid of stopping. I want to, more desperately than ever. I am retired, no longer worried I will quit my job, or make some other rash decision. But what will happen if I do discontinue? under a doctor's guidance of course. Though my current doctor (not the original prescriber) is very reluctant to have me stop.
Warnings must be included in any initiation of these extremely powerful drugs.
13
Lifesart, anxiety clearly keeps you from trying to stop taking Effexor, but you say you want to stop more desperately than ever. Could you find a "cognitive therapy" counselor to help you with the anxiety at the same time as you taper off the meds?
1
It's important your voice is heard. Thank you for telling us about this unfortunate side-effect of lost creativity. Is it because you have no motivation to create or no ideas for what to draw or something else?
Are you also seeing a clinical psychologist who can help you with CBT?
I wish you the best in your desire to stop in a safe way.
8
As an artist who also suffers from Major depression, I remember trying an anti-depressant many years ago that killed my desire to create in the manner you described. The solution was to try a different antidepressant, and my creativity was restored. As you state, for those of us who are artistic, creativity is too important to our sense of self to lose. I would encourage you to speak with your doctor about trying something else.
2
After analysing and teaching this subject for years, I can say that the overall benefit of the so-called antidepressants is between negligible and zero. When patients say that they feel some benefit in the first month or two, it's often just a side-effect that they are feeling, which leads them to think that the drug must be doing some good. But, all these so-called antidepressants have no prolonged uplifting effect, if any effect at all. Current testing of ketamine offers promise, because it has a dopamine-like action, but has some risk of long-term addiction. More needs to be done in this field.
14
There is no substitute -- pharmacological or otherwise -- for meaningful human connection and a sense of mattering, belonging. We hurt when we feel isolated and unloved. When that happens early in our lives, we carry it with us, body and soul. To the commenter below, that is what Harry Harlow's work showed us. (Read Deborah Blum's "Love at Goon Park.")
I am heartened by growing global conversation about the detrimental effects of loneliness.
We need each other.
28
And if one doesn't have that, tough luck. No help for you?
7
Thank you for this. The disease model of depression ignores the fact that people in difficult life circumstances may be depressed for good reason.
For example, lack of social connections and poverty are good reasons to be depressed. Antidepressants may mitigate the symptoms but do not address the underlying causes of the depression.
12
True, but not relevant when talking about "major depression." I had an exceptionally great marriage, to the love of my life, my true life partner, but despite this most wonderful of human connections, plus a loving family, dear friends, and fulfilling work, I still suffered from major depression. It's not sadness; it's neurological.
18
The sole purpose of any corporate activity is to increase profit. Antidepressants are extremely profitable so the answer is yes, they work splendidly.
14
What is very strange with trials lasting eight weeks, is that most doctors will tell their patients that if you take an SSRI, it’s going to take 6 to 8 weeks before the effect kicks in.
Before that time the patient is going to feel so bad from increasing anxiety that they often need benzodiazepines like Valium to calm down. And in this meta-analysis, studies including benzodiazepines are allowed.
That means that if the patient was feeling really bad from the effect of the antidepressant, they could get a benzo to calm them down. Are we really testing the effect of the benzo or the antidepressant?
There is probably another reason why these drugs work so quickly in research. It is because the patients were on similar drugs before they started, and in the beginning of the new trial, they were left without their drug for 10 days before they were tested and found to be very depressed. Then one group it was given back a medication very similar to their previous, while the placebo group would continue in cold turkey withdrawal. The surprising fact is how well the placebo group does. Many of them become as relieved actually stopping their previous antidepressant as those who get back a similar drug. The placebo group usually hits the same good response rate one week later than the drug group.
17
Do you have a source for these statements?
Can anyone answer this question for me?
Antidepressants are typically compared to a placebo, with both the investigator and the patient being unaware of whether they received the drug in question or a sugar pill. But the validity of this control requires that the patient continue to have no information about whether they received the placebo or the active drug (other than an improvement in their symptoms). For example, if a patient in a trial of an "antidepressant" that does not work to ameliorate depression notices a change in her sleep pattern shortly after being administered a pill, she might assume that she was given an active (antidepressant) drug rather than a sugar pill and possibly experience a placebo effect. This patient would no longer be in a trial with a valid placebo control. Do drug companies ask patients during the course of a trial to guess (based on a symptom not related to depression) whether they are on placebo or active drug, i.e., to verify that they are blind to their treatment assignment (except for any inferences they might make based on an improvement in their depression)? The question is especially important for antidepressants, because actual effects of the drug beyond the placebo effect may be very small.
4
Good question. The scenario of the patient/participant you described still fits with a valid placebo/control group. In fact, what you described fits the definition of the placebo effect and the reason why the control group works. It's important not to equate the patient's "assumption" with actual "information". The patient/participant you described remained ignorant of actual information from the researcher or other participants -- and as long as each patient is Randomly Assigned to the treatment or control group -- any differences in the reactions of other patient's in the control group (or treatment group) will be controlled for effectively. This is why researchers measure the degree to which the actual drug's effect is above and beyond the averaged placebo effects of the control group. By contrast, if the patient/participant asks the researcher or another active participant, and the researcher or other patient gives the participant information about which group they belong to (regardless of whether the info is accurate or not), then you have introduced a methodological threat to the internal validity of the study.
2
Studies are designed in a way that they look at how many people drop out in each arm (placebo vs drug). They use statistics to determine whether the differences in outcome are due to con-founders *such as a patient drooping out in mid-trial for any reason, such as the one you gave in your example.
2
Thanks for your reply. But let's assume for the sake of argument that all patients taking the active drug noticed that they came down with a mild case of hives on the first day they took the active drug. You could say they were uninformed about their medication in a blinded trial, but what if they thought along the following lines: I have just taken a med which is either a sugar pill or a real drug. I noticed a bodily side reaction that I never experienced before. I will infer that I have taken the active drug. Let's also assume that you quizzed all patients on whether they think they had taken placebo or active drug. If a proportion of them that was statistically significantly higher than 0.5 gave the right answer on day two of the trial, perhaps based on the kind of reasoning just described, then one could could argue that the study is unblinded and the placebo control is no longer valid because the patients are not uninformed.
The power of the placebo effect + the power of seeing the "authority" ("someone who can help" says the mind = strong medicine
The actual medicine + a human being = a dedicated customer for life for Big Pharma, which = Not Strong Medicine, but Good Business.
It is your choice.
10
Harry Harlow, the researcher who made a living torturing primates, explored depression. He placed primates into blacked out inverted pyramids, where they would be isolated and not able to escape from the unrelenting pain of being locked up. He was surprised that every one emerged seriously depressed.
Isn't depression just a learned dysfunction, and if so, calling it a mental illness and heaving mind numbing drugs on sufferers mostly a way for Big Pharma to get rich?
If one has a friend who is seriously depressed, perhaps one needs to ask just what impossible painful situation they are trapped in, or were trapped in. That worked for me...fighting back against bad jobs, relationships, whatever, they work...pills just add to the illusion that there is a disease rather than an traumatic injury.
Hugh Massengill, Eugene Oregon
16
Depression is not always due to situational factors. Physiological issues such as chemical imbalances in the brain and elsewhere and underlying and undiagnosed illness (thyroid) also cause depression. Tests are often run before anything is prescribed to check for any physical issues that could be addressed alongside the depressive symptoms.
Treating depression is not a one-size-fits-all proposition. It’s not helpful to downplay depression by suggesting that it is not a disease and is something that can be easily fixed by “talking it out.”
Sometimes it’s a little more complicated than that.
48
That is true but in too many cases there are other issues causing the problem and doctors, other than and including mental health professionals, are prescribing anti-depressants as a solution. Unfortunately the same is true with lots of other medications. Doctors are treating symptoms and not problems.
In my case, unlike yours, I spent 30 years medicated and am now suffering from the side effects of the drugs. I have been without anti-depressants for 7 years now...and the cause was environmental.
I think the bottom line is that we need better screening for determining who does and doesn't need to be taking these drugs. Finding the cause can be complicated...but that is the job of the health care professional.
Good question about "learned dysfunction": Some psychology researchers actually defined depression as "learned helplessness" since in the 1970s, and there's research supporting the use of behavioral and cognitive-behavioral interventions that framework. That said, researchers have found a clear partly biological (and partly genetic) explanation of depression. If there were not abiological component, then anti-depressant meds would not work for anyone. Situational life events certainly influence mood (and onset of major depression), especially in the short-term (days/weeks/months) too. Big Pharma attempting to get rich is another story.
7
One particularly nasty side effect of antidepressants for MANY people (as a retired nurse I have known hundreds, on many different mess) is Hyperhydrosis, extreme, relentless sweating of the upper trunk, neck and head. For residents of the freezing northern states, the choice is frequently between life-crushing depression from whatever multiple factors, and soul-crushing depression because of constant, embarrassing, socially unacceptable sweating, and becoming - literally - a walking icicle every time you walk outside. There has got to be a better way.
4
A whole body of literature regarding anxiety-related disorders (as a reason for taking antidepressants) is overlooked here. That is the beauty and curse of these types of medication.
10
It all depends what you mean by "work"--heroin works as a painkiller for plantaar fasciitis but a daily dose wouldn't make sense to most people...also if you look at the meta-analysis I believe they excluded studies with high dropout rates...which arguably means even that study was biased towards people having a response to psychotropic drugs.
5
Meta analysis has already been done by Cochrane report. The result found is this report are similar to Cochrane with anti-depressant only being helpful in the short term for people with severe major depressive disorder.
These anti=depressants are dangerous drugs that make big Pharm enormous amounts of money and have high risk of serious side effects .when Prozac was first released we were told to tell pts. they should try it and if it doesn't help just quit taking it. That information was terribly wrong and its difficult and dangerous to suddenly stop your anti-depressants.
If these were street drugs the Gov't would be adding them to the War on Drugs. They are just as difficult to quit as opioids .
When I worked in mental hospitals many people were committed for taking drugs , illegal drugs but no more dangerous or destructive than the drugs they had to take in order to be released from the hospital.
This is an extreme violation of our civil rights , take the drugs you like and go to jail/hospital where you will be given just as dangerous drugs and if you don't take them then you stay committed or in jail.
Big business runs our country , be afraid be very afraid.
18
I am a retired psychiatrist and wrote 1,000,000 Rx over my 41 year career, often for ADs. What I discovered through trial and error, and with the cooperation and collaboration of 25,000 patients, was that NO ONE AD works well without serious side-effects and that combinations of two ADs are highly effective, but the dose weights must be carefully determined to find the right balance between seritonergic and dopaminergic effects and side-effects. For instance, 50 mgm of sertraline increases brain serotonin but, also, decreases brain dopamine, so that SEs of lethargy, sexual SEs, and lack of motivation are common. Adding bupropion 150SR or XL with the sertraline in the AM balances both effects, restores normal mood, and they cancel out each-other's SEs. I have NEVER seen this info in print or talked with another psych who had discovered this empirical fact. ADs are marketed one at a time by Big Pharm and they don't want a competitor's product involved. Unfortunately, too many MDs/DOs buy their propaganda and, thus, patients are getting lousy treatment, which is reflected in the lukewarm outcome studies. I'm retired and the psych journals won't print my extensive clinical findings. Thanks for doing this important article! The real question, of course, is what's causing these epidemics of anxiety and depression. I believe it's our over-activated stress response and have written a free e-book on the subject, "Stress R Us". Thanks, again!
38
And psychiatry, in my opinion, is actually neurology. A good psychiatrist can recognize that there is brain activity that needs to be re-ordered for normal functioning. When are we going to start calling psychiatrists "neurologists," as they treat essentially the same disorders that neurologists encounter in their examinations of patients. Imbalance, misfirings, excess/insufficient biological exchanges through the synapses are all part and parcel of psychiatric/neurological anomalies.
The real problem is that "normal" people are being treated for no reason. Sertraline is a lifeline for myself and one of my adult children; atavan (spelling?) is also a life-saver for both of them. I do not know what other medication my second child is taking; we are all doing well over the past 20 years.
We thank psychiatry for our successes.
10
Ultimateliberal, "neurology" means involves many physical things that psychiatry does not cover.
I'm also taking bupropion with a different medication. It makes a big difference.
4
I should also add that there are virtually no controlled studies on the use of marijuana for almost all of the conditions for which a number of states how now approved their use most notably for any form of pain. Yet it seems many people seem to consider anecdotal evidence to be sufficient for this but quality studies on antidepressants not to be.
5
I suffered from major depression caused both by family inheritance and by trauma. Psychiatrists told me I was on the highest risk level for suicide and would have to take these pills for the rest of my life. I was on antidepressants for 13 years - Zoloft, Paxil, Trazadone, Cymbalta, Wellbutrin, Prozac. They helped only a little and the side effects were horrendous. Being on them and still suffering as badly as I did felt like being imprisoned; I felt like I would be lucky if I could keep myself alive for five more years.
Then I found out that I have a genetic anomaly (the MTHFR gene) that causes my body to not absorb Vitamin B complex. I started taking methylated B complex, exercising, acupuncture and meditating - and it worked. I am very vigilant to do all these activities as my safeguard against major depression. I think perhaps tests for this genetic anomaly should be considered, or tests for Vitamin B levels. Each case has individual variables; the medication may not work for all. A website, MTHFR.net has a lot of info on this genetic anomaly.
It took a lot of effort and work, but I have not taken any medications for years now, and I am better than I have ever been.
17
I too suffered from depression and was medicated for 30 years. Got rid of family, friends and an abusive now-ex-husband and I have been medication free for 7 years. Re-learning ways of dealing with stress and anxiety and recognizing that my reactions to trauma and oppression are normal have helped a great deal.
5
How did you find out you had that genetic anomaly, Barbara? I assume you had genetic tests, but something must have made you think about having the test. Thanks for your story.
2
Glaringly missing are studies about people coming OFF anti-depressants, or is it just accepted that once started you will take them for life?
25
If you truly need these medications, YES! You should be taking them for life. The brain is damaged and activity in it needs to be corrected; it does not "heal itself."
3
Well that should put some extra spring into Big Pharma's step.
I think the claim that the brain is permanently damaged can't be made until we know much more about how it works. How much do we know now of what there is to know? 10%? 1%? Let's remember the claims about how we only use 10% of our brains and that most of our DNA is "junk".
1
For people who cannot come off them, ultimateliberal, have you thought that it may be because the medication has damaged the brain so it now cannot cope without it?
I feel this column is negatively biased. Please read the journal article if you have interest in this subject. All 21 antidepressants were shown to be "signicantly" better than placebo and none "non-significant" when compared to placebo. In some cases, the odds ratio was impressive.
16
There is a difference between statistical significance and real world, clinical significance. The latter is captured by the notion of effect size. If the impact is statistically significant, but the effect size is small, the clinical usefulness is limited.
8
They meant "significant" in a statistical sense. It doesn't refer to the size of the effect.
No mention of rigorous research from Johns Hopkins Medical School showing strong, long term gains from two doses of psilocybin in cancer patients suffering from major depression and anxiety. The study has been replicated by leading medical schools in NY and Los Angeles.
Even the NYT took notice of this potentially revolutionary advance. See: https://www.nytimes.com/2016/12/01/health/hallucinogenic-mushrooms-psilo...
10
Like with anything else in life there is the good, the bad and the ugly or the three thirds theory of life.
For some it can be a lifesaver, preventing suicide.
For others it can help them function.
For others it can do no help and make kill them.
With all come big side effects and the pill is no cure.
Only take them if you are not able to function or worse.
14
I write this knowing that I suffer from depression, yet I am not feeling depressed.
I have been taking anti-depressants for the past 26 years, ever since I want to rehab for alcohol abuse. About 15 years ago, I was feeling severely depressed and went to have my 'meds' checked. The psychiatrist determined that I suffered from 'dysthymia' (persistent mild depression), and switched me to my current anti-depressant (Venlafaxine HCL). That switch turned out to be very positive.
Since I believe that depression is as much a chemical imbalance as a 'mental' issue; in terms of treating the body chemistry I am convinced that anti-depressants have been a major help for me.
But I am also a devout (and very Godless) member of AA, and that is my #1 treatment for the 'mental' component of my depression. As we frequently say regarding dealing with the mental change component: 'Positive thinking does not lead to positive actions / behavior, but actions / behavior leads to positive thinking'. In other words, we need to get off our butts and 'do the next right thing, even if 'too depressed' to do so.
13
I may not know much but I do know there is literature supporting the benefits of antidepressants for depression while there is none supporting the purported benefits of opioids for chronic pain. Yet whenever you publish an article on opioids and proposed restrictions you get a ton of comments from people claiming how much they need these drugs. Curious how skeptical people are about antidepressants but not about opioids despite the destruction the latter have caused to society
Also readers might assume from the first sentence of the article antidepressants are only prescribed for depression. In fact, they are also first line medications for the treatment of many common pain conditions including fibromyalgia, diabetic neuropathic pain, and shingles. I am not aware of any study on the number of prescriptions written for antidepressants that has sought to separate the number written for depression and the number written for pain.
10
Placebos at best
4
If you are on an antidepressant, DON'T just stop cold turkey. Doing so can cause very troubling mental agitation. Wean off slowly, preferably under the guidance of an MD.
16
I have heard that two common side effects are: interference with sleep and difficulty with libido and achieving orgasm. There is a lag time for getting used to these drugs sometimes involving nausea.
3
Not all meds are alike, of course. As one who watched several family members improve with meds following years where nothing else helped w their depression & related anxiety, I was predisposed to support “meds” as a solution. Now I’m not so sure.
Far too many US physicians don’t seem to care enough to learn the cautions within the deeply researched, rigorous work that’s widely available — such as this from the UK, summarizing information that has been widely available AS EARLY AS 1988 !!!
https://www.benzo.org.uk/manual/
Benzodiazepines have always been recommended ONLY for VERY short-term use. Completely ignoring this, however, too many US physicians continue to prescribe them for months, even many years, until they are doing vastly more harm than good.
“Popping them like candy is OK” is a direct quote from our well-respected Boston doc; he did not even read the 1980’s-era research papers we discovered and gave him.
See also http://www.benzobuddies.org/, a forum of >100,000 individuals who are helping each other withdraw — it is a true hell, I can say from our experience. Still not fully recovered after 4 years.
It’s criminal that docs in the US seem to listen to big pharma marketers rather than to their patients.
8
Benzos are not antidepressants.
1
I experienced several bouts of major depression coupled with crippling anxiety many years ago. I resisted going on medication and tried talk therapy, yoga, meditation,exercise.
They were minimally helpful but I wore out and started prozac. It took weeks to start working but gave me great relief. I stayed on it for a year and then weaned off. Months later, I crashed again. Went on zoloft for a year and then weaned off. Crashed again. Each episode was devastating and my sleep and eating were severely disturbed. I would cry all day and have horribly negative thoughts. In 2003 after another bout, I threw in the towel and went on 50 mg / day of zoloft. I would not characterize it as a happy pill nor will it work miracles. But, I haven’t been disabled by an episode of major depression since committing to this regimen and I feel it has saved my life.
145
The bottom line: some drugs work for some people some of the time. This can be extrapolated to all medications. In my experience some patients benefit from antidepressants and if they discontinue them they return and ask for a new prescription because symptoms have returned. Some patients who discontinue the medication abruptly have real withdrawal symptoms which is why I always advise patients to taper off. And some patients get no benefit at all from these medications.
19
And some patients cannot taper off of them at all. I take 5 mg (half of the smallest tab) 1x/day. Can't get off of it no how.
4
You might do research to see if your Rx comes in a liquid form and taper off that way.
I neglected to say that the 5 mg are of paroxetine.
As always, there is still bias galore.
BUT, as we docs know, if you happen to be that patient where the drug really works just like it's supposed to do then it's wonderful.
This, as we know, applies to ANY drug.
Statistics are great and useful, but patients are not statistics.
18
Yep. Bias galore.
BUT, what you ignore is the dangerous SIDE-EFFECTS, including suicidal or homicidal ideation.
If you happen to be that patient where the drug really makes you murder your family then it's not so wonderful.
This, as we know, applies to just about ANY mind-altering drug.
Statistics are great and useful, but patients are not statistics.
8
The methodology of these large studies doesn't capture the reality of clinical efficacy very well. Any given antidepressant will work only for a subset of people with depression, and not work for many others. That means that a study that looks at the average effect of a large group of antidepressants will underestimate the efficacy of antidepressant treatment in actual practice.
As a psychopharmacologist for the last 37 years, I have treated several thousand patients with depression. The process is sometimes long and frustrating, since often several — occasionally many — antidepressants need to be tried before finding one that has clear benefit for that individual person. (Unfortunately the current genetic testing available rarely gives much guidance in the search.) Once an effective medication is found, however, people feel definitively better, to a degree not hinted at in the large meta-analyses cited in this column. If someone has tried 4 medications before responding robustly to a 5th, we should not conclude that antidepressant treatment is only 20% effective.
Not all depression is responsive to medication, and psychotherapy can be crucial for many people, but the majority of my depressed patients have found them to be extremely valuable, and sometimes life-saving. To those who point to studies like Dr. Ioannidis's to question the benefit of these medications, I can only say that I have treated many, many people who would strongly disagree.
101
What you're saying is you have to treat your patients as guinea pigs in an uncontrolled and potentially dangerous experiment.
You're ignoring side-effects, including possible suicidal or homicidal ideation. To those like you who point to your depressed patients who thought it was extremely valuable, I can only say there are many, many people devastated by the side-effects who would strongly disagree.
12
Yes, side effects are not be ignored. If they don't go away, then it's the wrong drug, and it's time to try something else. The "devastation" from side effects is temporary, although sometime immensely distressing, but to condemn all antidepressants because some people get side effects on some of them is throwing the baby out with the bathwater.
It does feel as if you're being treated as a guinea pig, but the brain is too complex for us to be able to predict in advance which medication will be right for any given person. In the end, if you find a med that really works, all the discomfort from meds that caused problems or didn't work becomes just an unpleasant memory.
1
"What you're saying is you have to treat your patients as guinea pigs in an uncontrolled and potentially dangerous experiment. " That is simply unfair. The patients come to him for help. I am sure he tells them how the process will work, and that he will have to experiment in order to possibly help them, since drugs work different ways for different people, and some may not work at all. Some people simply can't forgive doctors for not having every answer to everything!
I have had major depression. I tried a few different antidepressants. One antidepressant - just one - got me out of it. The others were useless or had negative effects. I don’t think the same antidepressant works the same way for everyone.
38
Correct! And a competent psychiatrist or neurologist can figure out which drugs are right for your individual cases. Once, I was prescribed the wrong one, and it was devastating. After four weeks I thought I was going to die from a heart attack or suicide. Another saved me, and I've been using it for twenty years. Life is grand!
9
When rigorous statistical analysis of large data sets tells a counterintuitive or otherwise uncomfortable story, we resort to anecdote to defend our preconceptions and practices. It is said, with more than a grain of truth, that the three most dangerous words in medicine are "in my experience."
5
Depression is a complex, multi-faceted illness, afflicting a heterogeneous cohort of patients. Asking "Do Antidepressants Work?" runs the risk of each person having a different definition of the word "work."
As a clinician, I strive to lessen a person's distress and improve their functioning; this involves much more than can be evaluated by a patient's score on the type of rating scales used in research trials. In real life, I am free to take aggressive measures (e.g., combining multiple agents; exceeding usual dosages; using agents for off-label indications, etc.) which are prohibited in research trials. Thus, I will always achieve in my practice results which are far better than those in n any research trial.
Treating depression for four decades has both impressed me with the potential of antidepressants to improve the quality of people's lives and reminded me of the limits to what any and all medications can accomplish for patients with severe, treatment resistant illness. While many patients have their depression treated by their primary care physician, a psychiatrist is usually best qualified to treat people who fail to respond to two or more adequate trials of an antidepressant.
32
Anti-depression drugs should only prescribed and monitored by a psychiatrist.
1
There are not enough psychiatrists to help the people who need antidepressants. Most cases can be treated perfectly well by a family doctor, as mine was.
"The bad news is that even though there were statistically significant differences, the effect sizes were still mostly modest." The author fails to mention that, as is the case with most medications, the effects can vary widely across patients. The average effect of a medication could be zero and yet it could be very helpful to half the patients and counterproductive to the other half. It is not enough to report point estimates of average effects. Report confidence intervals too.
20
Virtually every anti-depressant medication can be improved through therapy and other boosts such as diet, exercise, and therapy----it is a long term process with substantial rewards as long as those afflicted and affected manage the process! And, it no longer has the smell nor shame of years ago, thanks to real stars like Art Buchwald, William Styron, Johnny Carson, and others who stepped forward to bring their own light to a common occurrence in the world.
11
After giving birth I suffered for at least nine months of postpartum depression before my general practitioner prescribed an antidepressant for me. Starting the very first day of taking the medication the effect was immediate. After months of no sleep, experiencing ruminating and intrusive negative thoughts, and almost unable to swallow food, suddenly the world lit up and all my anxiety lifted - after one pill. And the world truly did light up because suddenly the trees were brighter and the wind moving the leaves was exquisite and I felt that I had entered life again. I remember that intense enlivening moment the drug kicked in from nearly twenty years ago. It was a powerful reengagement. A week or two later I was suddenly able to laugh. I knew then I could never go back to the life I had of unending anxiety that was fully triggered by the hormonal cascade of pregnancy and delivery. Antidepressants do work if your brain chemistry needs them.
60
I will never forget how it felt for my brain to re-engage with the world after my first week on anti-depressants for post-partum depression. It truly felt like a miracle.
13
As a doctor who has treated hundreds of patients with depression I must say the medications can be a life saver. However, they must not be given without ongoing weekly therapy. In my practice most, patients wean off the meds after a year in therapy. Further the meds are not for everyone. I taper them very carefully up to the dose that relieve symptoms and that dose is usually below what the pharma recommends. In some cases, the choice of ECT can also be a life saving treatment. Depression has been the price of being human along with anxiety. Living in an isolated community does not help. Everyone is looking at their electronic devices rather than each other. I remember growing up in Brooklyn that going for a loaf of bread or a quart of milk was an hour affair as you spoke to everyone along the way down the block!
60
I also grew up in Brooklyn in the 1950s and was surrounded with many friends who I would walk to school with and spend the whole day play games on the streets. There were also many caring adults who know who I was. Zero social isolation. It was a wonderful time and place to grow up.
7
As I sat down to eat my oatmeal followed by my now "weaning off" daily dose of Prozac, I was of course interested to read what this article has to say. As a scientist, I was also interested in what the data say. And of course, as a human, I was interested to see what other people had to say as well. I think all the comments make great points, but I especially agree with the comments that point out that we need to get better at diagnosing depressive ailments in order to better prescribe medications and therapies that work.
For me personally, medication saved my life. I wasn't suicidal, but I wasn't actually living. Therapy did nothing for me, I understood my thoughts were irrational and were not "me." They were an illness. But it took time and effort to access a mental health professional who could see that I needed medication to help my brain function reset. A low dose of Prozac combined with a mood stabilizer (for a very short time) had an immediate effect. I am lucky, I know, to have responded so quickly with no side effects. A year later, I am, under the supervision of my doctor, starting to taper off of the medication.
If we as a society continue to put resources toward solving these problems, we can help so many people lead fulfilling lives. I'm finally optimistic about something, but we do have a long way to go.
38
Please be careful and have someone supervise you for the next year or two. I weaned off of SSRI's a few times and always had my depression come back so slowly it seemed normal to me, it took an outside eye to tell me I needed a doctor and medication again.
5
I've tried nearly ten antidepressants over the past 20 years, and after this long period of trial-and-error, I've come to the conclusion that antidepressants are a blunt, uncertain tool used against a nebulous problem. This problem is so difficult because depression is not a disease but a syndrome, a constellation of symptoms. Each person's depression is their own, a completely unique product of their psychology. The depression of 10 million people is thus 10 million different problems. How effective could any drug be for that?
Finally, let's not forget that researchers still don't really understand how antidepressants work (that is, assuming they do work).
I've been off antidepressants for a year now. I feel exactly the same way as I did when I was on them. I'm glad I don't bother with those pills anymore.
31
As to not knowing how drugs work, it might interest you to know that no one knows how the most widely used pain reliever, acetaminophen (Tylenol), exerts its analgesic effects. Nor, by the way, although opioids have been used to relieve pain for centuries do we k.now how they do this.
If you want to use lack of knowledge about actions to be a deciding factor in whether or not drugs are used, you're going to lose a majority of our current medications.
9
I was so surprised by your claim about acetaminophen that I doubted it at first, but I looked it up and yeah, clearly you're right. I'm in shaky scientific ground here because I simply don't know enough. But is it possible that one of the reasons both antidepressants and acetaminophen's mechanism of action is unknown is because they both address something so subjective as pain, whether physical or psychological?
I've been on antidepressants for 7 years and therapy for 5 of those years. It's likely that I'll be on them the rest of my life. They saved me from suicide.
Antidepressants aren't the answer in all cases. Or maybe most cases if the meta-analysis is correct. The side effects can be terrible. But until mental health care (therapy, the number of qualified and able therapists, psychiatrists, social workers, and beds for in-patient cases) is accessible to rural, poor, immigrant, and people of color populations, antidepressants will continue to be prescribed as a long-term solution.
9
The six comments appearing so far are all good. That's refreshing!
Based on my own experience with depressive episodes, I'll emphasize how important it is for people with major depression to keep trying different antidepressants. After trying four other medications, I've now been on duloxetine (Cymbalta) for 12 years, and I've not had a depressive episode in that time. Although anecdotes are not data, I'm convinced duloxetine is working for me.
As Dr. Sabet observes, the term "major depression" is currently applied to multiple distinct conditions, though they undoubtedly share some neuropsychiatric pathways. I agree with 'anonymous' that new diagnostic tools are needed to distinguish variants in individual patients, to determine which treatment will be most efficacious.
I've had multiple forms of psychotherapy in the past, and IMO the only form that's had any effect is cognitive behavior therapy. I believe it's most helpful for 'left-brained' people like me, who prefer to think our way out of problems. CBT is probably more effective when the patient's mood is stabilized with the correct medication first.
Lastly, I've recently come to understand that some "major depression" may be rooted in personality. Personality factors appear to highly heritable, i.e. we're born with them. Psychotherapy for depression may simply bring the patient's attention to the personality dimensions their depression is rooted in, so they at least are able to 'police' their thoughts.
19
I was on a very low dose of Lexapro last year, which helped as I met with a counselor (after I got over the side effects). But over time it wasn’t working as well — coincidentally (or not), my relationship with my counselor was also deteriorating at the same time.
I think antidepressants work to provide an initial stability to get one into a better, more receptive place for therapy, be it CBT or something else. They then can help maintain more optimum brain chemistry as therapy moves forward, creating a “win-win” situation as well. You need the right combination of medication and therapist, which I haven’t been able to find. Rather than keep upping my dose, I discontinued, and needless to say, the thought of auditioning psychologists right now exhausts me. I’ll get by the best I can.
25
Our family has had a negative experience with anti-depressants. One member was put on paxil along with nexus, not specifically for depression but for stomach problems. He had side effects and so was put on another anti-depressant to counter act the effects of the first. He wanted to simply stop taking the first, but stopping is none too easy-- there is a "discontinuation syndrome" that would effect his ability to concentrate. It is advised to reduce anti-depressants slowly and stepwise, and to take a few weeks off of work (and family) with every step. That was not possible-- until he had a hip replacement and took advantage of that time off to decrease the dosage, and then again with his next hip replacement two years later. Meanwhile, the side effects continued. The doctors who prescribed these never suggested a change in life style or seeing a therapist. - Oddly enough, if I talk about our experience with extended family or friends (or Facebook), people are immediately protective of their antidepressants and even go so far as to tell me that I don't care if people commit suicide. --I hold a degree in toxicology (Cornell University), and know that studies, esp. long term studies, on how these anti-depressant drugs work are limited. My questions are valid-- yet they seem to be personally threatening to many I know.
42
Like all medications for all conditions they are one tool in the tool box. We have scores of data that exercise works better than medication for depression (as well as diabetes and heart disease) but I have to get my patient to be able to exercise - which is the long term strategy.
A lack of omega 3 fatty acids in the diet can cause panic disorder yet we still treat it with medication because dietary changes will take time to take effect.
Dietary shifts and exercise should still be the main prescription for ANY health condition, including depression, the medications are adjuvants. That does not mean they do not work.
56
I'll accept what you say if you ever get cancer, you will consider dietary shifts and exercise to be the main prescription for treatment.
As for diabetes, diet and exercise are not the main prescriptions for Type 1.
16
And how do you get a severely depressed patient to exercise???
6
Citation needed. All of your claims are dubious. There is no good research showing “that exercise works better than medication for depression” (in fact the opposite is true: studies of exercise for treatment of depression have been a bust). Dietary shifts for depression?! Diet and exercise “should be the main prescription for ANY health condition?!” Presumably this includes snakebite, pneumonia, and cancer. Good luck with that.
Anyone peddling a one true cure looks like, walks like, and sounds like a quack.
8
While this review is helpful, additional contextual information would make it easier for the reader to evaluation the data. For example, what would a comprehensive meta-analysis show for 'Statin medications for hyperlipidemia, or Angiotensin Receptor Blockers for hypertension ?
The results of research are biased by a great many factors. It's useful, then, to ask how antidepressant research compares with research on other treatments.
10
A great book to read would be Anatomy of an Epidemic. The author looks at records from Bellevue Hospital in the 1940s, before pharmaceuticals were available. He found that just as many people suffered from depression back then. The treatments used led to a cure in about 6 months to one year in most people with very few relapses. After pharmaceuticals came around, people got 'better' faster but were dependent on drugs, turning a mostly acute process into a chronic condition.
31
what were the treatments used that worked within six months?
3
Sending people to spas for rest, psychoanalysis, phototherapy......and most likely it was time and waiting it out.
I would heartily second the comments of my colleague Dr Sabet. As a psychiatrist, now retired, who practiced in federal, state and local mental health systems for almost 30 years, it has always been clear to me that our diagnostic nosology was somewhat crude. But the medical profession and our colleagues in psychology have been aware of this and much progress has been made. The current focus on epigenetics and functional imaging to better define the neuropathology and risk factors for all mental disorders is yielding great results, and the pace of discovery is accelerating. Mainstream treatment, though, still consists of medication plus some sort of evidence-based psychotherapy, particularly for the more severe variants of depression. Funding for basic and clinical research regarding the brain and its mechanisms is vital, and will hopefully continue.
14
Generally speaking, they work. However they are NOT some miracle cure. They are not "happy pills." I've been on a low dose of an antidepressant for a few months now, but before that I was (and still am) seeing a psychotherapist. The pills themselves are just one tool in a tool box that helps me to cope with depression. The other tools being exercise, therapy, a good diet, meditation and marijuana.
32
Marijuana can mess with the effectiveness of psychomeds. Use with caution.
4
In my opinion, what scientists should be looking at is not whether antidepressants work, but how to determine which antidepressant will work for which person. I know there are some gene testing services that can provide guidance, but I’m not sure how well these work. For me, treating my major depressive disorder was a long process of trial and error with many despondent months wasted on antidepressants that did nothing for me. When I found the right combination, I finally started to get better. Asking if antidepressants work is the wrong question; the question should be how do we find better ways of targeting which antidepressant will work for a particular individual.
153
I didn't see your comment before I posted mine. I think the gene testing may be only roughly indicative of what works--but I think it may be more suggestive of what will NOT work. For the life of me, I don't understand why doctors don't say more to patients about the availability of these tests.
2
The problems lies with what we call major depression. This is not one human condition, it ranges from severe brain based disability with strong genetic, epigenetic and environmental contributors to variants to life responses imposed on prone to negative emotion individuals. This debate will not die down until we have a better way of categorizing what is depression. As a psychiatrist I have witnessed antidepressant save countless lives and not work depending on these factors.
115
Absolutely.
I have dealt with what I believe to be a genetic depressive predisposition since my early years.
In my community, I have seen success and failure of antidepressants.
It’s not a simple situation.
Throw in the need of the pharmaceutical industry to make a lot of money, and it becomes even more so.
10
That work must include helping people understand the difference between sadness and depression. These days, people are afraid to feel sad. But sadness is a signal emotion; we feel it for a reason. It's telling us something about our lives. We should pay attention to it, not numb it out.
10
I expect that depression will turn out to be several different diseases. Nothing worked for my husband until he was put on a mood stabilizer, I suspect he actually had bipolar disorder with his manic episodes so rare and relatively mild that they didn't get noticed.
I have anhedonic depression, where I don't experience happiness or desire to do anything. Life is a slog. SSRI's help, but even more I was helped by a diagnosis of diabetes where I was prescribed metformin. I suspect that my depression is literally the inability of my metabolism to use energy properly. I note that seratonin is also very important in the functioning of our digestive tract, perhaps it works there and not in the brain? I've tried a few times to get off my SSRI, and it always ended badly, I need it to be able to enjoy life.
People are complicated, and I think there will be many other variations of depression, all responding best to different medications.
9