Sunday, 2 March 2008

Back on the SSRI's (again)

SSRI's have been back in the news again, with some controversy as to their effectiveness compared to the placebo effect (to put it very vaguely).

The first blog post I ever published was a couple of years ago on Frank Fisher's now-defunct site, and was written in part as a response to someone else's article about antidepressants and other treatments. Following last week's fuss, I thought it would be interesting (maybe) to dig out this article, which was intended as a measured defence of antidepressant medication.

I've taken the first couple of paragraphs out purely for reasons of context, in that they related to Frank's site and the article I was responding to. The rest of it is the same as was written and published at the time. I wonder if I still have the same opinion overall as I did then:

...I'm not a medical person so I don't claim to have in-depth, clinical knowledge of how the different groupings of antidepressants work. The main groupings are the older Tricyclics, through to Monoamine Oxidase Inhibitors, and on to the more recent batch of Selective Serotonin Re-uptake Inhibitors (Prozac, Seroxat etc). Catchy titles, all of them.

All aim to work in their differing ways by affecting or regulating the chemistry of the brain, particularly the areas which control mood. Although I've done some reading on precisely how they achieve their intended effect, I'd say it was best summed up by a consultant psychiatrist who, during a talk on the general use of psychiatric drugs, likened it to "trying to fix a delicate clockwork mechanism with a big hammer".

With that in mind, any defence of antidepressants is going to have to be a measured one.

I'll first address a source of misconceptions, namely the media (surprise surprise). To give the newspapers their due, there has been some responsible reporting of legitimate and sometimes urgent concerns which have arisen in relation to unwanted and unforeseen effects of SSRIs. Frustratingly however, there were many media reports when drugs such as Prozac first came to
prominence, desribing them misleadingly as "happy pills" or "wonder drugs". They are neither, and such sensationalised descriptions variously serve to undermine or overstate what the drugs can actually do.

Another point of concern which may lead to antidepressants being viewed with greater mistrust, is the increasing tendency in some quarters of the pharmaceutical industry to symptomise behaviours and then develop drug treatments for them. Antidepressants may be seen as being at the thin end of this particular wedge, regardless of the status of depression as an at times very severe illness.

Let's take a look at antidepressants themselves. As with any medicine (perhaps with the exception of herbal treatments) they are a poison and can give rise to unwelcome side effects. As regards their benefits, the bottom line is that they do not constitute a cure: they are a palliative, ie they relieve symptoms.

The obvious comparison to make is with painkillers, in that they make a reasonably good job of masking pain and discomfort, but they emphatically do not treat the cause of the pain. I'm reminded also of the argument that the glass of water you drink is of greater medicinal benefit than the paracetamol you're using it to help swallow down, but that's perhaps a different

I personally don't like to take painkillers of any form. However I had two wisdom teeth out last week and can vouch for the fact that an Ibuprofen every four hours for a few days afterwards made my life a great deal more bearable and less uncomfortable, and during this time my body began to get on with the process of healing. Analagous to this is that the severe dips in mood, the intrusive, incessant and unwelcome thoughts, decrease in motor functions and the other main
characteristics of depression can be alleviated by a carefully controlled dose of an antidepressant.
By providing such respite, it may be then possible to begin to address the causes.

I'm not trying to suggest that this is going to work or even be desirable for many who find themselves in this position. My perspective, as such, is that antidepressants are not the answer but that they have their rightful place within the range of possible treatments. From my point of view problems arise when:

a) Antidepressants are overprescribed or too quickly prescribed, when other treatments may suffice or be more desirable

b) They are prescribed as the sole treatment rather than in conjunction with other treatments

c) The patient is unaware of what the antidepressant can and can't do, which in some cases may result in the false hope that their depression will be cured, or that they need not make any effort towards changes which may influence long term recovery.

While resources are likely to have an impact on some of the above, my own fortunate experience is that having a GP who listens rather than just prescribes, makes a huge difference.

If it seems as though I'm mounting a defence of antidepressants based on what they DON'T do, well, fair enough. By being aware of the various misleading claims or assumptions which are often made about them, I would say that that would be of use in making an informed and realistic choice. It hopefully (though not necessarily) follows that the onus is still firmly on taking steps towards addressing the causes of the illness, with a view towards a more sustained recovery
and the development of healthy coping strategies.

So - antidepressants don't fill the gaps in your life; they don't provide the answers; they don't cure; they don't address societal problems or the pressures that life can bring to bear on an individual. The list could go on. What they are often extremely good at however is providing relief from the various symptoms of depression. That in itself has been enough to contribute towards saving the lives of a number of people I know or have known - some individuals that I
have worked with as a mental health worker, and at least two individuals who I count as close personal friends. For me, right now, that's good enough.


B said...

Well I've never used antidepressants myself, so can't speak from personal experience, but all that seems to make sense to me.

*Do* you still agree with all that then?

Pixie said...

I think anti depressant's are good. In that they lift someone's mood suffiecently that they can function. Then if therapy happens as well then people are getting the optimum care to elevate their depression.
There is no quick fix to depression at all. It is a long haul to get over it and really difficult to do it without help.

steve hayes said...

All of us have different DNA and different metabolisms. Some herbs and vitamins work better than others. The first thing that is needed is proper nutrition and a good physical exam. As the director of Novus Medical Detox, I often see patients who are on alcohol or opioids, central nervous system depressants, also taking antidepressants. When they detox they find they don't need the antidepressants.

This is good news because a Swedish study showed that 52% of the 2006 suicides by women on antidepressants. Since antidepressants work no better than placebos and are less effective than exercise in dealing with depression.

There is a prescription drug epidemic and these are leaders in the list of terrible abuses.

Steve Hayes

Neon said...

When I was 17 I had a very bad breakdown for which (once I eventually seeked help) I was prescribed Seroxat and went to therapy. I was on them for 3 years and I can honestly say they changed my life. In conjunction with therapy antidepressants are totally fine- but personally I dont think they are the answer on their own. Over the years I've heard a lot of negative press about Seroxat but it was perfect for me and helped me get my life back together again.

trousers said...

Hi b, I'm still thinking about it. I don't think there's anything controversial in what I've written, but I'm certainly going to see how the debate (in general, not on this thread) about SSRI's progresses.

pixie, I agree though with the reservations that are in the article. If anything has changed for me since I wrote it, it's around such concerns as the agenda of the big drug companies and how they control trial data. So in some respects antidepressants are for me tainted by association with the agendas of the big firms, though that's not a comment on their effectiveness.

Hi steve, thanks for dropping by and making those points, though for some reason I wonder if you actually read what I wrote?

Hi neon, long time no see :)
Yes there's been a lot of bad stuff written about Seroxat and its ilk, and not without good reason. But I'm glad it worked for you, and you're certainly not on your own in being able to say as much.

anticant said...

Anti-depressants and pain killers are useful crutches if moderately used as temporary expedients. The danger is that taken on a longer term basis they become addictive.

See my post 'depression and political snake oil' in Anticant's Arena:

zola a social thing said...

This is all so depressing.
I will be off for another beer.

szwagier said...

Well now. Some authority on antidepressants in general and SSRIs in particular I can claim to have.

I don't care if it's an SSRI, a tricyclic, a sugar pill, CBT, DDT or a heap of horse manure If it helps people get through depression it's worth it.

End of.

szwagier said...

And in all the hoohah about the Kirsch report, every single piece has quoted his view that "the researchers conclude that there is little reason to prescribe new-generation antidepressant medications to any but the most severely depressed patients".

Every piece of coverage I've seen has had a variation on that. And in that respect every piece of coverage I've seen has either deliberately or negligently taken the quote out of context.

Here it is in full:
"the researchers conclude that there is little reason to prescribe new-generation antidepressant medications to any but the most severely depressed patients unless alternative treatments have been ineffective".

That is a very different finding.

trousers said...

Thanks anti, I'll be sure to come over and read that at the Arena. Well to be honest I came over and read it this morning, but it was too early in the day to digest it fully. Have to say it looked like good stuff though.

Get a beer in for me while you're there, will you zola?

szwag, I'd refrained from saying anything except for the most general things about that report: I'd been led to believe that most of the coverage of it hasn't exactly been faithfully reporting the whole story in terms of its findings (Mrs Melancholy has a piece about it on her "Confessions.." blog, which was the spur for me to repost this article). My attitude in that respect has been one of, wait and see. So thanks for posting that, it's very useful to know.

szwagier said...

They have also neglected to mention, in their readiness to condemn, that Kirsch doesn't exactly have the solid support with his peers. A maverick with his own agenda.

Less and less credible as the days pass.

trousers said...

It will be interesting to see what any further studies or findings bring, in light (or regardless) of this one. Mind you, I still know less about this one (and it's author) and more about the reporting of it: which you could say is symptomatic of a lot of things these days..

DJ Kirkby said...

I took Sertraline for 6 months several years ago and I can def say they helped a great deal and the horrid side affects only lasted a fews days and were well worth the end result once the anti D's started working properly (about 10 days). I wouldn't hesitate to use them again if I felt the need.

Ms Melancholy said...

Hey trousers, a well balanced argument, almost all of which I agree with. My view is that they will often work well enough to enable people to engage more effectively with their internal world, and genuinely transform their experience through therapeutic or other means. Shame the pharmaceutical industry is run by cynical self serving fuckwits though.

trousers said...

Oh and better late than never, I hope: dj, yours is one of many such tales I've heard, and I'm glad it worked for you too. What I didn't post in this article was that I have past experience of having taken antidepressants too, maybe at some point I'll write a more personal piece about it (for the record, my overall experience was that they helped).

Hi ms m, I do agree with what you say, in fact (I think the part in which I mention masking the pain to allow the process of healing to begin, was a case of trying to express similar to what you've said, though you've said it much more eloquently). As with everyone else, thanks for coming over and reading it :)