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
debate.

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.