My grandma had an on-again, off-again relationship with antidepressants for her whole life. The cycle would begin with her lying in bed in the dark, crying and moaning. After months of persuasion the family would convince her that the level of sadness she was experiencing wasn’t normal and she’d start taking medication. After six weeks or so, she’d be out of bed, running errands, and even smiling. Once she reached that point, though, she’d stop taking her antidepressants, thinking that she didn’t need them anymore because she was happy. Then the cycle would begin again.
Depression appears to be caused by an imbalance in the levels of neurotransmitters in the brain. Antidepressants impact some of these chemicals, such as serotonin and norepinephrine, in an attempt to rebalance the brain’s chemical makeup. Some of the most common antidepressants are classified as selective serotonin reuptake inhibitors (SSRIS), such as Prozac and Zoloft, and serotonin-norepinephrine reuptake inhibitors (SNRIs), like Cymbalta and Effexor. Both medications block the absorption of certain neurotransmitters into the brain, leaving higher levels of those compounds floating around and returning the brain to a balanced chemical state.
Doctors diagnose depression through an evaluation of symptom severity and longevity, family history of depression, and suicidal ideation. Typically if patients presentlong-lasting and/or severe symptoms, they will be treated with antidepressants. Oftentimes this treatment is supplemented with psychotherapy so that the patient can work through life issues, learn how to cope with the illness, and manage its triggers. Patients usually have to try several different types of medications in order to find one that works, since everyone has different brain chemistry and symptomatic complaints.
Yet various researchers argue that this trial and error process might be a waste of time for some patients. According to analysis of clinical trial data from the FDA,taking placebo pills improved depressive symptoms almost equally as much as taking antidepressants. The only clinically significant difference occurred in severely depressed patients. Why should people are pay for medication that does them as much good as a sugar pill, these analysts argue?.
This does not necessarily mean that antidepressants are ineffective, however, and these studies fail to take into account a couple of important issues in the psychiatric field. For one, depression is currently over-diagnosed. According to a study done by the International Review of Psychiatry, nearly a quarter of the US population has been prescribed antidepressants at some point. Only about 10%, however, actually have a depressive disorder. Doctors often confuse periodic depression brought on by illness, substance abuse, or other factors to be a diagnosable mental illness and pop out the pills. Psychiatrists should examine patients carefully before prescribing antidepressants to avoid over-diagnosing the population with mental illness, as well as to avoid the potential risks. Psychotherapy, light therapy, and exercise can be just as effective in minor cases of depression and should be utilized by doctors more often as treatment.
In addition, many patients demand antidepressants from their physicians and, willing to please, doctors actually write them prescriptions to make them happy. Dr. Glenn Treisman, a psychiatrist at the Johns Hopkins Hospital, sees drug-seeking patients all the time. “They think they know what they need, so I have to remind them that I’m the one that went to medical school and I’ve been doing my job for over twenty years. I prescribe medicine to make them get better, not feel better.” He doesn’t hand out medicine to please patients, but many other medical professionals do, and this trend is contributing to overmedication.
Includingthose whoare only depressed temporarilyskews the data in clinical trial studies for antidepressants. Patients like my grandmother can be drastically improved by the medication, since they face a clinically significant health problem. But if a person without a chemical imbalance takes a medication designed to remedy chemical imbalances,the drug is obviously not going to be effective. Therefore you cannot conclude that antidepressants are ineffective, since non-depressed individuals frequently use them.
Additionally, as mentioned before, patients typically try several medications before finding one that fits their depressive symptoms and makes them feel better. Clinical trials do not account for this process of trial and error, and simply examine the data from each pill without examining each participant’s chemical makeup or response to other drugs. Maybe some antidepressants are ineffective for some patients, but others are still likely to be helpful for patients that truly do suffer from depression.
Because there are different kinds of depression, there are slight differences in depression medications as well.This makes the trial and error period necessary. The SSRIs are known to cause an increase in suicidal ideation, as well as increased irritability and aggression. My grandmother was unable to tolerate taking Lexapro, an SSRI, because it made her break out in tears at random and have fits of hostility towards her family. SNRIs are known to help with chronic pain in addition to depression, but can also cause high blood pressure and decrease libido. My grandmother found that Cymbalta, an SNRI, worked best for her, but every patient is a little bit different.
It is debated whether or not antidepressants should be used for their placebo effect. On the one hand, the drugs have potential side effects: suicidal ideation, increased risk of stroke in women, and general personality changes are just a few of the possible results. Additionally, antidepressants are often used over a lifetime, which can rack up quite a medical bill. On the other hand, however, if patients truly do feel better and need that reassurance to get through a difficult period of depression, some doctors argue that it is okay to keep prescribing the drugs.
Dr. Durga Roy, a psychiatrist at the Johns Hopkins Hospital, says that she will sometimes let patients take antidepressants, at least for a brief six-month period, to enhance their mood and boost morale. “Sometimes patients will come to me saying they are depressed because a relative just died or some other event occurred and that they need antidepressants. If they’re not at high risk for seizures or stroke I’ll let them take the medication to bump their mood. I’ve never seen any patients that have had personality changes or that suddenly started having seizures.” It seems that the prescription really must be based on the individual circumstance, and that making the broad statement that “anti-depressants don’t work” is unfair to the drugs.
It is difficult to obtain data on the effectiveness of anti-depressants when they work so differently for each person. “Depression isn’t one of those disorders where you can just point to something and say, oh there’s the problem! You have to work with the patient to try to figure out what’s best for them,” says Roy. In an ideal world, clinical trials would study each depressed patient individually and track which anti-depressants worked for them and which did not. In this way, researchers could still prove the effectiveness of the drug for certain patients and rule out the possibility that the study participants might respond better to another drug. Since this takes time and money, however, it is not currently a plausible solution.
It is also difficult to prove a drug’s effectiveness because mood change is self-reported on a number scale. Patients go into the study saying their mood is, for example, a 5/10 on a scale from 1 (saddest) to 10 (happiest). Then at the end of the study they say their mood goes up to an 8/10. This scale system is subjective, but it is the only way that clinical trials can study an ambiguous disease like depression. Depression is entirely an individual experience, and trying to define it with numbers and statistics is nearly an impossible feat.
Ultimately, the antidepressant-bashing data analysis of clinical trials is inconclusive and unproductive. Until scientists find a way to physically define depression, perhaps by using a brain scan that measures neurotransmitters or some other method, clinical trials will have to rely on subjective data that simply cannot prove general efficiency.