By Dr. Marcel de Roos -Psychologist PhD
The use of anti-depressants has increased enormously with the availability of modern medicine such as fluoxetine (Prozac) and paroxetine (Seroxat). They belong to the group of so called SSRIs (Selective Serotonin Reuptake Inhibitors). Especially the assumption (actively promoted by the pharmaceutical industry), that these modern anti-depressants are safe and have less side-effects than the older generation drugs, have made doctors prescribe them generously.
For a relative small group of severely depressed patients, anti-depressant (older and newer generation) drugs are a true blessing. Without them they could not have a more or less functional and regular life. But to be effective they have to be combined with psychotherapy. However, psychiatrists and general practitioners are busy people and as a consequence they usually lack the time. Besides this, adequately managing a patient with depression isn’t easy and is time consuming.
For the majority of the patients with a depression theirs’ is a light or moderate one. There is an abundance of research evidence (see below) that for this large group of patients, placebo pills or psychotherapy does a better job when compared with anti-depressants, and with no chance of possible (serious) side-effects. Nevertheless, for pharmaceutical industries their biggest sales are within this mild and moderate group of depressed patients.
The working of the SRRIs is based upon the theory that depressed people suffer from an inadequate amount of serotonin. This so-called neurotransmitter is used in the brain to transmit signals between neurons. SSRIs are said to work by preventing the re uptake of serotonin by the nerve cell that released it, thus forcing the serotonin to remain actively working. But there is no hard evidence to support this popular concept.
The basics are that in the 1950s scientists discovered that a drug called Iproniazid seemed to help some people with depression. Simply formulated, this drug increases brain levels of serotonin. This correlation does not mean that there is proof that low levels of this neurotransmitter can cause depression. For more than 50 years this chemical-imbalance theory of depression is based upon this. Direct evidence doesn’t exist. For instance when healthy people’s serotonin levels are lowered, it does not change their mood. This is strange because the chemical-imbalance theory suggests this. There is even an effective anti-depressant called Tianeptine that lowers the level of serotonin. This raises the question why depression can equally be affected by drugs that increase levels of serotonin and by drugs that decrease it.
Research financed by pharmaceutical industries very often has a specific design that is tailor-made to give an effect. But that said effect is almost totally explainable by the design. The majority of studies to the effectiveness of anti-depressants is financed by the manufacturers. In this research the focus is on small improvements within a specially selected group of depressed people.
The National Institutes of Mental Health (NIMH) in the USA in 2006 enabled a research on the effectiveness of anti-depressants with real people who sought treatment with real psychiatrists and real general practitioners (American Journal of Psychiatry 2006; 163:28-40).The results were shocking: with 70% of the people treatment with anti-depressants fails. The real world differs a lot from an experimental setting. From the patient’s side there is impatience with results, fear of addiction, and experienced side-effects (in the 15 largest studies about anti-depressants 59% of the users experienced side-effects). Managing a depression in an effective way from the point of view of a psychiatrist takes a lot of time and work. It’s about assessing the improvement of the treatment, assessing the (different) medication, assessing the psychotherapy. It’s not just writing out the same prescription in each control consultation. (Lancet 2006; 367:2041)
Several independent studies (which were not financed by pharmaceuticals) about anti-depressants give an equally distressing picture: (2008) N Engl J Med 358:252-260; (2008) PLoS Med 5:e45; (2010) JAMA 303:47-53. These studies for instance also include unpublished research where the outcome was not favourable for anti-depressants. The researchers invoked the Freedom of Information Act to obtain access to the Food and Drug Administration database of studies used in the initial approval for the most popular antidepressants. It contains all of the data from initial trials. Meta-analyses about pharmaceutical financed research show that the effect of SSRI’s in scientific experiments is not much different from placebo drugs. Other meta-analyses show that with mild or moderate depression there is no improvement, the only effect is with severe depression.
SSRIs have been presented as better drugs than their predecessors. This has not been confirmed in research: they are no more effective than the older generation and have no less side-effects (although these effects differ slightly in incidence). The most common side-effects of SSRIs in the first two till four weeks are: dry mouth, nausea, anxiety, strange feelings, diarrhoea and disturbed sleeping pattern.
Common long term side-effects which affect the quality of life in a serious way are weight gain (usually in the range of 5–25 kg) and sexual dysfunctions (not a pleasant thing when you are already depressed). The latter consists of loss of sexual drive, failure to reach orgasm and erectile dysfunction. Difficulty in tolerating these (short and long-term) side-effects is the most common reason for discontinuing anti-depressants.
There is a risk of addiction. About 30% of the patients who take SSRIs develop an addiction to the drug. It seems conceivable that the group of patients who formerly were addicted to tranquilizers (benzodiazepines like diazepam) are now addicted to SSRIs. This group typically consists of patients that doctors perceive as time consuming and “difficult”.
For all SSRIs the Food and Drug Administration in the USA requires a so called Black Box warning. It states that they double suicidal rates (from 2 in 1,000 to 4 in 1,000) in children and adolescents. For adults up to 25 there is an increased risk for suicidal behaviour and suicide. Doctors who do prescribe these pills to children need extra training (parents can also read the accompanying instructions for use). Children don’t need pills but a good therapist who talks with them and monitors the family.
Poisoning by anti-depressants happens regularly by means of excessive intake; either by accident or as a suicide attempt. Among children 50% of the deadly medication poisoning is caused by anti-depressants. Usually it’s about swallowing tablets without knowing what they are.
Less common possible side-effects are bone fractures, an increased risk of strokes and cardio-vascular death, an increased risk of suicide for adults (because the patient becomes more active but the mood improvement occurs later), serotonin syndrome (a potentially life-threatening adverse drug reaction) and increased aggression.
Anti-depressants are effective with patients who suffer from severe depression; with a mild or moderate depression prescription of these drugs is of no use at all. Psychotherapy or psychotherapy combined with anti-depressants is the most effective treatment because it focuses on causes and not on symptoms. In Sri Lanka when one is depressed and visits a doctor one usually leaves the room with a prescription for anti-depressants. Other possible solutions are rarely mentioned or not at all.
Of course the safety of these drugs is relatively good when you take into account the number of patients that have taken them. But there is a quite large group of patients that DO have problems because of these drugs. It could be you or your child. If you have any doubts or are suffering from a mild or moderate depression you should be critical and think along with your doctor. Knowing Sri Lankan society this could turn out to prove difficult but ultimately it’s your own responsibility for yourself and your family.