I was first prescribed antidepressants in 2000. Ever since, I have been on and off these drugs, mostly because the idea of taking them made me uncomfortable. It was a mixture of guilt, probably not unlike the guilt some athletes must feel for taking a prohibited doping substance; shame for needing a pill that had such a profound impact on my behaviour; and frustration with the recurrent episodes of depression that would bring me back to the antidepressants I would then quickly abandon.
I broke this cycle when my daughters were born and I realised that it would be irresponsible to stop treatment because being a good father meant having a stable mood. It was a purely pragmatic decision, made without resolving the existential issues that antidepressants had raised for me before. That being the case, I do not write with the fervour of the newly converted, although sometimes I speculate about how much smoother my life would have been had I decided much sooner to stick to the antidepressants.
Depression is widespread. According to the World Health Organization, in 2015 depression affected more than 300 million people, or 5.1 per cent of females and 3.6 per cent of males, worldwide. It was the single largest contributor to global disability, and the major cause of the nearly 800,000 deaths by suicide recorded every year – suicide being the second leading cause of death among 15- to 29-year-olds.
Despite these statistics, depression remains misunderstood by the public at large and is, it seems, best described by those who have lived it. The novelist William Styron wrote in his memoir Darkness Visible (1990) that: ‘For those who have dwelt in depression’s dark wood, and known its inexplicable agony, their return from the abyss is not unlike the ascent of the poet, trudging upward and upward out of hell’s black depths.’ Andrew Solomon’s memoir The Noonday Demon (2001) is a useful tome and the book on depression for the public at large. ‘It is the aloneness within us made manifest,’ he writes of the state, ‘and it destroys not only connection to others but also the ability to be peacefully alone with oneself.’
For those outside the experience, part of the confusion comes from the association of the disease with melancholia and sadness, feelings we all have experienced. Malignant sadness, or depression, is something else entirely, and it takes a leap of faith to accept that too much of something can become something completely other. (...)
It is obvious that the discomfort I once felt over taking antidepressants echoed a lingering, deeply ideological societal mistrust. Articles in the consumer press continue to feed that mistrust. The benefit is ‘mostly modest’, a flawed analysis in The New York Times told us in 2018. A widely shared YouTube video asked whether the meds work at all. And even an essay on Aeon this year claims: ‘Depression is a very complex disorder and we simply have no good evidence that antidepressants help sufferers to improve.’
The message is amplified by an abundance of poor information circulating online about antidepressants in an age of echo chambers and rising irrationality. Although hard to measure, the end result is probably tragic since the ideology against antidepressants keeps those in pain from seeking and sticking to the best available treatment, as once happened to me. Although I am a research scientist, I work on topics unrelated to brain diseases, and my research is not funded by the ‘pharma industry’ – the disclaimer feels silly but, trust me, it is needed. I write here mainly as a citizen interested in this topic. I take for granted that a world without depression would be a better place, and that finding a cure for this disease is a noble pursuit. Without a cure, the best treatment available is better than none at all. (...)
One reason for the recent surge of skepticism is a gigantic meta-analysis by the psychiatrist Andrea Cipriani at the University of Oxford and colleagues, published in The Lancet in 2018. While the earlier study by Kirsch had included 5,133 participants, Fournier’s had 718, and another study, by Janus Christian Jakobsen in Denmark in 2017, had 27,422, Cipriani and colleagues analysed data from 116,477 people – or 3.5 times more participants than in the three previous studies combined.
The sample size is not sufficient to ensure quality, but the authors were careful to select only double-blind trials and did their best to include unpublished information from drug manufacturers to minimise publication bias. They found no evidence of bias due to funding by the pharma industry, and also included head-to-head comparisons between drugs (which minimised blind-breaking). They concluded that ‘all antidepressants included in the meta-analysis were more efficacious than placebo in adults with MDD, and the summary effect sizes were mostly modest’. The results are summarised by a statistic, the odds ratio (OR) that quantifies the association between health improvement and the action of the antidepressant. If the OR is 1, then antidepressants are irrelevant; for ORs above 1, a positive effect is detected. For 18 of the 21 antidepressants, the ORs they found ranged from 1.51 to 2.13. These results have been widely mischaracterised and described as weak in the press.
It is not intuitive to interpret ORs, but these can be converted to percentages that reflect the chances of experiencing health improvement from the antidepressant, which in this study ranged from 51 per cent to 113 per cent. These percentage increases are relevant, particularly taking into account the incidence of the disease (20 per cent of people are likely to be affected by depression at some stage of their lives).
For comparison, please note the uncontroversial finding that taking aspirin reduces the risk of stroke – its associated OR is ‘only’ 1.4, but no one describes it as weak or has raised doubts about this intervention. It would be unscientific to describe the work of Cipriani and colleagues as the definitive word on the topic, but it’s the best study we have so far. The message is clear: antidepressants are better than placebo; they do work, although the effects are mostly modest, and some work better than others. This paper was an important confirmation in times of a reproducibility crisis in so many scientific fields. We don’t have to look too far: a major study was published this spring that does not confirm the association of any of the 18 genes that were reanalysed and had been proposed to be associated with MDD. (...)
The human body contains at least 12,000 metabolites. On the day of his final exam, a biochemistry major might know a few hundred, but most of us will be able to name only a few dozen, with a clear bias for the metabolites known to influence behaviour. We will immediately associate adrenalin, cortisol, testosterone, oestrogen, oxytocin and dopamine with stereotypical behaviours and personality types, but what about serotonin? The molecule is certainly no obscure metabolite. The French novelist Michel Houellebecq named his latest novel Sérotonine (2019). But would you associate the ‘happy hormone’, as serotonin is often described, with the formation and maintenance of social hierarchies and the impetus to fight observed across the animal kingdom, from lobsters to primates? Indeed, since SSRIs have been found to influence our moral decision making, naming serotonin the ‘happy hormone’ appears to be a mistake. Apart from its role in mood balance, this neurotransmitter is involved in appetite, emotions, sleep-wake cycles, and motor, cognitive and autonomic functions. In fact, most of the body’s serotonin production is not found in the brain, but in the gut.
We simply do not have a consensual overarching explanation for how SSRIs/SNRIs work in depression, and how to link these neurotransmitters to the environmental stressors, genetic factors, and immunologic and endocrine responses proposed to contribute to depression. It is also clear that restoring the chemical balance of monoamines in the brain with a pill, which only takes minutes or hours, is insufficient to immediately produce therapeutic effects, which take several weeks. Indeed, without a complete picture of the mechanism of depression, it is not surprising that the available drug treatments are not fully effective. In a study involving thousands of MDD patients consecutively encouraged to move to a different treatment if they did not achieve remission from the previous treatment, only about 67 per cent of the MDD patients taking antidepressants went into clinical remission, even after four consecutive treatments. Thus, there is a large group of patients who don’t respond to SSRI/SNRIs, which raises doubts about the monoamine hypothesis to explain depression in full.
Other ideas have emerged. One line of thought focuses on the neurotransmitters glutamate (involved in cognition and emotion) and GABA (involved in inhibition), among others. One of the most exciting findings in the field is the clinical efficacy of ketamine, which targets glutamate neurotransmission, producing immediate effects in patients refractory to SSRI/SNRI treatments. Along with the monoamine hypothesis, most of these newer approaches are somehow related to the notion of neuronal plasticity, the ability of the nervous system to change, both functionally and structurally, in response to experience and injury, which can take some time to occur. Thus, it could be that the decreased levels of monoamines are not the real cause of depression, perhaps not even an absolutely necessary condition for depression. The data certainly suggest that there might be better targets to be found, and that the pharmacological approach has to become progressively more tailored.
That said, the temptation to dismiss the monoamine hypothesis to score points against antidepressants shows a lack of understanding of how medicine has worked for most of its history; imperfect but useful therapies have been the rule, even as we refine our understanding of disease.
by Vasco M Barreto, Aeon | Read more:
Image: Gabriele Diwald/Unsplash
[ed. See also: Cipriani on Anitdepressants; and What to Make of New Positive NSI-189 Results? (Duck Soup/SSC).]
I broke this cycle when my daughters were born and I realised that it would be irresponsible to stop treatment because being a good father meant having a stable mood. It was a purely pragmatic decision, made without resolving the existential issues that antidepressants had raised for me before. That being the case, I do not write with the fervour of the newly converted, although sometimes I speculate about how much smoother my life would have been had I decided much sooner to stick to the antidepressants.
Depression is widespread. According to the World Health Organization, in 2015 depression affected more than 300 million people, or 5.1 per cent of females and 3.6 per cent of males, worldwide. It was the single largest contributor to global disability, and the major cause of the nearly 800,000 deaths by suicide recorded every year – suicide being the second leading cause of death among 15- to 29-year-olds.Despite these statistics, depression remains misunderstood by the public at large and is, it seems, best described by those who have lived it. The novelist William Styron wrote in his memoir Darkness Visible (1990) that: ‘For those who have dwelt in depression’s dark wood, and known its inexplicable agony, their return from the abyss is not unlike the ascent of the poet, trudging upward and upward out of hell’s black depths.’ Andrew Solomon’s memoir The Noonday Demon (2001) is a useful tome and the book on depression for the public at large. ‘It is the aloneness within us made manifest,’ he writes of the state, ‘and it destroys not only connection to others but also the ability to be peacefully alone with oneself.’
For those outside the experience, part of the confusion comes from the association of the disease with melancholia and sadness, feelings we all have experienced. Malignant sadness, or depression, is something else entirely, and it takes a leap of faith to accept that too much of something can become something completely other. (...)
It is obvious that the discomfort I once felt over taking antidepressants echoed a lingering, deeply ideological societal mistrust. Articles in the consumer press continue to feed that mistrust. The benefit is ‘mostly modest’, a flawed analysis in The New York Times told us in 2018. A widely shared YouTube video asked whether the meds work at all. And even an essay on Aeon this year claims: ‘Depression is a very complex disorder and we simply have no good evidence that antidepressants help sufferers to improve.’
The message is amplified by an abundance of poor information circulating online about antidepressants in an age of echo chambers and rising irrationality. Although hard to measure, the end result is probably tragic since the ideology against antidepressants keeps those in pain from seeking and sticking to the best available treatment, as once happened to me. Although I am a research scientist, I work on topics unrelated to brain diseases, and my research is not funded by the ‘pharma industry’ – the disclaimer feels silly but, trust me, it is needed. I write here mainly as a citizen interested in this topic. I take for granted that a world without depression would be a better place, and that finding a cure for this disease is a noble pursuit. Without a cure, the best treatment available is better than none at all. (...)
One reason for the recent surge of skepticism is a gigantic meta-analysis by the psychiatrist Andrea Cipriani at the University of Oxford and colleagues, published in The Lancet in 2018. While the earlier study by Kirsch had included 5,133 participants, Fournier’s had 718, and another study, by Janus Christian Jakobsen in Denmark in 2017, had 27,422, Cipriani and colleagues analysed data from 116,477 people – or 3.5 times more participants than in the three previous studies combined.
The sample size is not sufficient to ensure quality, but the authors were careful to select only double-blind trials and did their best to include unpublished information from drug manufacturers to minimise publication bias. They found no evidence of bias due to funding by the pharma industry, and also included head-to-head comparisons between drugs (which minimised blind-breaking). They concluded that ‘all antidepressants included in the meta-analysis were more efficacious than placebo in adults with MDD, and the summary effect sizes were mostly modest’. The results are summarised by a statistic, the odds ratio (OR) that quantifies the association between health improvement and the action of the antidepressant. If the OR is 1, then antidepressants are irrelevant; for ORs above 1, a positive effect is detected. For 18 of the 21 antidepressants, the ORs they found ranged from 1.51 to 2.13. These results have been widely mischaracterised and described as weak in the press.
It is not intuitive to interpret ORs, but these can be converted to percentages that reflect the chances of experiencing health improvement from the antidepressant, which in this study ranged from 51 per cent to 113 per cent. These percentage increases are relevant, particularly taking into account the incidence of the disease (20 per cent of people are likely to be affected by depression at some stage of their lives).
For comparison, please note the uncontroversial finding that taking aspirin reduces the risk of stroke – its associated OR is ‘only’ 1.4, but no one describes it as weak or has raised doubts about this intervention. It would be unscientific to describe the work of Cipriani and colleagues as the definitive word on the topic, but it’s the best study we have so far. The message is clear: antidepressants are better than placebo; they do work, although the effects are mostly modest, and some work better than others. This paper was an important confirmation in times of a reproducibility crisis in so many scientific fields. We don’t have to look too far: a major study was published this spring that does not confirm the association of any of the 18 genes that were reanalysed and had been proposed to be associated with MDD. (...)
The human body contains at least 12,000 metabolites. On the day of his final exam, a biochemistry major might know a few hundred, but most of us will be able to name only a few dozen, with a clear bias for the metabolites known to influence behaviour. We will immediately associate adrenalin, cortisol, testosterone, oestrogen, oxytocin and dopamine with stereotypical behaviours and personality types, but what about serotonin? The molecule is certainly no obscure metabolite. The French novelist Michel Houellebecq named his latest novel Sérotonine (2019). But would you associate the ‘happy hormone’, as serotonin is often described, with the formation and maintenance of social hierarchies and the impetus to fight observed across the animal kingdom, from lobsters to primates? Indeed, since SSRIs have been found to influence our moral decision making, naming serotonin the ‘happy hormone’ appears to be a mistake. Apart from its role in mood balance, this neurotransmitter is involved in appetite, emotions, sleep-wake cycles, and motor, cognitive and autonomic functions. In fact, most of the body’s serotonin production is not found in the brain, but in the gut.
We simply do not have a consensual overarching explanation for how SSRIs/SNRIs work in depression, and how to link these neurotransmitters to the environmental stressors, genetic factors, and immunologic and endocrine responses proposed to contribute to depression. It is also clear that restoring the chemical balance of monoamines in the brain with a pill, which only takes minutes or hours, is insufficient to immediately produce therapeutic effects, which take several weeks. Indeed, without a complete picture of the mechanism of depression, it is not surprising that the available drug treatments are not fully effective. In a study involving thousands of MDD patients consecutively encouraged to move to a different treatment if they did not achieve remission from the previous treatment, only about 67 per cent of the MDD patients taking antidepressants went into clinical remission, even after four consecutive treatments. Thus, there is a large group of patients who don’t respond to SSRI/SNRIs, which raises doubts about the monoamine hypothesis to explain depression in full.
Other ideas have emerged. One line of thought focuses on the neurotransmitters glutamate (involved in cognition and emotion) and GABA (involved in inhibition), among others. One of the most exciting findings in the field is the clinical efficacy of ketamine, which targets glutamate neurotransmission, producing immediate effects in patients refractory to SSRI/SNRI treatments. Along with the monoamine hypothesis, most of these newer approaches are somehow related to the notion of neuronal plasticity, the ability of the nervous system to change, both functionally and structurally, in response to experience and injury, which can take some time to occur. Thus, it could be that the decreased levels of monoamines are not the real cause of depression, perhaps not even an absolutely necessary condition for depression. The data certainly suggest that there might be better targets to be found, and that the pharmacological approach has to become progressively more tailored.
That said, the temptation to dismiss the monoamine hypothesis to score points against antidepressants shows a lack of understanding of how medicine has worked for most of its history; imperfect but useful therapies have been the rule, even as we refine our understanding of disease.
by Vasco M Barreto, Aeon | Read more:
Image: Gabriele Diwald/Unsplash
[ed. See also: Cipriani on Anitdepressants; and What to Make of New Positive NSI-189 Results? (Duck Soup/SSC).]
