Difficult Decisions About Antidepressants

By 2020, depression drug sales worldwide are expected to soar to over 20 billion dollars US. More than ever before, people are unhappy and looking to pills as part of the solution. If a drug can be part of alleviating anxiety and depression, they no doubt should. However, when money comes into play, motivations can be skewed, and so some important questions should be asked.

Do antidepressants (SSRI and similar) work?

The consensus is that psychotherapy combined with medication is an effective way to combat anxiety and depression spectrum disorders, but the details are more nuanced.  Pharmaceutical companies have cited “neurotransmitter imbalances” as part of the cause of depression, but as more research is performed, there is little to back that up. Trials using drugs that increase serotonin levels in the brain were found to have similar effects to those that decreased serotonin levels. Many FDA approval trials have concluded that the effects of SSRIs and other similar “next-generation” antidepressants have similar effects to that of placebo.

Placebo Isn’t Nothing

Before we go after pharmaceutical companies for selling placebos, it’s important to understand that there is something of value in a placebo. The brain is immensely powerful and can adjust its chemical functioning based on belief.

If a doctor gives a patient a placebo and tells that patient it’s something else, they will experience improvement in the symptoms of disorders like depression and anxiety. In fact, what may have given the SSRIs an edge over placebo in the clinical trials was the side effects of the drugs. Patients were not told whether they were given a placebo or a real drug, but they were notified of possible side effects. Side effects usually begin appearing in the first week of treatment, so naturally those who experienced side effects would assume they had been given a real, and thus more effective drug. In fact, in one study, 89% of the patient group were able to accurately guess whether they had received placebo.

Side Effects and Ethics

If doctors give a patient a sugar pill and tell them it’s an antidepressant, that could violate the trust between caregiver and patient, causing irreparable damage to the relationship and making recovery even more difficult for the patient.

On the other hand, if they give the patient a drug which has been approved for use and is effective primarily because its side effects reinforce the belief that it works, safety concerns arise. It’s important to give an effective placebo, but antidepressant drugs have a substantial side effect portfolio. Besides sexual dysfunction, the potential for withdrawal after cessation (called “discontinuation syndrome”), and potentially making relapse more likely, antidepressant drugs also carry a black box warning about increased risk of suicidal thought.

What does this mean for patients?

What does this mean for people deciding how to deal with depression and anxiety, both of which are real and devastating?

The first step is not to judge yourself (or others) for how they deal with their struggle. If an antidepressant provides a safe way to ease symptoms and helps someone to live a better life, that should not be looked down upon.

The second step is to think seriously about treatment decisions. Pills are less work than psychotherapy, but generally have shorter term effectiveness and may make depression worse in the long run if the treatment is stopped. They also have serious side effects, which psychotherapy does not.

I personally have been on the entire gamut of medication for a variety of diagnoses including dysthymia, generalized anxiety disorder, and panic disorder. Therapy seemed like difficult, uncomfortable work, so I tried these medications for more than nine years, but I found they dulled both the highs and the lows (in addition to the miserable side effects).

At the end what got me out of the woods was plain old talk. I don’t take medication anymore, and while I won’t say I’m always happy, I do get to appreciate the full range of emotions that life has for me.

Remember, nothing good was ever easy.

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