Jul 13, 2019 01:02 AM
https://aeon.co/essays/why-the-constant-...-is-absurd
EXCERPT: . . . Broadly, depression is a chronic, recurring and debilitating disease that turns you into a prostrated citizen, an absent or incompetent employee, a needy friend, a self-absorbed partner, a useless parent. You can’t think clearly, you can’t make decisions, often you can’t get out of bed in the morning and, even if you manage to stand up, you won’t find anything worth engaging with, not even your regular hobbies or your dearest friends and relatives. You also tend to ruminate endlessly, fuelled by feelings of guilt and worthlessness, which sometimes leads to suicide ideation, suicide attempt and death.
[...] 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 [...]
[...] Even decades after many of these treatments emerged to change the landscape of psychiatry, they are still hotly debated by people ‘full of passionate intensity’, to quote from W B Yeats’s poem ‘The Second Coming’ (1921). The American actor Tom Cruise, boosted by Scientology, and the English writer and critic Will Self, universalising what must have been a terrible personal experience with therapeutic drugs and a psychiatrist, have both pontificated against antidepressants, spreading the typical ideology-driven myths.
Some of those myths, such as the idea that these drugs are addictive ‘happy pills’ that produce the ‘high’ of a recreational drug, are pure lies; anyone who echoes them could be easily exposed as dishonest or ignorant. The most common antidepressants do cause withdrawal symptoms such as nausea, but reports of addiction to antidepressants are rare and tend to occur in patients with a history of drug or alcohol abuse. Unlike recreational drugs that are highly addictive, such as cocaine or heroin, antidepressants do not hijack the reward circuit that is associated with the euphoric rush of another neurotransmitter, dopamine.
The discussion gets more complicated when the scientific evidence for or against the effectiveness of antidepressants is evoked. Such evidence comes mostly from randomised trials [...] The conclusions of these studies can be distorted by different sources of error. The most important source of error is publication bias; much of the research is funded by the pharma industry, where there is a tendency to report studies that find positive effects for antidepressants, while studies that find no effect are left in the drawer.
[...] All these issues are compounded in the popular mind by the tendency to emphasise not individual randomised trials but meta-analyses that combine multiple studies to increase the sample size, iron out discrepancies between different studies, and eventually extract a more valid, that is to say, statistically robust, conclusion. However, the ‘garbage in, garbage out’ dictum of computer science applies perfectly to these exercises. If a relevant proportion of the original studies is fundamentally flawed, the meta-analysis will not fix that problem.
[...] It would be unscientific to describe the work of Andrea 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. Now that the scale has dramatically tilted in favour of antidepressants’ efficacy, it is likely that the critics will keep insisting that we remain mostly ignorant about the causes of depression.
[...] 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 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.
[...] If you ever tried to convince someone to take antidepressants, maybe you used the argument ‘antidepressants are to depression as insulin is to diabetes’. This recurrent comparison might be useful to diminish the stigma around antidepressants, but for the depressed individual the analogy has two major problems. The first is trivial: he has the option not to take antidepressants, which creates the burden of choice, whereas the diabetic will die without the insulin shots. The second is subtler, but goes to the heart of the issue: a diabetic would be furious if told that he had never needed insulin in the first place, that he had been a victim of a big scam to extort money from him for life. If the same story were told to a lifelong consumer of antidepressants, he might display public indignation as well, but deep inside some pride could emerge from the realisation that, after all, he survived on his own, without any drug. We have an inbuilt need for self-control, and the idea that a drug fixes our behaviour is not attractive. Thus, unconsciously or not, each time someone poses as a contrarian skeptic or whistleblower claiming that antidepressants don’t work, he is essentially a crowd-pleaser.
The key difference between insulin and antidepressants is that the former heals the body, whereas the latter fix the mind, and our sense of self is more strongly attached to the mind than to the body. We do not spend a minute thinking about our pancreas, unless it fails to work. In contrast, our conscience can easily become fixated on a moral dilemma when we take drugs to change the brain. Antidepressants restore the healthy state just like any other medicine, but by tapping into processes so intimately connected to our perception of the self and our moral compass, they raise an existential problem – one that is likely to gain relevance as these drugs become more refined and we leave mental-health restoration for the realm of cognitive enhancement.
The constant trashing of antidepressants has created an absurd situation. These drugs are the most rigorously scrutinised treatments for depression we have to date, yet they keep getting a bad press while ‘holistic’ approaches such as practising sports, yoga or salsa dancing, and consuming St John’s wort, Omega-3 fatty acids, soul food, daylight, Radiohead or J S Bach, perhaps even poppy extract and donkey’s milk, get a pass from everyone. Antidepressants don’t fix the sources of depression that can trigger the disease, they merely fix a biochemistry that makes some of us more vulnerable to stress and life in general. It is a truism that these drugs should be combined with life changes, and that transformative life events remain relevant for depressed individuals taking antidepressants. (MORE - details)
EXCERPT: . . . Broadly, depression is a chronic, recurring and debilitating disease that turns you into a prostrated citizen, an absent or incompetent employee, a needy friend, a self-absorbed partner, a useless parent. You can’t think clearly, you can’t make decisions, often you can’t get out of bed in the morning and, even if you manage to stand up, you won’t find anything worth engaging with, not even your regular hobbies or your dearest friends and relatives. You also tend to ruminate endlessly, fuelled by feelings of guilt and worthlessness, which sometimes leads to suicide ideation, suicide attempt and death.
[...] 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 [...]
[...] Even decades after many of these treatments emerged to change the landscape of psychiatry, they are still hotly debated by people ‘full of passionate intensity’, to quote from W B Yeats’s poem ‘The Second Coming’ (1921). The American actor Tom Cruise, boosted by Scientology, and the English writer and critic Will Self, universalising what must have been a terrible personal experience with therapeutic drugs and a psychiatrist, have both pontificated against antidepressants, spreading the typical ideology-driven myths.
Some of those myths, such as the idea that these drugs are addictive ‘happy pills’ that produce the ‘high’ of a recreational drug, are pure lies; anyone who echoes them could be easily exposed as dishonest or ignorant. The most common antidepressants do cause withdrawal symptoms such as nausea, but reports of addiction to antidepressants are rare and tend to occur in patients with a history of drug or alcohol abuse. Unlike recreational drugs that are highly addictive, such as cocaine or heroin, antidepressants do not hijack the reward circuit that is associated with the euphoric rush of another neurotransmitter, dopamine.
The discussion gets more complicated when the scientific evidence for or against the effectiveness of antidepressants is evoked. Such evidence comes mostly from randomised trials [...] The conclusions of these studies can be distorted by different sources of error. The most important source of error is publication bias; much of the research is funded by the pharma industry, where there is a tendency to report studies that find positive effects for antidepressants, while studies that find no effect are left in the drawer.
[...] All these issues are compounded in the popular mind by the tendency to emphasise not individual randomised trials but meta-analyses that combine multiple studies to increase the sample size, iron out discrepancies between different studies, and eventually extract a more valid, that is to say, statistically robust, conclusion. However, the ‘garbage in, garbage out’ dictum of computer science applies perfectly to these exercises. If a relevant proportion of the original studies is fundamentally flawed, the meta-analysis will not fix that problem.
[...] It would be unscientific to describe the work of Andrea 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. Now that the scale has dramatically tilted in favour of antidepressants’ efficacy, it is likely that the critics will keep insisting that we remain mostly ignorant about the causes of depression.
[...] 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 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.
[...] If you ever tried to convince someone to take antidepressants, maybe you used the argument ‘antidepressants are to depression as insulin is to diabetes’. This recurrent comparison might be useful to diminish the stigma around antidepressants, but for the depressed individual the analogy has two major problems. The first is trivial: he has the option not to take antidepressants, which creates the burden of choice, whereas the diabetic will die without the insulin shots. The second is subtler, but goes to the heart of the issue: a diabetic would be furious if told that he had never needed insulin in the first place, that he had been a victim of a big scam to extort money from him for life. If the same story were told to a lifelong consumer of antidepressants, he might display public indignation as well, but deep inside some pride could emerge from the realisation that, after all, he survived on his own, without any drug. We have an inbuilt need for self-control, and the idea that a drug fixes our behaviour is not attractive. Thus, unconsciously or not, each time someone poses as a contrarian skeptic or whistleblower claiming that antidepressants don’t work, he is essentially a crowd-pleaser.
The key difference between insulin and antidepressants is that the former heals the body, whereas the latter fix the mind, and our sense of self is more strongly attached to the mind than to the body. We do not spend a minute thinking about our pancreas, unless it fails to work. In contrast, our conscience can easily become fixated on a moral dilemma when we take drugs to change the brain. Antidepressants restore the healthy state just like any other medicine, but by tapping into processes so intimately connected to our perception of the self and our moral compass, they raise an existential problem – one that is likely to gain relevance as these drugs become more refined and we leave mental-health restoration for the realm of cognitive enhancement.
The constant trashing of antidepressants has created an absurd situation. These drugs are the most rigorously scrutinised treatments for depression we have to date, yet they keep getting a bad press while ‘holistic’ approaches such as practising sports, yoga or salsa dancing, and consuming St John’s wort, Omega-3 fatty acids, soul food, daylight, Radiohead or J S Bach, perhaps even poppy extract and donkey’s milk, get a pass from everyone. Antidepressants don’t fix the sources of depression that can trigger the disease, they merely fix a biochemistry that makes some of us more vulnerable to stress and life in general. It is a truism that these drugs should be combined with life changes, and that transformative life events remain relevant for depressed individuals taking antidepressants. (MORE - details)
