Are psychoactive drugs fueling an epidemic of mental illness?

June 6, 2011 10:13 PM

Is the contemporary epidemic of mental illness fueled by useless or even harmful anti-depressants and other psychoactive drugs? A review of books by Irving Kirsch, Robert Whitaker, and Daniel Carlat, notes that per Kirsch, "[a]n active placebo is one that itself produces side effects...there was no difference between the antidepressant and the active placebo" (new research claims very severe cases are different). Whitaker argues that psychoactive drugs may actively "disturb neurotransmitter function" and cause mental illnesses which a mounting cascade of drugs are then needed to manage. (previously, previously)
posted by shivohum (113 comments total)

Its rhetoric like this that kept me and those I knew from getting treatment when we needed it. Wish I'd been on them much younger.
posted by Lovecraft In Brooklyn at 10:17 PM on June 6, 2011 [56 favorites]

Exercise : the other antidepressant
posted by Afroblanco at 10:19 PM on June 6, 2011 [6 favorites]

Fascinating. All those people I know with depression must have been secretly taking anti-depressants, and that's why they got depressed. Further, while they claim to be using a single treatment like Zoloft, they must be hiding the 'mounting cascade of drugs' they're also taking. Bastards.
posted by obiwanwasabi at 10:20 PM on June 6, 2011 [13 favorites]

Per Kirsch? "How much placebo?" "Six Kirsch's!" "That's too much!" "No such thing as too much placebo!"
posted by tumid dahlia at 10:25 PM on June 6, 2011 [1 favorite]

Each of the major antidepressants have FUCKING MOUNTAINS of documentation supporting their efficacy, especially the ones that have been around for a while. We as a society with many many people benefiting greatly from antidepressants need to start calling this bullshit out as the demonstrable bullshit it is. It keeps real people away from often profoundly life altering and lifesaving treatment.

Assholes.
posted by Blasdelb at 10:28 PM on June 6, 2011 [19 favorites]

I believe that antidepressants are over-prescribed these days, at least in part because of the business of it all.

I also believe that there are many people whose lives have been immeasurably improved by those drugs.

What I don't know is where to find the level where people who truly need them get them, and those who don't are helped in other, less drastic ways.
posted by stavrosthewonderchicken at 10:28 PM on June 6, 2011 [13 favorites]

Is there any evidence that anti-depressants make normal people 'more sad'? Or do they make them 'more happy' or what?
posted by delmoi at 10:39 PM on June 6, 2011 [1 favorite]

As someone who has severe depression and who is off and on meds depending on a number of factors, there is significant problems with both the placebo effect and self reporting. They stop working, they might never work, the side effects are often too difficult to live with, and the medical model often prevents people from maintaining autonomy and control.

I welcome work that allows for the idea of depression as having many sources, and many ways of working, around, through or with it...i wonder about what happens when we handle it as an object of selfhood and not as parasitical.
posted by PinkMoose at 10:48 PM on June 6, 2011 [5 favorites]

those who don't are helped in other, less drastic ways.

What's 'drastic' about taking anti-depressants?
posted by obiwanwasabi at 10:49 PM on June 6, 2011 [2 favorites]

IT seriously fucks w. yr neuro-chemistry, and we have yet to figure out exactly how the neuro-chemistry works.
posted by PinkMoose at 10:52 PM on June 6, 2011 [3 favorites]

Each of the major antidepressants have FUCKING MOUNTAINS of documentation supporting their efficacy, especially the ones that have been around for a while.

The author of the first book has several review articles of antidepressant studies, including a relatively big one:

Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration.

The study showed that SSRIs did have a relatively minor effect for patients with severe depression. Interestingly, when data from unpublished trial data (I assume referring to non-drug company experiments) was included, the results were below the level for clinical significance.

Most drugs in use are selective serotonin reuptake inhibitors, or new classes that combine that with norepinephrine reuptake inhibition. But we still don't really know why they work for depression.

It gets even more complicated when you realize drugs like Tianeptine, which is a selective serotonin reuptake enhancer, also help treat depression.

Which seems to point to some mechanism we still don't know enough about, maybe related to the neuroprotective aspects of SSRIs.

I'm not saying they can't help people, but please don't treat skepticism as an attack on science. it doesn't mean the person voicing concerns is a Scientologist or anti-vaccine crusader.
posted by formless at 10:53 PM on June 6, 2011 [43 favorites]

Obiwanwasabi, I don't think any of these authors are arguing that treatment with anti-depressants doesn't work, but that we really don't know the specifics of how they work, and a placebos seems to work just as well. It's a very fine distinction, but the generally agred upon thrust of all three books seems to be, "If we can get the same results without the side-effects, why should we even be bothering to use these drugs?"

I could be wrong; I've only read Whitaker's book, which I thought started well and ended as a bit of a screaming rant. Still, even Whitaker acknowledges that short term anti-depressant treatment can show positive results. That's really Whitaker's point (which he will repeatedly hammer into you, should you choose to pick up his book), that the poor understanding of these drugs leads to poor management of their effects, which leads to poor outcomes in the long run. He then cranks that idea up to 11.

Blasdelb, I believe you'll find your concern over the data addressed in the section that starts (amusingly) "Do the drugs work?" It's about halfway in.

Finally, Shivohum, you're only going to post part 1 Fighty McGrarryPants article? And this looks like an advance copy of the NYRB, so part 2 probably won't be forthcoming soon? You, my friend, are playing on the edge of post-deletion.
posted by Panjandrum at 10:56 PM on June 6, 2011 [2 favorites]

I have no doubt drugs help some people with mental illness. But the medical community and the media have really let us down by pushing the message that this is all a 'brain chemical imbalance' and we have it all figured out.

This article elucidates my point of view quite well.
The Myth of the Chemical Cure

Also cause mental illnesses which a mounting cascade of drugs are then needed to manage This is the first thing that came to mind. Antidepressant-induced mania and cycle acceleration
posted by psycho-alchemy at 10:58 PM on June 6, 2011 [4 favorites]

I have no doubt drugs help some people with mental illness. But the medical community and the media have really let us down by pushing the message that this is all a 'brain chemical imbalance' and we have it all figured out.

Meds got me into the state of mind where I could get therapy.

There's a line from my fave band: "We're not going to save you, but we're going to get you into a state where you can save yourself".

Meds might be like that.

disclaimer: my depression was pretty mild, compared to many people, so I don't want to speak for everyone. but the meds cleared out some disordered thinking and let me see i had a problem.
posted by Lovecraft In Brooklyn at 11:04 PM on June 6, 2011 [8 favorites]

I am fairly anti-antidepressant. I haven't kept up with the literature for years, but last I checked they were very over-commercialized and promoted to prescribers in extremely sleazy ways; their efficacy was up in the air and the risks were real but not well understood.

I ordinarily stay quiet about my point of view, because I understand that when you're depressed, you're willing to try anything, and the act of doing something at all can help, for a time; but medicating depression is a practice I'll never agree with. I think it's based in a fundamentally fallacious view of depression, emotion and the human experience that will look as silly as phlogiston in a handful of centuries.

Anyway; I wanted to say that because I've seen MetaFilter be very pro-antidepressant in the past and it makes me a little angry when people treat them like magic pills (or even a valid long term treatment) because that's extremely careless and many people do suffer with life destroying side effects and I just wanted to counter that with something, even though it's late and I'm falling asleep and I'm not the most eloquent person in the world even on my best days.

So, /rant.
posted by byanyothername at 11:05 PM on June 6, 2011 [20 favorites]

Each of the major antidepressants have FUCKING MOUNTAINS of documentation supporting their efficacy, especially the ones that have been around for a while. We as a society with many many people benefiting greatly from antidepressants need to start calling this bullshit out as the demonstrable bullshit it is. It keeps real people away from often profoundly life altering and lifesaving treatment.

Did you read the article? His point is that the mountains of evidence of efficacy are countered with mountains upon mountains of evidence of inefficacy which drug companies choose to not publish.

The article is compelling and I've heard these things before. I've struggled with depression my whole life, and though I made massive improvements through changes in lifestyle and self-therapy, it wasn't until I began taken Wellbutrin last year that the final piece of the puzzle--eliminating the truly terrible, weeks-long slumps--began to improve. But now I'm paranoid for my brain.
posted by schroedinger at 11:07 PM on June 6, 2011 [3 favorites]

Panjandrum: Antidepressents like fluoxetine have demonstrated statistically significant benefits over placebo. The effect size is small, with a high number needed to treat, so yes, in a lot of people placebo may work just as well.

formless: The mechanism of action of tianeptine is not well understood, and there is a lot of uncertainty surrounding its SSRE effect.

psycho-alchemy: The treatment for bipolar disorder is mood-stabilizers, not anti-depressants. No doctor would treat a patient with suspect mania with anti-depressants, so saying that wide spread anti-depressants use causes/exacerbates mania is pretty inappropriate.
posted by yifes at 11:13 PM on June 6, 2011

there are vast differences between placebo effect and actual efficacy.

but that's only the experience of my 13 years and 12 different medications.

Are we as a society overmedicated?
Yes

Are antidepressants/mood stabilizers/antipsychotics the worst of our problems?
No
posted by aloiv2 at 11:20 PM on June 6, 2011 [1 favorite]

The problem with the world today is that no matter what you do, somebody will say its wrong. Circumcision, eating meet, Apple Computer, you name it.
posted by Ironmouth at 11:20 PM on June 6, 2011 [6 favorites]

Discussing this is difficult because:

Personal anecdotes both feel very important to the person sharing them, and also have value. They're just not the same as large-scale, good-quality research.

And, depression is horrible, and so the need for useful treatment is great.

This makes thinking critically and being open to more than one way of thinking about this challenging.
posted by serazin at 11:22 PM on June 6, 2011 [13 favorites]

Yeah, I can't really spend much time in this thread because psych meds one of those things people like to get all GRAR about. But as someone who's had a lot of various issues for which there's no clear treatment, I am very skeptical of "it worked for me." And not just because of placebo effects, or because everybody's mind and body are different, or because when people are suffering, truly suffering, anything that promises even a smidgen of relief is welcome -- although those are all salient points. But let's put those things aside for the moment and assume that you've found something that works.

How do you know there isn't something better?

Just a reason to keep an open mind...
posted by Afroblanco at 11:27 PM on June 6, 2011 [4 favorites]

I wish I could quote the whole Up To Date* article on initial treatment for depression in adults. Some quotes of interest:

Multiple randomized trials of patients in the primary care setting have found similar efficacy for drug therapy and psychotherapy [5,22,23], with no clear predictors of which treatment is best for individual patients

Publication bias should be considered in evaluating the literature regarding antidepressant trials. ... In a study comparing published antidepressant drug trials with drug trials registered with the FDA, 94 percent of published trials reported positive results, compared with 51 percent of trials tracked by the FDA [35]. Thus, as with other drugs, published trials of antidepressants are likely to show a greater effect size than may be actually present.

A meta-analysis of six randomized trials (718 adult outpatients) compared the efficacy of antidepressants with placebo in treating major and minor depression [36]. The benefit of antidepressants increased with the severity of depression, from little or no benefit in patients with mild to moderate depression, to substantial benefit in patients with very severe depression.

Now, Up To Date (and most physicians) also has plenty of positive things to say about anti depressants, and I don't mean to claim they have no value. It's just to say that a discussion of the lack of evidence for efficacy, at least in the mildly or moderately depressed person, is part of the mainstream medical discussion on this issue.

* Up to Date is a website written by and for physicians that collects the best and most recent evidence into a narrative format for use as a reference tool
posted by serazin at 11:34 PM on June 6, 2011 [4 favorites]

I created an account pretty much just to post this message. Its just my first hand account with my experience with psycho-pharmaceuticals. I realize my anecdote doesn't stand up to actual clinical data, nevertheless I think it has value if only to show one example of how an individual interacted with the portion of the mental health profession that prescribes such drugs, and how I came to a decision about their use in my life.

Basically, I started on SSRI's when I was 12. I was just entering middle school, in a new building, and was having, shall we say, adjustment problems to my new environment. Specifically, I was having problems adjusting to the fact that, as a relatively un-athletic, small, intellectually inclined individual I was going to spend the next 6 years of my life at the low end of the social totem pole in my somewhat dysfunctional, heavily working class public school. To put it mildly, the institution was not set up to cater to my needs.

As a result, and I am not proud of this fact, I went looking for attention - and I got it. I'm not saying that I wasn't *sad*, but looking back, I would think that negative feelings were a perfectly logical response to my situation. Nevertheless, I ended up on Prozac. Then Prozac plus lithium. Then Prozac plus lithium plus Welbutrin. Or maybe it was just lithium plus welbutrin. I don't actually remember because the different cocktails and combinations of the drugs truly were amazing in their variety.

What I do remember was the weight gain, the slowing of my thoughts (which really freaked me out), and the feeling of being a zombie, all of which occurred after I went on the drugs. What I don't remember was actually feeling better. In fact, my condition deteriorated to the point where, in 10th grade, I ended up in an in patient mental mental facility. During that time the number of drugs I was on dwindled to just one.

After I got out I changed schools starting in the next school year, and my condition took a dramatic turn for the better. I won't say that everything was sunshine and roses from then on, but I do attribute most of my later problems to scars left over from previous bad experiences, as well as the general problems of growing up.

I stayed on a very low dose of anti-depressants until I was two years out of college, at which point I just decided to stop. It seemed absurd, and a little distressing, to me that I was going to be on this pill for the rest of my life. I also started to question the reasons that I was on the pills. They started to seem like a crutches to me, or agents of misdirection that caused me to avoid my problems, and avoid making difficult decisions in my life. So I stopped taking the drugs, and I feel generally as I did before.

Again, I won't claim everything was sunshine and roses, but, then again, I also lived through a massive economic dislocation that rendered what I previously thought was a safe, lucrative career choice a dead end one that certainly did not suit my needs. Again, negative emotions would seem to be the appropriate response to such a situation. I got through the difficult times though, without killing myself or thinking about it, and so here I am, having made the difficult decisions and adjustments necessary to get me to where I am today - on a pretty good path.

All that being said, I don't want to diminish other people's experiences. I don't doubt that anti-depressants help many people, and indeed save lives. If they are working for you - great. I'm just giving my own experience on the drugs, which, on the whole, I've evaluated as a negative one.
posted by eagles123 at 11:59 PM on June 6, 2011 [17 favorites]

The treatment for bipolar disorder is mood-stabilizers, not anti-depressants. No doctor would treat a patient with suspect mania with anti-depressants, so saying that wide spread anti-depressants use causes/exacerbates mania is pretty inappropriate.
posted by yifes

That's the point. They did not have mania until they were put on antidepressants, before that there were only symptoms of depression.


eagles123

I fully agree with you. Many of our environments are not optimal to meet our needs, our diets are often lacking, many people lack coping skills and often it takes real creative solutions to find ways to channel our energy into positive directions and get our needs met. Although it is somewhat dated and not correct on all points, Desmond Morris does an excellent job examining this in The Human Zoo.
posted by psycho-alchemy at 12:07 AM on June 7, 2011 [1 favorite]

Is the contemporary epidemic of mental illness fueled by useless or even harmful anti-depressants and other psychoactive drugs?

No, people are genuinely depressed by modern life.
posted by wcfields at 12:12 AM on June 7, 2011 [17 favorites]

I should also mention that I don't blame any of the mental health professionals that helped to to treat me either. The brain is, pardon my language, fucking complex. The interactions between the brain, its environment, and its development are even more complex. Any type of professional can only go by what their profession tells them - which at the time, the mid 90's, was very pro drug. Nobody wants to be in a position where they let a patient walk out of their office without a treatment that the available research says will help, only to have that patient then slit their wrists.

The drug companies, on the other hand ............
posted by eagles123 at 12:12 AM on June 7, 2011 [2 favorites]

Once upon a time I read about a monkey study in which the monkeys were placed (individually) in these big upside-down metal pyramids with steep walls that they couldn't climb. For a while, the monkey would struggle to climb out, always falling back down into the center of the pyramid. But eventually, the monkey would give up and start displaying signs of depression.

Which is to say that sometimes the problem isn't treatable by drugs.

I had also read many times about the pharmaceutical companies gaming their studies to produce results which beat out placebos, while suppressing trials that were less favorable. I'm deeply skeptical of these companies and their methods.

For my own intermittent depression, I find a combination of exercise and meditation to help a lot. The internet, on the other hand....
posted by kaibutsu at 12:13 AM on June 7, 2011 [6 favorites]

psycho-alchemy:

I think you're reading the study wrong. Those were 51 patients with already diagnosed refractory bipolar disorder, with episodes of mania induced by antidepressants. Their bipolar disorder was not caused by the use of anti-depressants. Basically you linked an article that confirms a nowadays well known contraindication to anti-depressants.
posted by yifes at 12:14 AM on June 7, 2011 [2 favorites]

What's 'drastic' about taking anti-depressants?

It's an altering of the "normal" constitution of one's chemical balance, which as many have already commented, is an extremely complex concern. Maybe drastic's the wrong word, but taking any mood/consciousness altering drug on a regular basis should never be taken lightly, particularly when there's an elephant in the room like Big Pharma.
posted by philip-random at 12:25 AM on June 7, 2011 [1 favorite]

I've been back at the RIP Bill Zeller metatalk thread, and the consequent Help Wiki (thank you folk, for putting it together) because I am currently experiencing abnormally high suicide ideation, lack of concentration/focus, sleep disturbance, loss of appetite etc. After kicking anxiety drugs mere months before my marriage breakdown (and finally realising that an unhappy marriage was a big part of why I needed them), I'm facing either a real struggle to manage a normal life or go back on antidepressants.

Sometimes they work. Sometimes they lift that vulture off your back, and you can look at a blue sky with gratitude instead of disinterest.

Sometimes they're over prescribed like any medication today (antibiotics, I'm looking at you).

But, I think we need to ask ourselves, why the epidemics of not-transmittable disease like obesity and depression. What are our societies doing wrong? Where are we not meeting basic human needs for love and connection that our brains fail under stress and we develop false appetites that are nearly uncontrollable. These epidemics are not the fault of the doctors, the scientists or the drug companies. I put these down to capitalism and the overall drives that are forced on us, buy more, need more, work more, work harder, be successful or a failure, you're not good enough unless you meet the Barbie/Ken-standard, the Jones' standard, the who the fuck knows standard. Sure, some people thrive in that sort of competitiveness, and enjoy the rewards. I don't think most people do.

So, is my current depression related to this sort of dynamic? I wrote a big screed to support my hypothesis and then realised, I don't actually know. Maybe after I take some drugs I will.

You get told a story when you're quitting smoking that nicotine forces new pathways for your neurotransmitters, and when you quit, those pathways are lonely or empty or something which is why you miss it so much. If this analogy is any way true, I've figured, surely the mental illness relief drugs I've taken have had at least the same effect. I should have stopped before I took the first one, if it lead me to be dependent. Sometimes I think if I had, though, I might not have lived this long.

Rage against big pharma, if you like, and call all the pills harmful placebos that do more damage than good. I don't care. I don't really care about anything right now. Maybe in 6 weeks, after the placebos kick in.
posted by b33j at 12:33 AM on June 7, 2011 [17 favorites]

Is the contemporary epidemic of mental illness fueled by useless or even harmful anti-depressants and other psychoactive drugs?

No, people are genuinely depressed by modern life.

I haven't read the links yet but I just want to say that this is a very widespread misconception, that somehow because now it's all out in the open and there is psychiatric medication and psychotherapy, all of which are faily recent 'inventions', that somehow depression is something modern, a reaction to modern life.

But if you look through history of mankind, even just through literature and art and history and any testimony we have of a specific era, even ancient mythology, well, you see depression has been around a long long time. It's human. It can take so many forms and can be called and viewed and approached in so many different ways but it's nothing new. It used to be "melancholy", or "melancholic disposition". The ancient Greeks probably blamed it like everything else on some of the gods in the Olympus playing tricks on humans out of spite. Religious texts blame it on sin and divine punishment. In the Renaissance for artists it was a mark of genius. And so on and so forth and so on.

What's modern is just the current definition and approach to it, that's all.
posted by bitteschoen at 12:39 AM on June 7, 2011 [13 favorites]

I'm not saying that I wasn't *sad*, but looking back, I would think that negative feelings were a perfectly logical response to my situation.

The complex looping interplay of emotional/mental state and life situation seem impossible to disentangle but also vastly more important than nearly ever given credit for these days. We've somehow convinced ourselves our own personal, internal representation of the world becomes defective because one of a handful of tanks of chemicals in our brain is low, and we just need to boost up those chemicals or keep then in the system longer

It's a ludicrously oversimplified hand-wavey view of what the brain is, or really what we are as people. I'm sure some people do get into maladaptive mental ruts through some acute, point-at-it-on-a-scan reason, the same way some people get fat because of defective thyroids or become a pedophile due to a brain tumor. But for most people I think mental disorders arise from a complex interplay between their society and situation and their own internal mental/emotional state

And the rates of "mental illness" in the US, like the obesity rates, is insanely high. Day-in day-out we have threads about the corruption and unfairness and inequality in American society where people just throw up their hands and start joking about guillotines. Does that zeitgeist not permeate down to the proles? We know inequality increases mental illness as well as nearly every other social ill

This is not a few people with leaky serotonin tanks, it's tens of millions of people being made physically and mentally sick by the society they live in
posted by crayz at 1:10 AM on June 7, 2011 [10 favorites]

It's an altering of the "normal" constitution of one's chemical balance

...and? Oh, sorry, BIG PHARMA. Yes, you needn't say anything more.

I am fairly anti-antidepressant. I haven't kept up with the literature for years, but last I checked they were very over-commercialized ... I think it's based in a fundamentally fallacious view of depression, emotion and the human experience that will look as silly as phlogiston in a handful of centuries.

Yeah, thanks for your awesome, not-informed-by-literature, anti-commerce-biased, underpants gnome theory of mental health. If only all scientists could wave their hands around say "Oh, it's just fundamentally fallacious, I think! I've checked - not lately, I admit - and there's money involved! That's right, it's quite commercial! Yes, the C word! Just you wait 500 years!"
posted by obiwanwasabi at 1:56 AM on June 7, 2011 [6 favorites]

I get the feeling that all the "I STARTED TAKING BRAIN DRUGS BEFORE THEY WERE COOL AND I LOVE THEM NOW THAT IT'S COOL NOT TO" people haven't actually read the article, nor considered its terrifying references to the physical harm these drugs are causing.

I had brain drugs forced on me during my adolescence after a single meeting with a sample-happy psychiatrist. It became cocktail as described in the article, and, like other commentors and the grand majority of people I know who were also subjected to this as children (which is a large number, seeing as I come from Marin), all I experienced was emotional numbness and erratic behavior, and never ended up addressing the real problems that were causing my anxiety. Who knows what kind of permanent damage those chemicals did to my developing brain? My psychiatrist sure doesn't, he's busy enjoying the yacht Pfizer bought for him!
posted by Mooseli at 2:41 AM on June 7, 2011 [8 favorites]

everyone gets depressed sometimes. once when I was feeling down, I got some zoloft on the advice of a friend. it made no difference at all, except that I couldn't cum. I decided it wasn't for me and haven't tried any since
posted by moorooka at 2:56 AM on June 7, 2011

I've been lucky in that my episodes of depression (the last was more than a decade ago) have always seemed to be situational (adolescent freaking out about college, family conflict post-college, dealing with the deaths of my parents). I responded well to talk therapy, and was also fortunate that either my insurance would pay for more than 10 sessions (per year!) or I was able to find a sliding-scale therapist and pay out of pocket. The St. John's Wort I took for about six months was probably good, in a placebo kind of way.

The brain is complicated; not all drugs will work the same way in people displaying similar symptoms; insurance companies would rather pay (some) money for customers to see a psychiatrist once a month to get their 'scrips than for a year's worth of talk therapy sessions. It's a clusterfuck.
posted by rtha at 3:02 AM on June 7, 2011

...nor considered its terrifying references to the physical harm these drugs are causing.

I read the articles, and I do agree that over-medication and the overzealous diagnosis of mental illness is a problem. On the other hand, despite what 10 years of lithium has no doubt done to me physically, it still beats thinking people are reading my thoughts or threatening to kill people with my mind. I do have occasional and extreme bitterness about the fact that I am dependent on medication and wonder what would happen if I were to taper off, and the idea raised here that medication itself is perpetuating the illness is certainly something I've struggled with. I can relate to the feeling that psychiatrists may not have your best interests in mind when prescribing the drug-du-jour, constantly wondering if it's based on merit or the fact the maker is hosting a big conference in Belize, or handing out tote bags or whatever it is they do.

What's modern is just the current definition and approach to it, that's all.

So true, and I imagine in the future people will look back on the dark age of psychiatry in the same way we now view things like the four humours or phrenology. After a decade of various diagnoses from different doctors, countless prescriptions and experimentation with off-label stuff it's obvious that doctors on the ground are still more or less clueless.

everyone gets depressed sometime

Wast talking about this with a friend this afternoon, it's something people (and by people I mean myself) who suffer from depression hear often. There is a huge difference between feeling down and having a major or psychotic depressive episode and it can be difficult to convey that to anyone who hasn't been to that place. The research does say major cases are a different story, but still can't help but mention this.
posted by Lorin at 3:11 AM on June 7, 2011 [13 favorites]

sorry, I do understand the difference and didn't mean it that way. I think it's a problem that the same word gets used for a mood as for an actual illness
posted by moorooka at 3:41 AM on June 7, 2011 [1 favorite]

I've got major depression & generalized anxiety disorder and have been on multiple anti-depressants—yet only felt effects on particular ones. I go into each medicine with the same hopes, yet only some work. These placebos suck!
posted by autoclavicle at 3:55 AM on June 7, 2011 [4 favorites]

If you're saying "we don't know how this or that aspect of neuro-chemistry even works" but believe it is acceptable that people ate food prior to our having the complete Krebs cycle worked out, I'm going to tend to think you're a hypocrite.

On the other hand, if you're saying this and you think it's unacceptable that people ate food prior to our having the complete Krebs cycle worked out, I'm going to think you're insane.
posted by Kid Charlemagne at 4:44 AM on June 7, 2011 [3 favorites]

If anti-depressants work about as well as placebo, then of course they have helped some people. About a third of people who take them, on average. That's how placebos work. One person, ten people, a thousand people who pipe up and say that an SSRI saved their life has absolutely no bearing on the scientific question of whether they are differentially safer, more efficacious, or in any sense 'better' than other forms of treatment or no treatment at all, when examine for aggregate effect sizes across populations. For any effective cure, thousands of people will swear by it. For any quack cure, the same.

Here are some conclusions from actual scientific literature, from a paper that I felicitously happened to have read yesterday:

• "Despite the pervasive belief regarding the effectiveness of antidepressants...among physicians and society at large, STAR*D [the largest, most expensive clinical-setting antidepressant study to date] shows that antidepressants...fail to result in sustained positive effects for the majority of people who receive them" [emphasis mine].
• "Antidepressant studies with favorable outcomes were 16 times more likely to be published as those with unfavorable ones."
• "New drug application studies with favorable outcomes were almost five times more likely to be published as those with unfavorable ones."
• "26.5% of pre-specified primary outcome measures were omitted from journal articles of new drug trials" (leading to "hypothesizing after the results are known")
• "Of the 43 primary measures not supporting efficacy, 20 (47%) were not included in the published results."
• "17 measures were only presented in the published studies and 15 of those showed positive effects for the new drug."
• In a review of 47 trials for 6 FDA-approved antidepressants, researchers "found that the weighted mean difference between groups on the 17-item Hamilton Rating Scale for Depression was only 1.8 points and 57% of the trials found no significant drug/placebo differences."
• "Regarding the common belief that drug effects are more enduring than placebo effects, Kirsh et al found that while patients' initial positive responses to both decrease over time, the correlation was higher for antidepressants than placebos, suggesting that the effects of antidepressants diminish more rapidly than those of placebo."

Pigott, E.H., Leventhal, A.M., Alter, G.S., & Boren, J.J. (2010). "Efficacy and Effectiveness of Antidepressants: Current Status of Research." Psychotherapy and Psychosomatics, 79, 267-279.

I could go on, but there's no point. I've done an extensive amount of reading in the psychological and psychiatric literature, looking not merely at the results of RCTs but also at critical studies, statistical methods, and rhetoric. To be frank, a lot of the work done in psychology on so-called "empirically supported treatments" and in psychiatry on psychopharmaceuticals leverages dubious, often patently internally invalid study designs, disingenuous argumentation, and poor (and sometimes just incorrect) statistical techniques. A lot of what is considered "gold standard" science is actually very shoddy science, when you look at it carefully.

And so, even though we (and certainly do include the psychologists, psychiatrists, and neuroscientists in that) to all appearances haven't the foggiest idea of how to honestly and rigorously create a framework for starting to ask the right questions, we all be perfectly happy to scream at each other about what we 'know' the answers to be.
posted by mister-o at 4:44 AM on June 7, 2011 [30 favorites]

I suspect part of the problem is that the U.S. healthcare system makes it easy to get drugs but difficult to get adequate and ongoing therapy. And then drugs for mental illness can be prescribed by a GP, which is probably mostly fine, but the GP doesn't have the special expertise in mental illness for when it's NOT run-of-the-mill depression. It would probably be better for an initial diagnosis to come from a psychatrist who then works with a GP, neurologist, therapist, even a dietician or physical therapist or whomever, in whatever combination, to come up with an appropriate program of treatment that takes ALL aspects of treatment into account for that individual.

I imagine it'd be expensive and annoying at first set-up, but it would probably save money over the long run and prevent some of these problems.
posted by Eyebrows McGee at 5:04 AM on June 7, 2011 [6 favorites]

Once upon a time I read about a monkey study in which the monkeys were placed (individually) in these big upside-down metal pyramids with steep walls that they couldn't climb. For a while, the monkey would struggle to climb out, always falling back down into the center of the pyramid. But eventually, the monkey would give up and start displaying signs of depression.

This anecdote is utterly terrifying and I would love a link so I can learn more about it!
posted by Greg Nog at 5:06 AM on June 7, 2011 [2 favorites]

"No, people are genuinely depressed by modern life."

This isn't exactly a new claim or even one that is unique to modernity. Its one that philosophically has been floated in various forms probably for centuries. The trouble with it is that while it may be undeniable that a persons situation has an effect on their mental health teasing out how to fix that for one person is hard but doing so for an entire society may be impossible.

Some philosophers believe that the the formation of civilization itself was a fall from a state of grace which irrevocably scarred man by cutting him off from a "natural" state of life.

I mention all this as a way of pointing out that these issues are philosophically really complex.

My only hope is that research and debates like this don't serve as a platform in which stigma against people with mental illness is perpetuated.

It seems to me that there is always an edge of "well its just lazy to take pills" that pops up when in reality the cost/benefit analysis of taking or not taking medicine, especially keeping in mind the difficulty of knowing how an individual person will react to a given medication.

The real fault seems to lay in a system that doesn't allow individuals the resources to make more informed decisions free from the huge value judgement that people make of those diagnosed with mental illness.
posted by SpaceWarp13 at 5:09 AM on June 7, 2011 [7 favorites]

...that will look as silly as phlogiston in a handful of centuries.

On the one hand, yeah, it looks silly in hindsight. On the other, if you look at the data they were looking at when they came up with phlogiston it makes a lot of sense. In fact, I can take their theory and run with it and give you a molecular weight and draw you a Lewis dot structure for the stuff.

It's just that eventually someone got around to purifying and then burning things with all solid combustion products (not like those silly organics) and it became a lot simpler to put +O2 on the other side of the equation.

The thing is, without the work of the guys who came up with phlogiston, would someone have gotten up one morning and said, "Hey, Oxygen!" Doubtful.
posted by Kid Charlemagne at 5:11 AM on June 7, 2011 [3 favorites]

"leading to "hypothesizing after the results are known"

My career (as I currently have it planned):

Observation, hypothesis, experiment, observation, hypothesis, experiment, observation, hypothesis, experiment, observation, hypothesis, experiment, observation, hypothesis, experiment, observation, hypothesis, experiment, observation, hypothesis, experiment, observation, hypothesis, experiment, observation, hypothesis, experiment, observation....death.

If you see a problem here, let me know.
posted by Kid Charlemagne at 5:22 AM on June 7, 2011 [2 favorites]

Each of the major antidepressants have FUCKING MOUNTAINS of documentation supporting their efficacy, especially the ones that have been around for a while.

I don't think you read the article.
posted by OmieWise at 5:42 AM on June 7, 2011

kaibutsu: "Once upon a time I read about a monkey study in which the monkeys were placed (individually) in these big upside-down metal pyramids with steep walls that they couldn't climb. For a while, the monkey would struggle to climb out, always falling back down into the center of the pyramid. But eventually, the monkey would give up and start displaying signs of depression.

Which is to say that sometimes the problem isn't treatable by drugs."

Ah, your story doesn't show what you think it does. It shows that futility can cause depression. If they'd attempted to treat it with drugs and found no results, then you could say that it shows the problem isn't treatable by drugs.
posted by galadriel at 6:22 AM on June 7, 2011 [1 favorite]

From Afroblanco's link:

Severely depressed people often have trouble just getting out of bed. How can a therapist get patients to take those first steps?
What’s important is that we can add exercise to the treatments that work, such as cognitive and interpersonal therapy and antidepressants. We now know that exercise works, but getting people to exercise is an art. Let’s be frank — Americans are abysmal at adopting exercise. So our approach is to use cognitive behavior therapy to target exercise adoption and help people really stick with it.

Sort of like the energy crisis, there is no single perfect fix but rather an array of treatments designed for you by a well-trained, experienced doctor who genuinely cares. Finding, or affording, such a doctor is a whole other challenge however and one most people will fail at.

God that's depressing.
posted by Godspeed.You!Black.Emperor.Penguin at 6:31 AM on June 7, 2011 [8 favorites]

The issue here is that depression rarely comes from nowhere. Like the sad monkey story related above, someone can only beat their heads against the wall for so long until they give up. Give the monkey some Zoloft, and he may well start trying to climb the wall again. For a while, until he again learns that it will do no good and becomes depressed again.

If you take a pill and don't change your circumstances and thought patterns, you will probably return to depression. The failure isn't that SSRIs don't "work", because they do. The failure is that SSRIs aren't a cure, and too many people believe they are. They may not work for everyone, because everyone doesn't have the same form of the disease.

(Of course SSRIs slow down thoughts and blunt emotions, etc. That's what they are supposed to do, because a lot of depression comes from an overload of those things.)

Depression casts a wide net, and it is scientific folly to call all types of depression one thing, and then measure drugs against that one thing. They could likely do a similar study with Advil and its efficacy against pain. "My arm got cut off and Advil didn't do shit! Fuck big pharma!" It isn't just apples and oranges- it is all fruits. "Orange juice is yummy, tomato juice is yummy, why isn't green pepper juice yummy? It's a scam, man."

The reality is: if SSRIs don't work, you don't have the disease they "cure". With the corrolary to that being: it is often easier and more effective to try a couple of different "cures" than it is to narrow down someone's troubles to specific neurotransmitter receptors in specific parts of the brain.
posted by gjc at 6:37 AM on June 7, 2011 [6 favorites]

The monkey experiment sounds like learned helplessness, for anyone who'd like to read some more.
posted by Infinite Jest at 6:40 AM on June 7, 2011

gjc, the efficacy of talk therapy would problematize that no?
posted by PinkMoose at 6:47 AM on June 7, 2011

Tianeptine is an interesting drug, because it has other effects besides depression. It helps asthma, purportedly. It probably has something to do with this:

Reuptake is necessary for normal synaptic physiology because it allows for the recycling of neurotransmitters and regulates the level of neurotransmitter present in the synapse and controls how long a signal resulting from neurotransmitter release lasts.

If the neurotransmitters do indeed get recycled, enhancing reuptake would seem to allow the vesicles to have enough serotonin to do their jobs effectively. If the receptors are swimming in a bath of free serotonin, when a vesicle fires, the receptor can't really tell the difference. But if something "vacuums up" all that free serotonin and puts it back on the shelf, the signal can again become clear.

Too bad it isn't available in the US...
posted by gjc at 6:48 AM on June 7, 2011

I have, fortunately, only had a brief experience with depression. At the time I thought I had mono. Now, looking back, I can see how my anxiety disorder got out of hand and led to depression.

Frankly, that experience made me grateful for my anxiety, which responds well to treatment and no longer impairs my life in a big way. CBT and meds have made a huge, noticeable difference in my life-- I went from being awake until 3 or four in the morning every night, my brain too busy to let me sleep, to having basically a normal human sleeping pattern in a matter of days after starting meds. And CBT helps me notice and avoid the harmful patterns of thought that would otherwise make me more and more and more anxious.

But anxiety isn't depression, of course, and what works for me might not work for someone whose brain is wired a whole different way. One of my best friends has severe, so-far-intractable depression, and it's been really tough watching her struggle to find the right combination of meds and therapy. Not as tough as it is for her to do it, though, obviously.

I don't think a blanket dismissal of SSRIs is really very useful, is the thing. They're going to work for some people, and they're not going to work for others. What we need are better tools for the people who aren't well-served by SSRIs, not tossing SSRIs out of the toolbox so they can't help anyone.
posted by nonasuch at 6:59 AM on June 7, 2011 [4 favorites]

gjc, the efficacy of talk therapy would problematize that no?

I don't think so, because talk therapy isn't 100% effective either. I think my long winded point was that statistical studies only measure the effectiveness of something against a group. Running a placebo versus treatment study against a group of people gives some useful information, but it doesn't judge the effectiveness in individuals.
posted by gjc at 7:01 AM on June 7, 2011

last I read, researchers never did safety studies longer than the FDA required 11 weeks for SSRIs. Meanwhile, Docs like to say crazy meds have to be taken for the rest of the patient's life.

The two issues of "down-regulation" and "gene expression" are both measures of permanent change as the brain adapts to long term use of these drugs.

But in the end, I'm sure BigPharm would never market marginally effective meds that cause permanent damage to the delicate ecology of a patient's mind simply because it was profitable. Large corps never do stuff like that. NEVER.

(whatever you do, don't juxtapose this issue against the WOD. That would be depressing)
posted by Fupped Duck at 7:24 AM on June 7, 2011

Too bad it isn't available in the US...

You can add this to the reasons for Big-Pharma-hate. Amidst the discussion of whether psych drugs work, whether it's all placebo effect, and whether they're actually harmful (and that was a wowser of an article, I wish the second part was available) or what...there's some large percentage of us that are going to end up back at the psychiatrist's office begging for more help, and when we do, and when we present the fact we've already been on a number of SSRIs (and perhaps big cocktails including bipolar meds, tranquilizers and antipsychotics), it would be nice to have an option that is not an SSRI. Even if it's a new improved SSRI that they added a molecule on to keep a patent.

The fact that this is all commercial is actively hindering the search for effective treatment. And that sucks.
posted by mittens at 7:26 AM on June 7, 2011

It seems that Americans are in the midst of a raging epidemic of mental illness, at least as judged by the increase in the numbers treated for it.

Hm. The disingenuous opening sentence of the article stopped me. Do we even agree with the premise that there really is a comparative "raging epidemic" of mental illness in recent years (compared to previous decades)?

I suspect a combination of much-more-comprehensive diagnostic schemes that lead to pharmacologically-aggressive treatments, coupled with it becoming less socially-acceptable (at least for the stratum of people who read the NY Review of Books) to self-medicate heavily with alcohol, cigarettes, and heavy foods (as probably happened in our grand- and great-grand-parents' generations), suggests reasons more people may be turning to prescribed anti-depressants. I do suspect if current standards for diagnosing mental illness were applied to people in any other time and culture, they would find just as much "illness" that requires intervention.

I don't know whether this says something about the human mind itself (modern or more generally), or something about contemporary American aspirations to some perfected state of mental hygiene and self-actualization -- but I do think this is an important consideration.
posted by aught at 7:34 AM on June 7, 2011 [2 favorites]

Do we even agree with the premise that there really is a comparative "raging epidemic" of mental illness in recent years (compared to previous decades)?

Keep reading. It's pretty interesting--and I think the answer the article offers to your question would be a solid no.
posted by mittens at 7:36 AM on June 7, 2011 [1 favorite]

The article lumps anti-depressants and anti-psychotics together, which I find wildly inappropriate.

I've seen cases of over-prescribing, and there are docs in my town who over-prescribe pretty routinely. I've been helped by anti-depressants, including the tri-cyclics that were all that was available be fore Prozac and its descendants. I know a number of people who have been helped by anti-depressants. If it's a placebo effect, fine. I'm quite thankful for anti-depressants.

The unanswered question isn't Are anti-depressants bad or good? but What is it about the way we live now that makes us so sad? It's not just anti-depressants that are heavily marketed and oversold, but giant houses that separate people from one another, tv that shows us all the things we can't have, and encourages us to want more, more more. Bullying and outright meanness is shown on tv and movies as funny and acceptable. Talk radio and talk tv promote hate, ridicule and disrespect.

I don't believe in god, so I'm not religious, but I do wonder what we can do to replace the role of religion to promote morality and community.

People connect less and buy more. It doesn't seem to be working.
posted by theora55 at 7:53 AM on June 7, 2011 [5 favorites]

I will venture a guess that I have had more direct and indirect experiences with antidepressants than most posters, having run two community mental health agencies for 30+ years. A few observations. With some exceptions most of what has been said here is accurate: antidepressants work and they do not work, we do not know why they work and we do know how they work. there is no good science to support their use and there is ample science to suppoert their use. there is not enough 'talk therapy" and there is way to much "talk therapy". In the final analysis , for me, the advent of antidepressants, anti-psychotics and non addictive anti-anxiety agents(ssri's) is a blessing and a bit of a curse. Having been responsible for the care of thousands of patients before and after the advent of SSRIs and the newer anti-psychotics it is a nuch better world for many many people and world that is constantly improving. I forget which poster said it but the fact is: observation, hypothesis, experiment, analyze and do it again and again and again. Believe me, I would rather be dealing with disabling depression or anxiety today than any time before 1960. Before 1960 the choices were largely psychoanalysis which no body could afford and did not work, ECT, institutionalization, alcohol, drugs the equivalent of sledgehammers, addictive drugs, hope and prayers.
posted by rmhsinc at 8:06 AM on June 7, 2011 [8 favorites]

> Tianeptine is an interesting drug, because it has other effects besides depression.

Tianeptine is interesting for a whole other reason too, in that it is a Selective Serotonin Reuptake Enhancer, i.e. it has the exact opposite neurochemical effect as the most popular class of antidepressants, yet seems to work just as well. Like I (poorly) summed up earlier in thread before my warm comfy bed called: the main problem these authors, and a wide array of other antidepressant skeptics, seem to have is that we lack a firm scientific understanding of how these drugs work. This is a problem with any pharmaceutical treatment, but it becomes particularly complicated with psychiatric disorders, which don't fit into the disease model of Koch's Postulates.

The inability to locate some kind of Human Depression Virus Type A means we end up diagnosing mental disease by matching them to the suite of symptoms which best fits. Not that studies stating "X infection linked to depression" don't come out on a near weekly basis, but until they manage to grow a culture that makes rats meet a DSM-IV diagnosis, we're left with the Hamilton Scale and other instruments. These instruments, however, measure symptoms and are intended to narrow down a diagnosis of disease, not the causation.

At this point in psychoactive drugs we're like cavemen with an airplane or teenagers with sex: we know if poke certain things and pull on other parts we can get the desired effect, but we're not quite sure why it happens. Like I noted before, pretty much all the authors agreed that antidepressants can be effective over the short-term, but so can placebos. Of course, there are legions of grad-students, post-docs, and docs all out there working to quantify the effects of the drugs, which is why we can pin down the exact receptors certain drugs either inhibit or excite. But when it comes to question of "why do some people get depressed when they do?" we are left with some hand-waving about chemical imbalances and genetic predispositions.

That's why our parable of the monkey study is so interesting, because it raises the concept of depression as a social disease, or at least a social environment as a trigger for depression. That could just be more hand-waving, but if we are going to treat depression as adhering to a disease model than we have to admit that environmental factors could be significant. The way the current US system is trending in mental health care -- short, intermittent talk therapy combined with long-term medication -- seems to me like treating a TB patient, without treating all the other TB+ people he lives with. All you're doing is setting them up for a constant cycle of re-treatment, a real problem if your drugs are known to have diminished returns over time.
posted by Panjandrum at 8:30 AM on June 7, 2011 [6 favorites]

HOLY SHIT THE MONKEY STUDY WAS REAL AND TERRIBLE AND HAS THE BEST WIKIPEDIA PAGE NAME EVER
posted by Greg Nog at 8:34 AM on June 7, 2011 [15 favorites]

re: active placebo; Clearly, the side effects will drive you crazy.
posted by Ardiril at 8:41 AM on June 7, 2011

If I wasn't depressed before, reading about baby monkeys huddled in the corner going psychotic certainly did the trick.
posted by mittens at 8:43 AM on June 7, 2011 [2 favorites]

last I checked they were very over-commercialized and promoted to prescribers in extremely sleazy ways;

Not just anti-depressants, but pretty much all drugs are promoted in sleazy ways. I really hate that medicine has become what it is today. I left one doc when there were more pharmaceutical reps in the waiting room than patients. Everyone knows better than their doc because of what they see on a commercial, and asks for the drug, by name!

Yes, comment is slightly pruned out of context, but this issue really gets to me.
posted by kellyblah at 8:46 AM on June 7, 2011

What bothers me about the whole pushing of psychiatric drugs is the attitude of it being a solve all.

I've been on these drugs in the past, and if anyone else has these chemicals are not to be taken lightly. Between upping doses, changing medications, adding another medication(s), doctors have lost the fine art of therapy.

I truly believe that some people benefit from these chemicals. I also know that some of these chemicals can do some serious.fucking.harm! I also find it very unusual that doctors seem to think these medications are great to just prescribe these drugs to patients for life(some may, many probably not).

I really wish that for these types of drugs to be prescribed that a requirement would be to pursue some form of therapy. In my darkest days the best, and most helpful thing was seeing a psychoanalytical psychiatrist (that I disliked) who pushed me in directions to discuss things about me that I had buried and wished to ignore. This may not help everyone, but its my story.
posted by handbanana at 8:50 AM on June 7, 2011

Thinking a bit about this, but can we knock off the "magic pill" rhetoric? I don't know anyone who believes that taking a pill will do more than blunt some of the worst symptoms.
posted by KirkJobSluder at 8:50 AM on June 7, 2011 [1 favorite]

Kirkjonslunder,
You can, but some people really do think of these things as little solve alls. Sorry, but its truth from my perspective.
posted by handbanana at 8:53 AM on June 7, 2011

Wow.

I often thought, as a student hearing about Harlow's work with rhesus monkeys and maternal attachment that you had to have a heart of stone to substitute a wire mesh feeder for a mother, sit back and watch as those monkeys deteriorated for lack of maternal comfort.

Now, after reading about Harlow's wife's death and his experiments afterward from the link Greg Nog posted above, I'm convinced the man was, to put it in clinical terms, Totally Fucked Up.

Harlow was obviously severely clinically depressed, but channeling what was surely a brilliant scientific mind into to creating, basically, a torture chamber that exposed those poor animals to his own depths of despair is just monstrous, and I just don't know that anything we learned from that could justify the measures he used. I mean this stuff reads worse than the plot of a horror movie (TRIGGER WARNING: RAPE AND ABUSE):

"Harlow devised what he called a "rape rack," to which the female isolates were tied in normal monkey mating posture. He found that, just as they were incapable of having sexual relations, they were also unable to parent their offspring, either abusing or neglecting them. "Not even in our most devious dreams could we have designed a surrogate as evil as these real monkey mothers were," he wrote.[8] Having no social experience themselves, they were incapable of appropriate social interaction. One mother held her baby's face to the floor and chewed off his feet and fingers. Another crushed her baby's head. Most of them simply ignored their offspring."

And that's BEFORE he developed that inverted-pyramid experiment.

Wow.
posted by misha at 9:00 AM on June 7, 2011 [1 favorite]

I do not know the answer or what is right or wrong, I am sure there are shades, I don't want to give in to orthodoxy in either direction... but:

I only wish that something could give me back the mother that was taken from me by 15 years of debilitating side effects from powerful psycho-pharmaceuticals. She was overweight, reclusive, and emotionally unstable while I was a child, kept on an ever-changing cocktail of anti-depressants. I hardly recognize the competent, healthy, socially active woman that she is today since she made the decision to get off of them, thanks in large part to Whitaker's first book, Mad in America.

I wish the psychiatric industry had not repeatedly electrocuted my grandmother, kept her in an insane asylum and forced her to scrub floors with toothbrushes and then nearly lobotomized her, all for alcoholism and depression. She was a highly creative and intelligent person forced to be a housewife in Texas in the 1950s, married to someone she did not love, and deeply insecure after an abusive and impoverished childhood. I almost never got to experience the person who would end up being the most meaningful relationship of my life.

I do not understand why my 10 year old cousin, whose father died in a car accident, was given anti-psychotics because she told her mother that she could hear her dead father's voice. She has been on a various medications for over six years now, and has repeatedly attempted suicide. Her on and off again confinement in mental institutions has bankrupted her family.

I do not understand why my closest friend in college, whose paranoia and "bizarre thoughts" did indeed lead to a psychotic break when we were 20, probably intensified by heavy marijuana use, was given a powerful mixture of anti-psychotics that seemed to further destabilize his personality, made him overweight and sluggish, and all but wiped everything that I loved about him: his curiosity, his creativity, his idiosyncratic and strange heart. His confinement in institutions only intensified his sense of conspiracy against him, and indeed there was a conspiracy against him, against who he was; he became a "patient," a broken person. He needed therapy and understanding, a family that did not accuse him of illness. And he needed something this world cannot provide, just as it could not provide my mother or my grandmother: a world forgiving of irrationality and difference, a world that does not react violently against them.

"Deviants from the mass sexual stereotype, quietists, those who will not work for money, or fib and make arms for hire, or join armies in murder and threat, those who wish to loaf, think, rest in visions, act beautifully on their own, speak truthfully in public, inspired by Democracy -- what is their psychic fate now in America?"
-Allen Ginsberg, "Independence Day Manifesto"
posted by bukharin at 9:02 AM on June 7, 2011 [11 favorites]

As to the FPP, I have some conflicting thoughts.

I take anti-depressants, and I want to say right off that I although I do think they are over-prescribed for what I would consider normal reactions to stressful situations rather than episodes of clinical depression, I do think they are beneficial to those of us who have those severe episodes, and have most of our lives.

The fact that anti-depressants appear to show more efficacy to levels above 25 on the HRMI scale bears me out on this (incidentally, that scale goes all the way up to a possible 80 points, so 25 is relatively low, in my opinion, and I don't think we *should* be medicating people who, again, are likely just experiencing perfectly understandable moods).

I also think that this article is misleading when it speaks about changes to the brain being associated with psychoactive drugs, of which anti-depressants are a subset, when in fact the changes appear to only be connected to anti-psychotics, which are prescribed for very serious illnesses like schizophrenia and not clinical depression.

I have no doubt that in my case, anti-depressants are helpful. I do know that some work better than others for me, and that the withdrawal off of them can be hellacious; again, they should not be seen as a cure-all or a magic pill to take when you're sad.

But the difference, for me, is the difference between actively running possible suicide attempts in my mind to see which would work best, planning out the letter I would write to comfort my loved ones when I am gone and determining who would inherit what and actually realizing how fucked up even getting into that kind of mindset is.

And yes, exercise is very helpful when you're depressed. Suggesting that exercise alone can do what some of these medications can do ignores the fact that many severely depressed people cannot make themselves get up out of bed in the morning, let alone face the idea of heading to the gym.

I really would like to see more long-term studies done; I did find some that show promising results for patients on anti-depressants over 72 weeks of use, but the studies are underwritten by Eli Lilly, which has a huge financial stake in producing these drugs (which is why I didn't link them). In fact, it's hard to avoid the influence of big pharma on these studies, because scientists need funding and they have all the money. So I think we need to be cautious in both the prescribing of these drugs and in the conclusions we draw from the limited studies done this far.
posted by misha at 9:19 AM on June 7, 2011 [4 favorites]

"Deviants from the mass sexual stereotype, quietists, those who will not work for money, or fib and make arms for hire, or join armies in murder and threat, those who wish to loaf, think, rest in visions, act beautifully on their own, speak truthfully in public, inspired by Democracy -- what is their psychic fate now in America?"

Allen Ginsberg who, as a young man, was institutionalized due to his homosexuality. He even got better for a while, got a proper job, blended with the crowd ...

The issue here is

There's a whole bunch of issues here. How could there not be with something as complicated as the human brain (and dare I mention it, the possibility of an immortal soul) and how they/it interface with the so-called modern world? Hence, the frustration from many (some of it knee jerk, for sure) with anything even remotely suggesting that a few little pills taken daily could be a solution to something as mentally and spiritually complex and devastating as a full-on depression.

Clearly for some, the right meds at the right time can be a lifesaver, just as paramedics save many lives at accident scenes. So yeah (staying with the analogy), by all means keep researching and developing better equipment and practices for our paramedics. But let's not lost track of the real problem (and challenge) which is figuring out what's causing these accidents in the first place.
posted by philip-random at 9:20 AM on June 7, 2011 [1 favorite]

My Sad Story Anecdatum: a combination SSRI/SNRI treatment coupled with movement therapy gave me a rope when all I wanted (for days, weeks, months on end) was a knife.

Basically -- you do you, and I'll do me.
posted by sinnesloeschen at 9:23 AM on June 7, 2011

I've been on meds now since I was 23. Before then, I had near-constant anxiety that left me perpetually exhausted and (surprise, surprise) a diagnosis of depression that was changed to bipolar type II about 10 years ago. To top that off, I was diagnosed with sensory processing disorder (learning disability) at age 11.

Is is genetic - quite likely. Both my parents and my brother were diagnosed with mood & anxiety disorders as were a number of uncles, aunts & cousins.

Is it enviorment? Likely. I was relentlessly bullied in grade school and regularly humiliated by teachers who didn't understand that I had a learning disability. My parents were sometimes physically abusive and frequently emotionally abusive. I woke up every morning with my stomach in knots and my heart racing.

Does exercise, vitamins or talk therapy help? To a certain degree, yes. None of these, however, have helped me as much as medication. I tried going off medication this spring. I was unprepared for the onslaught of my old symptoms returning full force.

Are the meds risky? Probably, but the alternative is so much worse.
posted by echolalia67 at 9:27 AM on June 7, 2011 [5 favorites]

If I wasn't depressed before, reading about baby monkeys huddled in the corner going psychotic certainly did the trick.

Yeah, I could have happily gone my entire life ignorant of the existence of a monkey rape rack presented as legitimate science.
posted by elizardbits at 10:13 AM on June 7, 2011 [1 favorite]

anti-psychotics, which are prescribed for very serious illnesses like schizophrenia and not clinical depression

Unfortunately not entirely true, if my years on Seroquel were any example.
posted by mittens at 10:23 AM on June 7, 2011 [1 favorite]

I am confused by these efficacy studies. There is no depression disease, it is a list of symptoms with no well-known, agreed upon cause. Doctors ask you questions and come up with the diagnosis; there is no blood test.

Thought experiment: A clinical trial of a drug used to treat "lung illness" is performed. Lung illness is actually the common cold, the flu, asthma, emphysema, pneumonia, tuberculosis, and lung cancer. The drug used in the trial is penicillin. Penicillin is going to cause great harm to many of the individuals in the study, but cure those with the pneumonia.

The people with pneumonia will sing the drug's praises, those dealing with side effects and no relief will be disappointed.

Those experiencing a combination of the placebo effect and negative side-effects, and their sickness will do worse than those experiencing placebo effect and sickness alone.

The problem is not that antibiotics are useless, and perhaps worse than placebo; The problem is that "lung illness" does not exist as a disease, just a wide range of symptoms lumped together.

After antibiotics fail to treat a patient's "lung illness" move on to another strategy, which may end up being a different drug.

How many studies show the efficacy of drug treatment for depression after several drugs are tried? It seems reasonable that, if depression has multiple causes, one may have to try multiple drugs before finding the one that treats their specific cause.
posted by UrbanEye at 11:07 AM on June 7, 2011 [3 favorites]

Poor little monkeys.
posted by infinitywaltz at 11:18 AM on June 7, 2011 [1 favorite]

A long time ago, a friend of mine went on a new antidepressant. He snapped, set our shared house on fire, spent months in a psych ward, and was then found Not Criminally Responsible due to the medication.

So my thoughts on antidepressants are: YMMV.
posted by Theta States at 11:40 AM on June 7, 2011 [1 favorite]

I've been thinking that for years.
posted by chance at 12:49 PM on June 7, 2011

I had typed up a long comment last night about personal experience and overprescription, but then I deleted it because it was just too painful and weird.

But others in the thread have nailed much of what I wanted to say. But I should still share something.

Background: I'm dealing with severe chronic anxiety, PTSD and the related depression that was caused by severe child abuse/trauma. For me it's not the depression that really gets to me, it's the anxiety and PTSD that feeds back into the depression. If I can manage the anxiety/fear, the depression more or less solves itself. Anxiety prevents me from doing basic things, trusting people and forming connections, accomplishing goals, not being hypervigilant - and it's these failures and guilt that reinforce the depression.

I don't actually mind being depressed. I can deal with that. But I can't deal with having adrenaline surges every time someone slams a door or starts shouting within hearing range.

So, just over a year ago (as some mefite members know and will attest to) I was really at the end of my rope. I was a walking zombie. Not alive. I'd had enough and I ended up at a local low-cost community health care clinic.

I talked to a general practitioner who had absolutely no case history, no records and all of two minutes of discovery before he was writing me a scrip for Zoloft. No psychiatrist, no therapist - just a bottle of pills. These were dispensed from the in-house pharmacy where I noted they were kept in stock by the case, like they did this every day. (This is warning number one. It was ignored.) "Ok, this is what people do," I thought, "They take their pills and listen to their doctors." I did some homework before I started taking them, didn't like what I read at all and I still took them.

So I started taking them. Like clock work, on time, every time. I was on a low dose of Zoloft, and Zoloft is apparently one of the milder SSRIs. I first started noticing effects in the first 24-48 hours, and very noticeably at 72 hours, rather than the 1-2 weeks as indicated in the literature and by the doc. (This is warning sign number 2, also ignored.)

The first couple of weeks were great. Colors looked more colorful. I could smell things better, food tasted better. I had a deep interest in life and being social again, being social felt "right". I could actually feel feelings better, both good and bad. My brain lit up. This was all fine.

But there was a thick drug fog building up. It was slowing my thoughts down, clouding my thinking. It was like being severely stoned on pot all the time but without the relaxation or enjoyment, creativity or clarity, just dull, sodden and woolly. Somewhere around week 2 I missed a single morning dose and within 3-4 hours I experienced "brain zaps" and the edges of what I suspect was Serotonin Syndrome. (This is warning sign number 3, also ignored.)

At weeks 3-4, everything crashed. Badly. I went from "Hey, I'm pretty ok and doing better!" to "I'm a pile of used battery lead slowly melting in corrosive acids please put me out of my misery!" in the space of 12 hours. No change in the dose or timing or habits. It was like someone flipped a switch in my head. Everything, everything was absolutely terrible.

I was already familiar with chronic full body pain from depression, but not like this. Take the emotions of shame, overwhelming sadness, humiliation, fear... basically every negative human emotion, and mix them all up together. Now amplify it to 1000x stronger than natural, even compared to severe chronic depression. Now, you know that really intense, acute sort of pain when you get when you hit your thumb with a hammer, or you get your fingers slammed in a car door? My entire body felt like that. I was more than dead, I was burning in a private hell that followed me everywhere I went. It was like burning alive from the inside out, but there's nothing I could do about it.

I'm not trying to exaggerate, here. If anything I'm understating the subjective experience. You should be informed that I'm something of a masochist. I don't like pain killers or opiates. I've lived through impacted, infected wisdom teeth falling out of my head without so much as an ibuprofen tablet. I've danced the night away on broken toes. I kind of like pain. A bike ride isn't a good bike ride unless my legs and lungs are burning. Sex is boring unless it's a bit kinky and rough. I dance until I have blisters on my feet or I'm passing out from lack of oxygen. Pain makes for good art, it's an essential flavor and spice of life. But this, this was something else entirely. Every nerve in my body was on fire and screaming at me, and it was literally all in my head.

So I tried to stick it out, and I did for another two weeks. Two weeks of that kind of pain, standing in the darkness of Seattle rain in the winter, chain smoking, unable to think or feel anything but pain and unable to think beyond "This is it, I'm already dead. Just finish yourself off already. It'll make the pain finally stop." And I was really close to accepting that solution.

I finally gave up and went back to the doctor and told him that the drug wasn't working, but making things worse. He told me I could just stop cold turkey, so I did. (Warning sign number 4. Stopping an SSRI cold isn't good advice - please avoid.)

The next 3-5 days were interesting. So I still have the intense negative emotions and pain going on, but now I get the "brain zaps". It's like being shocked with a cattle prod or stun gun inside my head and body every few seconds, or as much as several times a second during the peak of the withdrawals. (And I know how both cattle prods and stun guns feel because I've been known to zap myself with those things for fun. I told you I actually kind of like pain, right?)

The pain finally receded a week after stopping the Zoloft. I slumped back into an even more severe depression, some of it was obviously situational at failing to get help, but a huge part of it was obviously biochemical. I was much worse off than I was before. I was still foggy. It took months for that fog to lift and for me to just climb back to my baseline depression that I knew before Zoloft. I still don't feel quite right, like something fundamental chemically changed inside my brain. It's a mild but persistent worry.

I honestly have no idea how people can take something like Zoloft at high doses every day and still function. I would personally find it easier to navigate life absolutely stoned out of my gourd all day, every day. It would be easier to take a heroic dose of acid every single morning. I know that an SSRI isn't going to cause the same side effects, but... that cloud and mental fog was awfully hard to think through. I don't know how people do it.

Yeah, I will acknowledge and concede that these drugs can help some people, but I still think they're massively over-prescribed, and that's not just based on my own experiences, but dozens if not hundreds of stories of people walking into a general MD's office and getting prescribed entire cocktails of strong psychoactive chemicals without the proper support, therapy or aftercare.

But at this point in my life I'm certain I want nothing to do with SSRIs in particular. They aren't for me. I think they're dangerous and being misused and outright abused. There really isn't any moral or ethical difference in my mind between this sort of doctor-assisted self-medication and the self-medication (and abuse) some people try to do with psychoactive, psychedelic drugs like MDMA or LSD.

I would even say that SSRIs and the new array of psychiatric medication is as dangerous -if not actually much more dangerous - than psychedelics/hallucinogens. Just as little is known about them in both fields, and if anything we know more about MDMA than we do Zoloft.

And MDMA isn't being pushed by drug sales reps and Big pharma companies who have a vested interested in assuring the public that they work, that they aren't barely more effective than a placebo.

What did help me was talk therapy. CBT and DBT in particular. And I'm not too good at it, because it's mighty painful to dig up that trauma and examine it, even if you intend to throw it away. But it helps. A lot. If anything it helps to gain perspective and know you're not actually alone. It also helps to process and accept the things you can change, and identify and accept the things you can't change. There's a lot about me I probably won't ever be able to heal or fix, but that's life. Psychic scars are just as real as physical scars. Sometimes you get injured, and if you're lucky life goes on and you adapt.

What also helped is exercise. Going on a bike ride almost always helps me. I get to go flying for a while and just be free. My brain and body get a workout. My confidence and outlook goes up. And it's much more enjoyable because it's natural, as in the benefits aren't hindered by some kind of crazy, hazy drug fog.

Eating better certainly helps, as well. And, yeah, all of these things are really hard to do if you're chronically depressed and you can barely get out of bed. I know that. I know it first hand. I've been there, and still am in many ways.

And I did find some drugs that worked when I did finally get to see a therapist and a new doc that better understood what was going on and listened to me. We tried hydroxyzine - the antihistamine medication - for anxiety. As any allergy sufferer will attest it slows you down and makes you a little dopey, which is just fine for general anxiety, without the heavy psychoactivity or addiction/dependence. The other one was prazosin - a drug originally used to lower high blood pressure. It suppresses adrenalin. It was prescribed to me to help me sleep without nightmares, which helps combat the PTSD - again without the heavy psychoactive effects or dependency.


So. I strongly feel that these psychoactive drugs should not be seen as chronic, long term solutions. That's doing it wrong, just like self-medicating by taking MDMA every weekend is doing it wrong. Yes, they can help a lot of people (so can MDMA!), but what we need to be doing is giving depressed people a bootstrap or step ladder out of the hole, and then providing better coping tools, better diets, encouraging exercise and vitamin D supplements.

Sorry, I'm rambling. This is a very complicated, dynamic issue with a lot of facets.


And as others have pointed out - our collective quality if life is often pretty shitty. We would do well with a cultural and social revolution to address that. There's a lot of deeply unfulfilled, lonely people in the world. There's also a lot of deeply traumatized people in the world. Violence and abuse lurks behind doors in your very neighborhood, perhaps even in your own home. War and strife still openly exist. The everyday traumas and adrenaline surges and stress of modern life don't help much, either.

Giving these people - people like me and you - a metaphorical Soma isn't going to cure that anymore than you can find happiness at the bottom of a bottle of rotgut whiskey.


Are psychiatric meds causing the epidemic of mental illness? No. Are they helping or making things worse? From what I've personally seen I think they're making things worse. For every one person I've personally seen that an SSRI has helped, it seems like there's three that have had a bad experience.

Are they overprescribed? Yes. Undoubtedly, emphatically so. I should have never been given Zoloft. The doctor knew I was already having severe suicidal ideations and this a contradiction and no-go for SSRIs like Zoloft. It says so right on the info sheet, and I took it anyway because I didn't really have any choice but to trust the doctor, because I was so far down in the hole of depression I couldn't think straight. I'm not alone in that scenario.


Last... if you need help - ask for it. Seek it out. But do your homework about drugs. Don't blindly take whatever a doctor tells you to take. If a doctor keeps pushing drugs you don't want to take - find a new doctor. Get into therapy. Find a support group whether it's official or ad-hoc. I know it's hard if not nigh impossible to do while you're depressed, but you can do it. You must be an active participant. There are no magic pills and like life in general there are very few shortcuts are actually shortcuts.

As they say, your mileage may vary.
posted by loquacious at 1:22 PM on June 7, 2011 [10 favorites]

I wish Harlow was still alive so that I could punch him in the face repeatedly.
posted by Justinian at 1:22 PM on June 7, 2011 [3 favorites]

HOLY SHIT THE MONKEY STUDY WAS REAL AND TERRIBLE AND HAS THE BEST WIKIPEDIA PAGE NAME EVER

Don't even think about trying to escape.
posted by adamdschneider at 1:28 PM on June 7, 2011

I understand that when you're depressed, you're willing to try anything, and the act of doing something at all can help, for a time; but medicating depression is a practice I'll never agree with.

When I was depressed I was unwilling to try much of anything, because it was obvious there was nothing that could help. It wasn't my brain that was the problem, you see: it was the entire world around me which was broken. My all-pervading inability to enjoy life felt like a completely rational response to a dark, empty, worn-out world.

It was not until I started taking drugs - recreational drugs, I mean - that I realized how awesome the same world could look through chemically-tinted glasses. Maybe, I started to think, it actually was my brain which was out of balance, and not the world I lived in. And it was not until I started taking antidepressants that I was able to straighten out my unhealthy thought-loops and learn to actually enjoy life.

Sure, undoubtedly people try meds that don't work for them, and end up with unpleasant side-effects. But what else are doctors supposed to do? Just let their patients stay miserable? Antidepressants work for enough people enough of the time that they are worth trying. They may not be perfect but they're the best tools we have.
posted by Mars Saxman at 2:00 PM on June 7, 2011 [2 favorites]

Reminds me of this comment in an old thread.

Which reads in part:

"Finally, know how we find new antidepressants? They take mice and abuse the shit out of them. Shake their cage, wake them up, withhold food, spray them with water, tell them their mother's fat, etc. These mice respond by never leaving the corner and shivering constantly (as would you). Scientists figure these mice are depressed, but who really knows? The mice won't tell us themselves. Anyways, they take these mice and well-treated mice and hang them up by their tails until the stop struggling. "Depressed" mice will generally not struggle that long, while the control mice will struggle for a while. A drug is considered an "antidepressent" if it can make the "depressed" mouse struggle as long as the control while not making the control mouse hyperactive. There are entire warehouses in the midwest full of hanging mice and hopeful scientists.

Ain't science great?"
posted by banshee at 2:01 PM on June 7, 2011 [1 favorite]

Is the contemporary epidemic of mental illness

I'm going to go out on a limb and suggest (without the reasons except that I've been reading more history lately) that to an extent we're all mad-hatters and always have been. Also that what's "acceptable" and not is largely culture-bias. (Yeah, Ron Laing got to me.) What is 'psychopathic' at home is A-OK overseas, no?

So the only 'epidemic' is the result of us finally noticing that ... going "OMG!" and trying to find ways to end it. So like byanyothername I think it will look as silly as phlogiston in a handful of centuries.
posted by Twang at 3:31 PM on June 7, 2011 [1 favorite]

But others in the thread have nailed much of what I wanted to say. But I should still share something.

Wow. Just wow. I am continually shocked by how, even if backgrounds and specific disorders (and, apparently, tendencies to shock oneself with cattleprods) are entirely different, the Bad SSRI Experience is so often the same.

It's like a script--the quick prescription, the lack of advice on side-effects, the lack of knowledge of the withdrawal...just some added variations on how many more drugs get tried and added before something (a) works or (b) makes you give up on the project entirely.

I gotta drag myself back in soon. At least I'll know I'm not being picky or crazy when I say, "Let's put me back on clonidine and Inderal rather than whatever new SSRI brand is currently decorating every pen and clock in your office."
posted by mittens at 4:32 PM on June 7, 2011

last I read, researchers never did safety studies longer than the FDA required 11 weeks for SSRIs.

I like how you imply that after phase 1 clinical testing, adverse events no longer matter, as if 79.7% of the people in phase three could have died of non-infection related meningitis and no one would bat an eye.
posted by Kid Charlemagne at 8:33 PM on June 7, 2011

It's like a script--the quick prescription, the lack of advice on side-effects, the lack of knowledge of the withdrawal...just some added variations on how many more drugs get tried and added before something (a) works or (b) makes you give up on the project entirely.

This is why in my opinion people should start with therapy, then move to the medications, (or both at once, but never medication without therapy) and educate themselves on the medications. The pharmacist will sit and talk with you about them if you want more info than the psychiatrist and if your therapist doesn't know. My therapist doesn't prescribe but walked through the emotional and scheduling pieces of the medication and the doctor's appointments with me because I was in terrible shape at the time.

For everyone who talks about magic pills, or happy pills -- I have never heard anyone ever tell me that they took an anti depressant and were instantly "happy," nor have I ever seen this is anyone else or experienced anything like this for myself. Like others have said, it made the therapy take, it made me not so tired all the time, it calmed my anxiety so I could sleep at night, and this was after months of ramp up and tweaking to find what worked. Depression is hell. I can't understand why anyone would think it shouldn't be medicated like any other illness.
posted by sweetkid at 8:52 PM on June 7, 2011 [2 favorites]

There were abuses.
posted by WinstonJulia at 2:14 AM on June 8, 2011 [1 favorite]

Wow. We have all the ingredients here to make Anti-Vacc Crusade Mk. II.

We have all the usual elements: dramatic personal testimony, rants about the eeeeeevil of BIG PHARMA, disparaging comments about the arrogant scientists and doctors who really don't know much at all, and salvation in the form of alternative treatments. And hey, as an extra special bonus, we have an alternative explanation to the biological one! It's all the fault of modern society and Capitalism! All we need now is for a major talk show host to take up the cause and we'll be set!

Except this is exactly the same bullshit I've been told all my life; all I needed to do was exercise, eat right, meditate, go into therapy, make the right life choices, buy this book, go on that diet, and so on. And if those things didn't work, well, it must be my fault because I wasn't trying hard enough, or I was blocking the trauma, or I really wanted to be sick.

Well to all the patronizing assholes on the internet who think that just because they read some study THEY know how MY mind works, FUCK YOU. The only thing that's worked for me is taking four years of experimentation to find the right combination of meds to allow me to function normally, and I am not going to ruin my life just to be an experiment for your precious philosophy about how it's just the evils of modern life that causes depression, and we'd all be fine if we just did transcendental meditation or some other hippy shit.

But thanks to the "dramatic personal testimony" and "alternative therapies" crap, at some point some senator is probably going to decide that psych meds don't need to be covered, or that they need to be banned. So thanks a fat fucking hell of a lot for your oh so special help. Maybe you can next go and talk about people who have spina bifida are really just begging for attention.
posted by happyroach at 2:29 PM on June 8, 2011 [7 favorites]

Man, yeah, just came in to post the wikipedia page for the 'pit of despair,' only to find Greg Nog had already found it himself. That stuff was far worse than I remembered; it's been many years since I first hear the story.

The basic point stands: environmental and life factors can directly cause depression. I can absolutely understand drug use in restricted forms as a way to break out of bad patterns and recognise that other kinds of thoughts and ways of living are possible. This is exactly what ecstasy was originally designed to do, by the by, and I know at least one person who used it very effectively in exactly that way. On the other hand, if you've got a drug that removes the symptoms of depression while leaving the causes untouched, it may not be the best thing to administer the drugs. One can imagine a slippery-slope leading directly to a Brave New World.

Fortunately, the science shows that the drugs aren't actually capable of accomplishing this.

happyroach: Your own dramatic personal testimony doesn't trump that of anyone else, sorry to say. And ultimately, the doctors and the pharmo companies really don't know your brain any better than anyone else, except perhaps yourself. And unlike the anti-vacc people, there's plenty of science to back up the claims in this thread, including systematic distortion of outcomes by the drug companies.

But, as they say, YMMV.
posted by kaibutsu at 2:49 PM on June 8, 2011 [2 favorites]

Giving these people - people like me and you - a metaphorical Soma isn't going to cure that anymore than you can find happiness at the bottom of a bottle of rotgut whiskey.

It's not a metaphorical Soma, a cure, or happiness. It's a treatment that blunts symptoms enough so that I can functionally deal with them using CBT strategies. Which, I will add, I only sought medical treatment after four years of CBT (and diet, and exercise, and just about everything else suggested here) failed to do much beyond lead me to the realization that I probably shouldn't be having DTs and formication while completely sober, or spend sleepless nights arguing with my delusions.

But perhaps I'm a unicorn in that I responded to escalating symptoms in spite of talk therapy with escalating modes of therapy. If the argument is that these decisions should be made with a comprehensive health-support team, by all means, I'm on board. If the argument is that vested interests have led to bad treatment, I'm on board. But I get rather nervous when the axegrinding on the morality of certain treatments gets rolling.
posted by KirkJobSluder at 3:44 PM on June 8, 2011 [3 favorites]

I'm with you, KirkJobSluder.

There's real concern with the effects of taking ANY drug, and most of the horror stories I'm seeing in this thread concerning SSRIs stem from uninformed, arrogant or unqualified doctors prescribing medications that are counter-indicated (or using them for off-label reasons) and patients not bothering to educate themselves on the medications they're prescribed, including side effects and red flags to watch out for, not the SSRIs themselves. That (really inflammatory) link about kids being medicated when they didn't need it? SSRIs are not responsible for abusive or neglectful parents.

And even the ones that don't are not necessarily causal. For example, the story about the roommate that set fire to his room is terrifying, but the fact that he did so after taking an SSRI doesn't mean that was the reason he did it. He was prescribed the SSRI for a serious mental issue--isn't it possible that underlying issue had something to do with his actions? Or maybe nobody recognized the potential warning signs of escalating mania, which IS a side effect of an SSRI, and something patients should be informed about.

I'm on an antibiotic right now. I'm allergic to penicillin and sulfa, and you better believe that I checked the label to make sure they didn't give me the wrong medication, and that I know what to look out for, because I don't want to stop breathing if I develop an allergic reaction to this antibiotic, too.

As consumers, we have to be aware of the potential risks of any medication we take. An anti-depressant isn't a magic pill (most of the time, they take a few weeks to kick in), and it won't solve your problems for you. But it can, and has, helped me not to feel so overwhelmed, so that I can solve those problems myself.
posted by misha at 4:10 PM on June 8, 2011 [2 favorites]

patients not bothering to educate themselves on the medications they're prescribed, including side effects and red flags to watch out for, not the SSRIs themselves

Well, remember, depressed, possibly suicidal but certainly hopeless patients. And not so much not bothering, as being faced with endless conflicting information (see this thread for an example) on whether the pill they're going to take is going to make things better or worse. And the basic part of patient education--talking to a doctor--being one of the more frustrating conversations imaginable.

Not to say that people shouldn't educate themselves, including on the realistic limits of the meds. I agree that that is an absolute must. But even after all these years, it still feels like early days with the SSRIs. Like, if your doc wrote you a penicillin prescription. "Doc, I'm allergic to this, I'll need something else." "Don't be silly, there's no such thing as a penicillin allergy, I've never heard of it."

I remember--and this is an anecdote, so it trumps everything else mentioned in the thread--getting really sick of the endless side effects on whatever the current cocktail I was taking was, with just no benefit at all. I'd been reading about this newish drug called Effexor (ah, innocent youth) and the success it had in my particular disorder. So I dutifully educated myself (for all my griping about SSRIs and their kin, I do try to be a good patient), and printed out reams of research on it. Which I then took to the psychiatrist. I handed him the studies, and asked to be put on it. "Mittens," he said, shaking his head, "this is not the way we do clinical medicine." And we upped the dose of what I was already on instead.

And I guess that's part of the problem with educating yourself...in the end, you have to be able to find a doc who will be a partner in that, who will guide the decision with knowledge and insight, not just shut you down because, horror of horrors, you did some reading on your own.
posted by mittens at 5:01 AM on June 9, 2011 [2 favorites]

Well to all the patronizing assholes on the internet who think that just because they read some study THEY know how MY mind works, FUCK YOU. The only thing that's worked for me is taking four years of experimentation to find the right combination of meds to allow me to function normally, and I am not going to ruin my life just to be an experiment for your precious philosophy about how it's just the evils of modern life that causes depression, and we'd all be fine if we just did transcendental meditation or some other hippy shit.

I mean this as sincerely as possible: You sound extremely angry, are you really sure the drugs you're on have got everything worked out?
posted by crayz at 3:52 AM on June 10, 2011

crayz: I mean this as sincerely as possible: You sound extremely angry, are you really sure the drugs you're on have got everything worked out?

Which is a classic bit of crazy-making, damned either way situation.
posted by KirkJobSluder at 8:04 AM on June 10, 2011 [3 favorites]

"gjc, the efficacy of talk therapy would problematize that no?"

Let's say a human is trapped in this cage. Trying to get out can't get out trying trying giving up.

Then a therpaist walks in "to talk".

Let's do some CBT.

Therapist says, "You need to realize that suffering is only in your mind. Change you thoughts, change your life! Change your behavior, change your life!"

Therapists offers some space to "work out past issues." The person says, "Well I've been really depressed and I feel like I can't get out of this cage. I've been trying and trying. And trying. It feels hopeless"

therapist nods. "Mhhm. Sounds tough, well why don't you just make these cognitive and behavioral adjustments we've talked about and you'll be feeling better in a jiffy."

Person feebly tries to climb out a few more time before thinking this blows.

Talk therapy doesn't work. That doesn't mean the anwer is pills. The answer is dismantling the cage.
posted by xarnop at 3:49 PM on June 15, 2011

xarnop: I'm going to channel OmieWise for a second and remind you that talk therapy does in fact have a good track record for treating depression.

And in these experiments you're talking about, the whole point is that a lot of the monkeys don't recover even after you take away the cage. Think of abused children: stopping the abuse is obviously the first thing that needs to happen, but it doesn't mean that then, automatically, the victims become psychologically healthy. So, removing the cage is a great start, but not a complete solution.
posted by en forme de poire at 4:54 PM on June 15, 2011 [1 favorite]

Talk therapy doesn't work.

What a weird thing to say. I've never had a therapist who acted or talked the way they do in your script.

Talk therapy, alone, won't work for all people in all circumstances, nor does it work for all conditions. Neither does medication. To declare categorically that it never works (ever, for anyone), is wrong.
posted by rtha at 6:06 PM on June 15, 2011 [2 favorites]

Talk therapy doesn't work.

What a weird thing to say. I've never had a therapist who acted or talked the way they do in your script.

If I had a therapist like that comment from xarnop, I'd walk right out and not come back.
posted by sweetkid at 7:49 PM on June 15, 2011 [1 favorite]

Talk therapy doesn't work.

Yeah, you're wrong about this. Talk therapy has effect size of ~0.80, for basically all forms of therapy. It helps ~79% of people who go into it wanting change, as compared to untreated control groups (such as people on waiting lists for therapy).

Your anti-psychiatric position is an ideological, not a scientific, one.
posted by OmieWise at 5:44 AM on June 16, 2011 [5 favorites]

"Talk therapy doesn't work"

sorry the way I wrote that was unclear. In the situation where the person needed to get out a cage and not be talked at---- talk therapy won't work. There are tons of things talk therapy can help with, but humans can't break metal with their hands and not amount of talk will make that so. You need to either dismantle the cage or give the person some tools to cut it apart from the inside.

There are surprising a lot of studies about making animals situationally depressed- then giving them fluoxetine to see if it helps.

It's a matter of wrong thinking. If the problem is that you're shocking the shit out of the rats till they are terrified, the solution is not fluexetine, or talk therapy--- it's stop shocking the shit out of them.
posted by xarnop at 7:10 AM on June 17, 2011

Of course one of the other ways they damage animals to test psych drugs is through maternal deprivation. Apparantly in mammals periodic seperation from the mother in early infancy is enough to skrew them up big time.

And that affects their adult functioning. So of course they want to treat that with fluexetine too, because from a public human health perspective it's important to shove more fluexetine on people, not to figure out if the way we're raising our children and the way our system is set up is affecting our later biological and emotional functioning.
posted by xarnop at 7:15 AM on June 17, 2011

Let me put this another way. We have a lot of research backing up that unhealthy prenatal conditions affect child development and adult health at the epigenetic and sometimes genetic level. We have a lot of evidence that being parented by a caregiver who is inattentive, distraught, doesn't smile as much, doesn't respond as much, doesn't supply interactive enriching involvement---- that affects biological and cognitive development. We have alot of research that being in an environment where there are indoor air contaminants such as molds, water damage, roach pollution, dust etc as well as outdoor air pollutions such as car exhaust affects brain development and immune function.

We have a lot of evidence that lack of environmentally enriching activities affects cognitive development.

So we have a huge range of capacity to function well in our kids because the environments are radically different accross critical periods of development.

THEN we put these kids in the school system. Kids who are dealing with immune disfunction, poor diet, lack of enriching environment, child abuse, neglectful parenting, etc are expected to function cognitively the same as the other kids.

Instead of seeing them as THE SAME human beings who faced different environments during critical periods of development and at present---- we label the kids who are struggling to perform as well in school as disordered. Rather than acknowledging that they may be busy dealing with real life issues other kids aren't facing, immune consitions and health problems the other kids are face, lack of parental involvement other kids aren't facing--- we label them as different.

They are disordered. The are ill. Further more as these same kids go through the school system struggling more with lower capacity to care about school to begin with (because they are busy dealing with facing a harder life) and more biological obstacle to doing better even when they try-- they enter the workforce with less education and less capacity to perform.

We then label them again--- we label them as deserving less than the other people. They deserve worse housing conditions, less fun activities, less access to fun technology, less access to health care, less access to emotionally supportive and therapeutic activities such as exercise coaches, massages, occupational therapy, high quality therapy, art classes, yoga, spas, etc etc. Less access to gyms, to healthy expensive restaurants that make it possible to eat healthy without cooking, less access to house cleaners and home maintenence people, less access to home organizers and ADD life management support.

Basically the world that is accessible to those with money is something we deem people at the bottom rung unworthy of, due to their poor performance.

Is it possible, this could cause depression in and of itself? We need to make sure people ahve living wage, that we treat our service people who make society possible with respect as equals in society and that we create better access to healthy living, well being, and enjoyable activities to people who quite frankly we need to take shit jobs or society won't function. We can't focus on giving everyone high end degrees--- society can't function that way. We need to focus on treating all people who are working and contributing to society in different ways as equally deserving of a qualitity of life that doesn't cause despair and misery.

We also need to do this because bottom working class people are going to have kids. You can be pissed off about it all you want, but unless you want and authoritarian dictatorship in which parenting is only perssimable among the elite educated classes we will be having poor uneducated people producing families. (And I think, as well they should.)

We need to make it possible for such families to have a quality of life that is beneficial for their childrens development so that their children have a better opportunity to do well in school and have a higher level of personal choice about their career direction than would otherwise be possible.

Telling poor people to stop being affected by these things with talk therapy will not stop them from being affected by these things (although talk therapy might be nice and all should get to experience it that want to.) If the system is skewed, then we don't need to increase talk therapy or meds--- we need to do better research on ways to address the imbalances in childrens quality of life in their home environments.
posted by xarnop at 8:20 AM on June 17, 2011 [1 favorite]

"perssimable" sorry about all my spelling mistakes. I'm a bit dyslexic.
posted by xarnop at 8:28 AM on June 17, 2011

If the problem is that you're shocking the shit out of the rats till they are terrified, the solution is not fluexetine, or talk therapy--- it's stop shocking the shit out of them.

But what I'm saying is, depression lingers after the shocks stop. Sometimes, forever. The physical cage has been replaced by a mental one. Therapy can help you realize that the cage is gone, to adjust to life without it: to analyze your thoughts and feelings, to understand why they're there, and to move on and continue to live despite them. And if that process could be sped up with fluoxetine, concerns about efficacy aside for the moment: I say, all the better.

And with respect to your second question - I totally, totally agree that we live in an unequal society, and anything we can do to remedy that is devoutly to be wished. But it doesn't follow that we must stop trying to treat depression, or that talk therapy is useless for poor people. Depression cuts across all strata of society. And while it's true that only political action can make our society more just and fair overall, therapy can give individual people the strength to leave abusive relationships, to realize they deserve to be treated with dignity, to not allow themselves to be bullied into submission -- as you put it before, giving people the tools to dismantle the cage from within. I wouldn't be so quick to write it off.
posted by en forme de poire at 10:38 AM on June 17, 2011 [1 favorite]

En forme de poire--- My statement talk therapy doesn't work should have read:

"In this particular situation, talk therapy doesn't work."

I wrote too fast and assumed my intent would be heard which is terrible confusing for the reader so sorry about that.

Talk therapy CAN have value and can involve giving people tools. But if you're in a cage-- the first thing is getting someone out of there--- and it might require more than just tools if they are so exhausted and despontant from trying to get out that their energy reserves have been depleated.

Yes poor conditions have long term affects on human beings. The efficacy of fluoxetine is indeed a pretty huge variable in considering it's use--- so without saying anything pro-or con on fluoxetine itself-- I will say that assisting humans with recovering health, processing experience, connectedness with others, trust, and regulation of bodily systems is a good thing. I think some people might need greater levels of support throughout their lives and I think sometimes we want to "fix" that without considering whether or not "fixing it" is actually the best outcome in the long term. Stopping a person from collapsing under trauma might seem admirable--- but it might interfere with a process that actually needs to happen-- causing worth physical and health outcomes that it the person had simply been allowed to recieve support in the state they were in.
posted by xarnop at 9:17 AM on June 19, 2011

"worth" = worse
posted by xarnop at 9:18 AM on June 19, 2011

The second article is now available: The Illusions of Psychiatry.
posted by russilwvong at 1:17 PM on June 20, 2011 [3 favorites]

I stumbled on this thread when I tried to post Parts 1 and 2. Interesting set of articles.

Psychiatry has been an evolving discipline since its inception. There's no reason to hold SSRIs to be sacrosanct. The idea that our knowledge would have plateaued somewhere around the mid-90s beggars belief.

Of course we'll constantly be learning knew things and seeing old things in a different light. If SSRIs seem to work for reasons we don't quite understand - let alone if those SSRIs do not, on average, work nearly as well as they've been advertised - then it would make sense that science would eventually catch up with that disconnect and then we'd see something else come on the horizon.

It's also pretty interesting how to see how easily you can see who hit "Post Comment" after reading the article(s) and who didn't.
posted by Sticherbeast at 11:09 AM on June 21, 2011

About the article: It's pretty clear by now that for most people, depression probably isn't caused by a defect in circulating serotonin, and the author is right to point that out. This still doesn't mean that SSRIs are useless, though. There's some recent data from animal studies that suggest that SSRIs may enhance neuroplasticity. I haven't read the literature enough to know if any significant proportion of the clinical trials in the meta-analysis were conducted in conjunction with psychotherapy, but I would guess not, because therapy has a pretty big effect size of its own. If SSRIs really enhance plasticity (and this is a big if, for sure) any beneficial effect might only be fully realized in conjunction with some form of therapy. Enhancing plasticity isn't always a good thing in and of itself -- it depends a lot on what inputs you're getting -- but it seems possible it could make a patient more receptive to rewriting old and harmful patterns of thought.

(Poking around in Pubmed it does seem like there may be some support for this idea but of course, someone would have to do an unbiased survey of the literature to find out if this hypothesis has any merit.)
posted by en forme de poire at 11:56 AM on June 25, 2011