Serotonin and depression link debunked?
July 25, 2022 7:59 PM   Subscribe

Here’s nice overview (Podcast with transcript) of the depression/serotonin history from Knowable magazine.
posted by dhruva at 8:11 PM on July 25, 2022

This has been clear for a while. It doesn’t mean SSRIs don’t work, but it does mean that the claims of “chemical imbalance” were more about advertising than anything else.
posted by haptic_avenger at 8:23 PM on July 25, 2022 [19 favorites]

I find this very validating as I have tried antidepressants to address my own depression and found it's effects severely lacking. A 'chemical imbalance' has never seemed like a sufficient explanation for my traumas or how I feel about the 'evils' in society. Somehow it was like doctor's expected a drug to change my philosophical, political, and existential views of life.

Can you imagine if it were that simple?

Not to say that drugs can't aid in the process of finding your way through depressive thoughts, feelings, and traumas.
posted by honor the agreement at 8:25 PM on July 25, 2022 [14 favorites]

I find this very validating as I have tried antidepressants to address my own depression and found it's effects severely lacking.

This is non-sequitur logic here: your validation should not follow this reporting, even if you previously had a different understanding of the mechanism of action. This study does not tell us antidepressants do not work.
posted by etc passwd at 8:37 PM on July 25, 2022 [42 favorites]

This doesn't say they don't work, honor the agreement. It says only that the serotonin deficiency hypothesis as a cause of depression has been debunked. The drugs work.
posted by OnTheLastCastle at 8:40 PM on July 25, 2022 [21 favorites]

Well it says that the serotonin deficiency hypothesis as a cause of depression has been debunked, and that "there is no other accepted pharmacological mechanism by which antidepressants affect the symptoms of depression".
posted by anazgnos at 8:43 PM on July 25, 2022 [2 favorites]

And yet, they work. The studies showing their effectiveness is unchanged. How is not known.
posted by OnTheLastCastle at 8:48 PM on July 25, 2022 [32 favorites]

I mean there's stuff like this. But it's true that they do appear to really work in certain short-term cases and even if it's ultimately a very expensive placebo, for a lot of people that means the difference between life and death.
posted by derrinyet at 8:57 PM on July 25, 2022 [1 favorite]

Most psych docs have not subscribed to this level imbalance theory for quite a while. There's nothing new here. It's wild to let that fact reinforce ideas the medications should be less effective.
posted by etc passwd at 8:57 PM on July 25, 2022 [5 favorites]

What’s the numbers on SSRIs vs placebo, anyway?
posted by egypturnash at 8:58 PM on July 25, 2022 [5 favorites]

Antidepressants definitely work... for some people (including myself). If it really was as simple as a serotonin deficiency then you would expect each drug to work quickly and very similarly for everyone with a similar type of depression, but that isn't how the antidepressants function at all. Instead the effects of a specific drug on an individual are hard to predict and somewhat random which is why most people have to try more than one antidepressant before they find an effective one. Scientists have known for about 5 years that the serotonin deficiency explanation was probably not true and this is just confirmation of that.

My rough understanding of the current best science is that antidepressants probably work by modifying the neurotransmitter feedback systems of different parts of the brains. When something like Prozac affects the brain it does cause serotonin to increase, but this is a short term effect and the brain quickly compensates by making less serotonin available in other ways. If this is what made antidepressants work then the effects would start immediately instead of several weeks into treatment. Neurotransmitter levels are maintained via a complex dynamic feedback system across your entire brain, and it seems like different antidepressants affect different parts of that system for different people. And for some reason that is not yet fully clear, this disruption of the feedback system seems to make people happier.
posted by JZig at 9:00 PM on July 25, 2022 [18 favorites]

More than anything else, it seems to me that this study puts SSRIs into the same category as lots of other antidepressants whose mechanisms of action are not well understood. For example, bupropion (Wellbutrin)
posted by angrynerd at 9:01 PM on July 25, 2022 [13 favorites]

"comprehensive review of prior research led by University College London (UCL) scientists."

So basically we're doing meta-analysis, which has been brought out as 'proof' and trashed over and over and over again.

What's one more on the pile?
posted by Tell Me No Lies at 9:03 PM on July 25, 2022 [1 favorite]

I have had profound depression for most of my life, it's under control now, but meds never worked for me; however ECT did. We don't know why ECT worked, or how it worked but for me it made me less likely to kill myself.

I am enough of a radical to think that what helps with depression is things like stable housing, regular food, a solid income--and also that depression is an approprite response to how terrible the world is.

In this way. I am reminded of Kpunk but then he killed himself
posted by PinkMoose at 9:17 PM on July 25, 2022 [20 favorites]

> What’s the numbers on SSRIs vs placebo, anyway?

Several teams have done very large meta-analysis studies of SSRIs, and the general conclusion is that in randomized trials they have a small but statistically significant advantage over placebos. The effect size seems to be around 0.3, which is defined as "subclinical" meaning that a psychiatrist would not be able to tell the difference on the scales they use for measuring depression. So if you randomly give most antidepressants to people that are depressed, they feel slightly better than people on placebo, but not to a degree that would be immediately noticeable.

This recent article about effect sizes tries to analyze what those numbers actually mean, and comes to the conclusion that the way depression is measured makes it very hard to detect if antidepressants actually work. Part of this has to do with the scales they use, and part of this has to do with the fact that different people respond to different antidepressants. Also, the placebo effects of drug trials are really strong against depression anyway, because doctors showing genuine concern for your well being and keeping a regular routine are both things that help depression on their own.
posted by JZig at 9:17 PM on July 25, 2022 [33 favorites]

The post title is an excellent example of Betteridge’s Law though.
posted by Tell Me No Lies at 9:27 PM on July 25, 2022 [7 favorites]

Reacting appropriately to things the way they are is maladaptive. That means it makes you less likely to survive, not that you're wrong. So, if you're into survival it seems appropriate to change your reaction - with meds, talk, CBT, whatever. It doesn't mean you accept the world should be this way, only that for your own reasons it's worth surviving instead of not.

Having been a person who wants to believe my appropriate but maladaptive reaction can somehow change how things are, I recognize the massive distortion of scale that represents.

So, it's fine if you find meds or any other approach questionable. If you want to survive, pick an approach. If you don't there's nothing anybody can do to make you - but it helps acknowledging that not surviving is not really effective at changing anything.

So, survive. Please.
posted by abulafa at 9:40 PM on July 25, 2022 [23 favorites]

I am not a neurologist, but it’s always been abundantly clear to me that we don’t get to throw a drug like a tricyclic antidepressant into a complex system like the human body and then isolate its effects to only one of the many neurotransmitters it affects.

Nobody treats depression, particularly severe depression, with a drug alone, so why would we ever think that we can isolate the effects of a drug within the life of a test subject? When we try, we end up with things like a 0.3 efficacy rate. Turns out, after stripping away all of the other noisy aspects of humanity, these drugs which work to help a lot of people, don’t show that they work very well at all. Maybe it’s those other aspects that matter more.

Maybe calling these drugs ‘antidepressants’ should have been a giant red flag.

I’ve seen more people I know come out of severe depression from psychedelic treatments in the past few years than I have seen in a lifetime of having friends on antidepressants. They are still on antidepressants while those who go the psychedelic route are off of them for months or years at a time. It’s to the point, now, that I am asking everyone I know on antidepressants if they’re willing to consider ketamine therapy.

If you’re on antidepressants, are you willing to consider ketamine therapy?
posted by Revvy at 9:42 PM on July 25, 2022 [9 favorites]

If anyone reading this needs help, there’s a new suicide and crisis helpline at 988 in the U.S. It’s the same as the old 800 number but now easier to remember. Additionally, more funding is getting put into this service. So if you are having problems and need someone to talk to, dial 988. More info.
posted by amanda at 10:00 PM on July 25, 2022 [18 favorites]

If you’re on antidepressants, are you willing to consider ketamine therapy?

This honestly feels to me like asking a diabetic when they're going to stop taking insulin.
posted by fifteen schnitzengruben is my limit at 10:10 PM on July 25, 2022 [29 favorites]

Whatever antidepressants do, I’m glad to see them being re-evaluated. They did very little for me, but were an absolute nightmare to stop taking.
posted by vanitas at 10:15 PM on July 25, 2022 [11 favorites]

Wow. What a great example of a study that was flawed from day one. You mean to tell me that a simplistic description pertaining to a set of complex process occurring inside the at-the-time largley unmapped human nervous system was of questionable completeness or veracity? Or did we just ignore those messy details because, y’know, publishing obligations, and you saw a slam dunk just waiting for you?

“Depression is caused by a chemical imbalance in your head.” Marketing, man. Short term profit —> long term collective misundertanding. I think that right after Sex Ed and The Basics of Banking and Credit, our youth ought to be taught “the crap that comes out of marketing departments is almost never worth beliving at face value.”

It’s a shame there will be so many people who consume this “new” information and have the same response — to leap to simplistic conclusions, like Antidepressants Don’t Work. Period. For anybody. Headline achievement unlocked!

“there is no other accepted pharmacological mechanism by which antidepressants affect the symptoms of depression".

Jesus Sigmund Christ. If that is what the reviewers say, then there is a serious level of incompetence at play. SSRI’s are of course highly proscribed but are barely representative of the entire spectrum of pharmacological methods to approach depression.

They work for some. Not for all. Of course this is the case. Only people who believe that billions of humans are built with carbon-copy neurochemistrys and would all respond uniformly to a treatment would ever think there is a single medication or other approach that would work for all. I mean, cancer treatments fail for many…. we therefore must conclude they work for none. Let’s throw them out!

I was told many years ago (by my proscriber) that antidepressants can get you [back up] to the level where you are able to then do the rest of the work needed to address the depression and learn tools and frameworks for managing it or getting past it. If one would conclude from that that antidepressants “don’t work” — because on their own they’re not sufficient to produce the complete and final outcome that can be measured with the standard empirical methods — then they need to spend sometime outside the lab, at the clinic, and talking to depression survivors throughout and to understand the arc of their experience.

Full disclosure: i write all this as someone whose mental health challenges were addressed far more effectively by medications that are not SSRI’s, as well as by trans cranial magnetic stimulation. But there was a time and a place for SSRI’s for me, and i’m glad thy were there, because they were part of what made it possible for me to stay alive long enough to get the help i needed.
posted by armoir from antproof case at 10:18 PM on July 25, 2022 [19 favorites]

This thread is difficult for me to read as I only recently got over my fear of taking medication to treat my severe anxiety.

I find it difficult to believe that placebo effect can entirely account for how much better I am.

I went from being in almost constant meltdown, and having ulcers in my stomach due to the constant cortisol dumps, to only having occasional stomach pain, and feeling fairly anxious sometimes.

Why would the placebo kick in and work for the drug, that I was pretty suspicious of, and not work for all the supplements, meditation, and other things I wanted to work so badly?

Now that I'm on an SSRI it's like all the techniques my therapist taught me actually make a difference. Before they were just keeping my nose above water.

I'm going to be trying new meds soon as I'm not happy with some of the side effects of my current medication, but I should probably not have read this thread.
posted by Zumbador at 10:24 PM on July 25, 2022 [36 favorites]

This honestly feels to me like asking a diabetic when they're going to stop taking insulin.

“Are you willing to consider” an alternative treatment feels the same to you as, “When will you quit” taking the drug that keeps you alive?

People don’t stop taking antidepressants while they’re in ketamine therapy. They stop after.
posted by Revvy at 10:26 PM on July 25, 2022 [4 favorites]

The studies showing their effectiveness is unchanged

The level of effectiveness shown by studies is not particularly high but the potential individual benefit (or lack of benefit) may be more dramatic than the averages suggest. Also SSRIs and related drugs are not actually only given for depression, and may work better for some of the other indications (anxiety, OCD etc.)
posted by atoxyl at 10:28 PM on July 25, 2022 [2 favorites]

Zumbador, stay the course, until you and your Dr decide otherwise. Almost nothing here in this thread is universally applicable. YOUR experience matters 1,000 percent more than something read on the internet. Even if it was written by science nerds in a lab. But IMHO : this study does sweet FA to inform the conversation about whether antidepressants work. All is says is some people with a particular and limited type of training looked at some numbers and came to a conclusion. The conclusion is not truth. The conclusion is something that fit the requirements of a journal.
posted by armoir from antproof case at 10:30 PM on July 25, 2022 [20 favorites]

> If you’re on antidepressants, are you willing to consider ketamine therapy?

It's not an either/or decision, at least not at the hospital I'm treated at. I was on anti-depressants when I was offered a round of esketamine treatment during my last reoccurrence of clinical depression, though I decided to go with rTMS instead because it had worked really well in the past. Also, I was already having severe dissociative symptoms, and didn't want to risk exacerbating it with esketamine. It's really reassuring to know that I have back up options if rTMS ever poops out, though.

Anti-depressants have kept me stable for longer in-between horrid bouts of acute depression - I went from relapsing something like every 6 months to 18 months. As far as my doctors are concerned, rTMS/esketamine/ECT work in tandem with anti-depressants, and they wouldn't consider weaning me off the latter unless I'm stable for 2 years +
posted by seapig at 10:32 PM on July 25, 2022 [6 favorites]

It's always seemed to me that our brains, the organ, are in complex but quasi-stable states that can be perturbed and sometimes changed for long periods. The available methods range in how much they can perturb the system, and some of them are the equivalent of hitting the malfunctioning machine with a hammer, so they work and they work from real effects but we can't usually tie what we did to how it worked exactly... and sometimes it doesn't work or makes things even worse. But we get better at deciding on where to hit, how big a hammer, how much force, etc.
posted by i_am_joe's_spleen at 10:55 PM on July 25, 2022 [4 favorites]

Zumbador, they're not saying SSRIs are a placebo, they're just saying the mechanism through which they work isn't what we thought it was. They still have real effects, through a mechanism that remains to be clarified.

(Also placebos genuinely have useful effects, but that's a whole other discussion).
posted by i_am_joe's_spleen at 10:58 PM on July 25, 2022 [12 favorites]

The lead author here apparently is pretty well known for her broadly skeptical views on psychiatric medication. Which isn’t exactly how I’d characterize my own views, but one thing she proposes as an alternative framing of psychiatric medication I like and actually kind of agree with - she says basically that we shouldn’t assume that psych drugs act to counteract a specific structural cause of disease, but that they have psychotropic effects that happen to counteract some symptoms for some people. Which is definitely a view I buy into on some level - while opioids work pretty well as antidepressants, that doesn’t mean that mu opioid underactivity is necessarily the root cause of depression. But personally I’m a proponent of using drugs to counteract symptoms in this way.
posted by atoxyl at 11:11 PM on July 25, 2022 [15 favorites]

I find this interesting now as my (limited) understanding is that the serotonin deficiency theory of depression has been out of favor in psychiatry for some time now.

And let’s not forget that prior to serotonin deficiency/imbalance, we thought it was an issue with norepinephrine and dopamine imbalances were at the heart of depression as increasing those improved depression. Now we just don’t know other than that they seem to work for many people even if the mechanism is so poorly understood.

My (again, limited) understanding is that current thinking is depression is more related to plasticity; changes in the brain structures and wiring lead to depression, and playing with neurotransmitters MAY cause changes that can go the other way with time, essentially encouraging additional brain plasticity where/when it is needed to rewire problematic neural pathways.

Also why therapy or other mental health care seems to be important, you need something to rewire to, or there isn’t anything to rewire to.

Maybe this is meant just as the nail in the coffin to the low serotonin theory?
posted by [insert clever name here] at 11:21 PM on July 25, 2022 [5 favorites]

As one doctor I saw respond to this said, paracetamol helps with headaches, but we don't think it works because we have a shortage of paracetamol in the brain.

As somone who's been on antidepressants for a long time, I've seen quite a lot of scepticism over the 'serotonin shortage' hypothesis for some time. Not least because drugs which increase serotonin in the brain do so rapidly, and wear off similarly - all within 24 hours, for some - so why does it often take weeks before people start to show improvement in symptoms? And people can have very different reactions to different drugs, such that part of therapy can often being trying different SSRI/SNRIs until one works for that person; again, if it's a simple chemical imbalance where the drugs all in theory work similarly to correct that, that makes no sense.

The evidence for anti-depressants is also pretty weak for those with mild depression, often barely or not even above placebo; talk therapies (such as CBT) and even exercise can be more effective. But anti-depressants do have a much more significant measurable impact, well above placebo, in those with moderate or severe depression. I can't speak for anyone else, but my second antidepressant had a huge impact on my quality of life. I still struggle sometimes with my chronic depression, but I do remember what it was like before. It was like being stuck in an endless grey fog, where the only emotion I could still feel was anger, mostly towards myself, and there was absolutely no way out, and no chance of ever doing so. I was alone, even in a group, and utterly miserable, and I *knew* I was a terribly useless burden on everyone around me, and I just longed for it to end, and death seemed like it was the only way that would happen.

Now when depression strikes, it's like flying through a heavy cloud - it's still grey and miserable, but I know I will come through it, and I have people that love me; and that feeling alone - of hope in a future that's worth living - can often be enough to dissipate the cloud itself. I've lowered the dose a few times with my GP, then had to raise it again when life got particularly stressful (between Brexit with an EU citizen wife, covid and now the cost-of-living crisis, it's been a rough 6 years) - I'm not sure I'll ever be able to come off entirely, and the withdrawal symptoms are no fun whatsoever if I miss a dose. (the brain zaps, they are definitely real!) Therapy helped a bit, but I know I'd be in a much darker place without my meds. If they come up with a better solution that lets me come off them - e.g. ketamine - then I'd leap at it. The evidence is promising, but still developing.

But that the mechanism of how they work isn't the quick and easy answer? Yeah, I'm not surprised. General anesthesia has been used for over 150 years, and I believe we're still figuring out how that truly works at the molecular level.
posted by Absolutely No You-Know-What at 12:09 AM on July 26, 2022 [23 favorites]

Ugh, I can’t see how the framing of this finding isn’t going to make it harder to convince people to take/stay on mental health medication. It’s irresponsible, in my opinion, to publish this article without giant flashing signs that say “depression is real and there is medication that can help you”.
posted by The River Ivel at 12:31 AM on July 26, 2022 [20 favorites]

Before my meds, I wanted to kill myself constantly. Since my meds, I don't. I mean, honestly, I don't care why they work because I'm happy to be alive. And I resisted switching to meds for a decade and firmly believed they would not work and only started because my wife and my doctor persuaded me over many years. I mean, everyone's mileage varies, but I've already seen this study used online as OmG dOn'T fAlL fOr BiG pSyCh and stuff, so I'm concerned there's going to be a bunch of people who had my former attitude who will use this as further evidence that they should not start helpful meds.
posted by Joey Michaels at 12:43 AM on July 26, 2022 [41 favorites]

Nobody treats depression, particularly severe depression, with a drug alone

Sadly, they really, absolutely do. Lots of doctors do. Ask me how I know.
posted by Dysk at 1:13 AM on July 26, 2022 [36 favorites]

As mentioned several times above, evidence against a particular causal mechanism doesn't mean that paticular treatments don't/won't work. In that vein, in case it's useful for anyone, here is the Cochrane review of TCAs and SSRIs for treatment of depression (plain English summary here).

Cochrane specialise in systematic reviews of medical literature to help practitioners and patients (I don't have any affiliation with them!).
posted by dill at 1:27 AM on July 26, 2022 [7 favorites]

Before my meds, I wanted to kill myself constantly. Since my meds, I don't.

I take an SNRI, and this is my experience.

A crucial point is that the SNRI does not necessarily make me happier, and as such the "anti-depressant" label occasionally seems a cruel joke. I've still been absolutely fucking miserable sometimes while on it. But I do not have the same suicidal thoughts, or the cycles of swinging into/out of them, and that is sufficient life improvement for me to keep taking it.

Certainly it works; but whatever it's doing is not just boosting the levels of chemicals in my brain. I'd imagine it'd feel more like MDMA if that was the case.
posted by solarion at 1:53 AM on July 26, 2022 [8 favorites]

The data for SSRI is actually better for anxiety than depression, but they got the depression indication first. The problem with pyschiatric disorders is they are syndromes(collection of symptoms). To reliably predict whether medication will work we need biomarkers for the disease. If you look at the NIMHResearch domain criteria it looks nothing like the DSM. Having struggle to help people with these issues its definitely hard. There are definitely people who benefit medication, but most get intolerable side effects. For the people who it works they tend to describe the experience pretty similarly, which is just a subtle change in the ability to stop the intrusive thoughts as well as some change in somatic symptoms(sleep in particular). Its not a slam dunk, but it can definitely make therapy easier for some. I wish I could say therapy is better, but getting a good stable therapists harder the trialing a bunch of medications. The problem is we cant tell with out trial and error. The one category of mood disorders I think that comes closer to being a receptor issue is menstrual related mood disorder which there is evidence change in expression of serotonin receptors under the influence of the hormonal cycle, but even that minimizes how complicated whats going on. If our society could handle a nuance perspective on cultivating health/disease(what are the conditions for health to occur? What are the factors that allow for disease to take root?) instead of magic bullets we would have made more progress.
posted by roguewraith at 2:29 AM on July 26, 2022 [6 favorites]

A crucial point is that the SNRI does not necessarily make me happier, and as such the "anti-depressant" label occasionally seems a cruel joke. I've still been absolutely fucking miserable sometimes while on it. But I do not have the same suicidal thoughts, or the cycles of swinging into/out of them, and that is sufficient life improvement for me to keep taking it.

One description I've heard for anti-depressants that seems apt enough to me is that they take you from suicidally miserable to just deeply unhappy. They don't fix the cause(s) of the depression, if there is one (and boy, there's enough reasons for _any_ sane person to be miserable these days), but mitigate the impact so you can at least function most of the time.

I can't say that the help - and meds - saved my life for certain, but there's a significant chance I wouldn't be here now if I'd had to go through the last decade unaided, I was definitely at the early stages of suicidal ideation. The side effects are no joke, but I'd rather them than the endless living hell it was before. Thing is, objectively, my life is pretty decent - not perfect, whose is - but I feel I should be happier than I am. But the depression's still *there*, sucking the joy out of things (hobbies and gatherings are still tough, even now), even if it now comes in much shorter, shallower bursts instead of a permanent unbearable crushing weight. And then I feel guilty that I'm not happier, the strain I'm putting on my wife and family, and why am I so broken, and woop, there you are, tricking me again, you sneaky little fucker of a brain. Chronic depression sucks, but untreated acute depression sucks a lot more.
posted by Absolutely No You-Know-What at 2:55 AM on July 26, 2022 [11 favorites]

I thought Lithium worked by stabilizing Potassium and another compound in a triad but couldn't find any citations on the Internet..
posted by Narrative_Historian at 4:05 AM on July 26, 2022

“One interesting aspect in the studies we examined was how strong an effect adverse life events played in depression, suggesting low mood is a response to people’s lives and cannot be boiled down to a simple chemical equation.”
This is one of those "well of course" results that it's nonetheless good to have quality scientific support for.
posted by clawsoon at 4:09 AM on July 26, 2022 [5 favorites]

Nobody treats depression, particularly severe depression, with a drug alone

Of course they do.

The most common adjunct to drug therapy, talk therapy, can be very expensive, and often unavailable. And a good many people live in areas where counseling/therapy simply does not exist, or requires a ton of logistics, including a not-insignificant time off work (or away from home) to travel a long distance to some regional mental health center to see a barely-out-of-school and severely over-worked LPC (or, if you’re lucky, an LCSW). And that’s only if you can afford the fee/copay every week.

And, there’s the very real situation where one has to wait weeks before they can even do an intake evaluation before they can even get on a counselor’s schedule. If you’re already severely depressed, you’re very likely to just say ‘fuck it’ and not even try to find help.

On the other hand, if your doctor is willing to prescribe something, most people are going to jump on it and avoid the overwhelming headache of finding therapy.

All that is to say that a great number of even severely depressed individuals are making due on meds alone. The system more-or-less requires them to.
posted by Thorzdad at 4:39 AM on July 26, 2022 [22 favorites]

The 988 line goes directly to cops and might not make people safer.


My understanding is that 988 is just an easier-to-remember adaptation for the old 800 number, which certainly did not go anywhere near the cops.
posted by Thorzdad at 4:42 AM on July 26, 2022 [13 favorites]

Not a big deal.
posted by rikschell at 5:18 AM on July 26, 2022 [1 favorite]

understanding the mind as a system of circulating chemical interactions was always the mistake. sure, it is that, and perhaps one day we’ll be able to grasp the almost infinitely complex causal chains that result in what it is we call having thoughts and feelings, but we’re clearly a long way off. you have to meet minds on their own level and understand them as understanding things. all antidepressants ever did was give me impotence and the only thing that ever helped me was talking to someone who was engaged in a genuine effort to understand me
posted by dis_integration at 5:44 AM on July 26, 2022 [4 favorites]

Hi, I'm on Prozac and would like to send a round of virtual hugs to everyone here.
posted by DirtyOldTown at 6:15 AM on July 26, 2022 [24 favorites]

Pinkmoose, 988 does not link to the police. It is a shorthand number for the national suicide prevention hotline, and connects to those call centers across the country. If you would like more information, is a great source of information on the ongoing development of crisis services related to 988. 988 will take time to develop fully, but it is a fantastic resource, please don’t discourage people from using it.
posted by MartialParts at 6:34 AM on July 26, 2022 [21 favorites]


I think most of us practicing medicine who have any sort of curiosity or tendency towards critical thinking have known for a long time that the serotonin hypothesis, or even the "biogenic amine hypothesis," (i.e. that other specific small molecule neurotransmitters are the cause of depression) is far from the truth. It keeps cropping up in medical school, and ends up being parroted by new doctors, mostly because I don't think anyone likes to admit that we have no idea how the brain truly works, and trainees just end up aping what their superiors say.

A major part of the issue, in my opinion, is that there's such a wide spectrum of what can go wrong with or be different about the brain from person to person, and not all of it is depression per se, even it gets labeled as such. Every day I see people who have a label of "anxiety and depression" (whether self-labeled or otherwise) and it does very little to capture their actual experience. Depression, to me, is a well-circumscribed period of decreased goal-directed activity; I liken it to turning down the saturation knob on a TV - everything just seems blah, too hard, and life just loses all its meaning and purpose. Often it comes about when a person finds themselves in a situation where they have lost control of their destiny, feel constrained by external or internal factors, and have no way forward. Author Mohsin Hamid described it as "a failure to imagine a plausible desirable future for oneself," and I find that sums it up well. It's just my opinion, but I think this type of depression, especially when it's treated soon after the onset of symptoms, that is more likely to respond to usual antidepressant medicines; I don't have data to back this assertion up, though.

Folks who have more chronic and longstanding low mood, or mood that fluctuates wildly from day to day, or who have significant anxiety that predates their low mood, have developmental trauma or other adverse childhood experiences, difficulties with frontal lobe functioning like ADHD, or neurodivergent brains, are probably a different kettle of fish and won't necessarily respond to the same kind of treatment. I suspect, but can't confirm, that a lot of the studies on anti-depressants may not have taken these complicating factors into account, hence the lacklustre difference from placebo in randomized controlled studies.

Just my two cents, YMMV.
posted by greatgefilte at 6:38 AM on July 26, 2022 [38 favorites]

988 is just an easier-to-remember adaptation for the old 800 number,

This is correct - at this point in time nothing about their policies has changed. 988 is the National Suicide Prevention Lifeline with a new shorter number.

which certainly did not go anywhere near the cops.

The overwhelming majority of hotline calls are kept confidential and any kind of EMS response is used as a last resort rather than a first one (they know how traumatic this can be, especially if not wanted, and try to avoid it if at all possible, and it's rarely the only way to help someone stay safe); however the NSPL has always reached out to 911 for a small proportion of calls, which can include a police response. From their FAQ:
The Lifeline recommends crisis counselors contact emergency services (911, police, sheriff) for assistance only in cases where risk of harm to self or others is imminent or in progress, and when a less invasive plan for the caller/texter’s safety cannot be collaborated on with the individual. Less than two percent of Lifeline calls involve emergency services. When emergency services are involved, over half of these emergency dispatches occur with the caller’s consent. We recognize that, for some individuals, having contact with emergency services can be traumatic and dangerous, and whenever possible we recommend alternate options such as collaborating on a safety plan, utilizing mobile crisis teams, collaborating with the individual’s loved ones or professionals, or supporting the individual to get to a Crisis Stabilization Unit, emergency department, or urgent care. For more information on our imminent risk policy, please visit this page.
posted by beryllium at 6:43 AM on July 26, 2022 [20 favorites]

In the flood of reactions I've seen since this came out, one thing I haven't seen talked about much is that the "chemical imbalance model" wasn't important because of its truth (obvs), but because it provided a simple story for doctors and patients, a story with a call to action attached. The folks above referring to it as marketing aren't wrong, because marketing narratives guide medicine far more than science does. It is appalling to have one's healthcare--perhaps even one's survival--determined by a story. To have the field suddenly admit "oh, yes, the story was wrong, we haven't believed it in years" is so frustrating.

We need, as a society, to remember how SSRI skepticism was received only a few short years ago. You would be treated as though you were an antivaxxer, a flat-earther. If you pointed out SSRI withdrawal symptoms, you were labeled a least until years later, when psychiatry suddenly announced that withdrawal was a thing, after countless patients suffered. Same story with the increased risk of suicide--you were clearly politically motivated if you brought that up--at least until the black box warnings went up.

All we ever needed from psychiatry was honesty. Tell us you don't know why the pills work, tell us they don't always work, tell us sometimes they stop working all of a sudden, and they're hard to get off of. Then people wouldn't be so anxious about the whole process, and the people who they actually help, can receive the help, and the people who aren't helped, aren't treated like they've somehow failed the wonder drug.

Better yet, admit that we don't even know what depression is. We don't know at all that it's a singular thing. My depression may not be your depression. It gets touched on, vaguely--maybe you'll get a thyroid test or something early on to look for other causes--but inevitably, once you are in the box marked depression, you receive your prescription for Zoloft or whatever and you are sent on your way.

To see that story changing, to see us admitting that the whole serotonin thing was always a little fake, a little weird, is a huge relief. I just wish it hadn't taken my entire life to get to this point.
posted by mittens at 6:55 AM on July 26, 2022 [19 favorites]

When I sought help I did CBT without medication since I had experience with family members who had gone through multiple medications before finding one that actually helped with their issues. My regular doctor was more than happy to prescribe medication if I wanted it (and still is). I wasn't interested in experimenting, though, and have no regrets. But ultimately it comes down to whatever works for you. Still, it would be nice if we fully understood how anti-depressants work.
posted by tommasz at 7:00 AM on July 26, 2022 [1 favorite]

The idea of chemical imbalance/serotonin deficiency is mostly a marketing tool rather than a theory actually propagated by researchers. I can't remember any scientists suggesting that there's truth to it. Neuromodulators are obviously not like vitamins. System dysregulation was the "proper" way to frame the topic for a while, which makes more sense in terms of what we actually know about the brain and how it works (admittedly not all that much).

This meta-analysis is more of a middle-finger to the practice of using this "theory" as a tool to explain to laypeople why SSRIs work. In reality, no one knows why SSRIs work. But it doesn't feel right to tell that to patients, which is why the myth of serotonin deficiency was born.

Also: SSRIs have an extremely weak effect. It's almost all placebo, with just a tiny morsel of an actual effect added on top. From that alone it should be obvious that it's not all about increasing levels of serotonin to cure depression. But that tiny effect, combined with the placebo? It works. Somehow. Which is why I'll never bash SSRIs until the day we see a good replacement. They've saved countless lives.

The serotonin system is ridiculously complex. Dopamine is by comparison easy peasy lemon squeezy. I can't overstate how counter-intuitive, paradoxical, and just plain strange it is. Which is why it's frustrating, of course, to see people talking confidently about it. Because the only people who talk confidently about serotonin are people who have no idea what they're talking about.
posted by windupbird at 7:23 AM on July 26, 2022 [1 favorite]

Depression isn't just one thing. It's not even just one observable set of symptoms, it's a combinatorial shopping list of symptoms. There's likely not just one mechanism for it.

It's important to interpret statements about effect size in that light. A small effect size does not mean "it's almost all placebo". It means when you take SSRI-takers' levels of improvement and average them all together, the result is small compared to the amount of variation. If, for some people, SSRIs are for whatever reason exactly what they need, but for many, they're not effective at all, you'll get the same effect size as if they did just a tiny bit for everybody.
posted by a snickering nuthatch at 7:50 AM on July 26, 2022 [14 favorites]

While it is factually inaccurate in one strict sense to say that 988 "goes directly to the cops", I can see why someone would consider that a functionally accurate way to describe any communication line where if you say the wrong thing, cops could be immediately dispatched to you.
posted by dusty potato at 7:51 AM on July 26, 2022 [4 favorites]

The treatment effect of SSRIs is tiny compared to the placebo effect and the NNT (Number Needed to Treat) is high. When I said it's "almost all placebo" what I mean is that the vast majority of people who improve on SSRIs owe none of that to a treatment effect. I'm not talking about specific cases where SSRIs may be helpful for any given individual, which is true.
posted by windupbird at 8:03 AM on July 26, 2022 [1 favorite]

While it is factually inaccurate in one strict sense to say that 988 "goes directly to the cops", I can see why someone would consider that a functionally accurate way to describe any communication line where if you say the wrong thing, cops could be immediately dispatched to you.

If that's the case, then every therapist, counselor, MD, nurse, etc. works for the cops. Hell, even my physical therapist asked psych eval questions on my intake.

In my experience, though, you have to be displaying some very aggressively dangerous and/or threatening action/speech for any knowledgeable professional (which, one would assume, includes the people on the suicide line) to jump to sending the cops. For anyone to jump directly to declaring 988 "goes directly to the cops" is a pretty willfully inaccurate depiction of how the system works.
posted by Thorzdad at 8:19 AM on July 26, 2022 [18 favorites]

Better yet, admit that we don't even know what depression is.

This comes to mind from Alan Watts (from an audio recording that I imagine has been kicking around for well over fifty years by now):

The truth of the matter is, that we are as successful as we are in conducting our every day practical lives because our brains do the thinking for us in an entirely unconscious way. The brain is far more complex than any computer. The brain is in fact the most complex known object in the universe. Because our neurologists don't understand it. They have a very primitive conception of the brain and admit it. Therefore if we do not understand our own brains, that simply shows that our brains are a great deal more intelligent than we are.
posted by philip-random at 8:32 AM on July 26, 2022 [3 favorites]

Hoey Michaels, Solarian:

Before my meds, I wanted to kill myself constantly. Since my meds, I don't.

I take an SNRI, and this is my experience.

A crucial point is that the SNRI does not necessarily make me happier, and as such the "anti-depressant" label occasionally seems a cruel joke. I've still been absolutely fucking miserable sometimes while on it. But I do not have the same suicidal thoughts, or the cycles of swinging into/out of them, and that is sufficient life improvement for me to keep taking it.

Thank you for sharing cause, well, me too. Cannot believe how much they helped (along with Therapy) all of which I resisted for forever. The comments in this thread are engaging and enlightening, thanks all.
posted by WatTylerJr at 9:00 AM on July 26, 2022 [7 favorites]

The researchers say this may imply that the increase in serotonin that some antidepressants produce in the short term could lead to compensatory changes in the brain that produce the opposite effect in the long term.

This this this THIS. I took antidepressants the first year I was struggling with severe pain and disability at the age of 27, while trying to make a go of my first real shot at college and incurring massive debt, in a place there was no support for older students or queers. I am not a naturally depressed person, but antidepressants sounded like useful tool to get me through a difficult semester when I couldn't afford therapy.

That first stint made it incredibly difficult for me to sleep, something that had always been easy for me.

Doctors force you to take antidepressants for pain, even when you're not depressed, so several years later I went on them again, even though I was generally happy. After the second round I became permanently unable to sleep without sleeping pills. It's been that way for ten years. I tried for an entire year to go off them (couldn't get sleeping pills in another country), and ended up flunking out of school, because I would go 2-3 days without any sleep at all, barely functional as a result, and then pass out, rinse and repeat. Towards the end of the year I started drinking myself unconscious out of desperation, which caused my physical conditions to go batshit.

It took multiple years for me to realize antidepressants did this to me, and I noticed because every time a new doctor would talk me into a course of them for Their Stupid Reasons, as soon as I started noticing the other side effects (like suppression of sex drive and loss of ability to climax), I would stop being able to sleep even with the highest doses of sleeping pills. My ability to sleep with sleeping pills would return as soon as I stopped the antidepressants and they cleared out of my system. My ability to sleep without sleeping pills at all has never returned since that second round of antidepressants many years ago.

I wish I could sue for the damage antidepressants have done to my life and I'm so toweringly angry about it. The sleeping pill I take is an antipsychotic (it's the only one they're willing to prescribe that works for any length of time) and it causes weight gain unless you're insanely pro-active, shortens telomeres (and thus your life), and causes chronic dry mouth, worsening the chronic thrush from immunosuppressants, and destroys my teeth, which I can't afford to deal with.

Antidepressants are cheap and easy, and even very stupid doctors can feel like they're Doing Something by prescribing them. They're handed out like fucking candy. When I asked for sleeping pills in Denmark I couldn't get them, but I was offered antidepressants which I didn't want or need because I felt incredibly happy and safe there, until the stash of sleeping pills I brought with me were used up. And the irony is I only needed the sleeping pills because antidepressants permanently broke my ability to sleep.

During the first round of antidepressants I was double-majoring, and one of those majors was creative writing. At the time I wrote well, nothing like today, when everything is rust and atrophy. I was on the track to being publishable. Antidepressants gave me what I can only describe as aphasia, and everything I wrote looked like it was written by a 5th grader. It was correct grammatically, but the word choice was incredibly simplified. I knew the words were there, but they were locked up somewhere I couldn't reach them. It was incredibly distressing on a personal level and frightening. I coped by obsessively picking up hobbies that I was incredibly ill-suited for and bad at and dropping writing altogether because sucking at something I was once good at was something I could not cope with at all. At least sucking at things I naturally sucked at wasn't painful. Eventually my ability to access words started to come back, although it's never returned in full (and that can be laid to other factors, possibly, but not the initial loss)

For years doctors (GPs) told me they'd never heard of aphasia or loss of words as a side effect, just as they'd never heard of severe, intractable insomnia being a side effect. The first psychiatrist I could afford to see said "Oh yes, the word thing isn't common but it happens." Because it didn't hurt me functionally, only because writing was one of my majors, I wonder how many people it hits this way who never notice.

I dated a guy once who had permanent sexual side effects from a course of antidepressants, and it was a thing that damaged our relationship because he couldn't get past his anger about it. Fortunately for me, the sexual side effects always went away, but I absolutely believe for him they were permanent, like the sleep side effects for me.

Antidepressants fuck with deep, dark areas of your brain. They're ugly, ugly things and the medical profession should be forced to be absolutely transparent and upfront about that. If things like therapy and community centers and grief counselors were subsidized, we wouldn't need them. If we made inroads in (American) poverty and healthcare, we wouldn't need them.
posted by liminal_shadows at 9:09 AM on July 26, 2022 [17 favorites]

"Antidepressants fuck with deep, dark areas of your brain. They're ugly, ugly things"

Lets not paint ugly with a broad brush an entire category of life-saving drugs. Mine -saved my life-. They saved my marriage. They saved my relationship with my family.

I empathize very deeply with your pain but god, please lets NOT DO THIS THING we do on Metafilter all the time where our personal experience means we condemn something beneficial to many.
posted by FritoKAL at 9:29 AM on July 26, 2022 [53 favorites]

Some good points (and a lot of bad ones) made in this thread.

Figuring out how the brain works is like trying to reverse-engineer advanced alien technology. It's ridiculously complicated, but it's also just strange and unintuitive. To make matters worse, there's very few ways you can experiment on the human brain that are both safe and ethical. It's basically a black box. We end up having to draw most of our nuts-and-bolts technical conclusions from animal experimentation and in vitro models.

With regards to antidepressants, it helps a little to understand how we got to this point. Before the 1950’s, there were no antidepressants as such, nor any idea how to go about creating them. Researchers at that time were studying a drug for tuberculosis called iproniazid and noted that it seemed to cause elevations in mood. They later determined that this effect was due to the fact that it blocks an enzyme (monoamine oxidase) that degrades neurotransmitters like serotonin, leaving more of it lingering in synapses. This led to the first major class of antidepressants, monoamine oxidase inhibitors (MAOIs). They weren’t very safe drugs, but they seemed to genuinely help patients with depression.

That same decade, doctors noted that a blood pressure medication called reserpine tended to cause depression as a side effect. Turns out, reserpine blocks the recycling of monoamines like serotonin, meaning more of it gets degraded and your neurons have less to work with.

Then came the tricyclics, also in the 50's. These were chemical cousins of first-generation antihistamines that had originally been studied for use as antipsychotics, but were found to have better efficacy in alleviating symptoms of depression. They're sloppy drugs, meaning they hit a lot of targets, but it was determined that their primary effect was due to the inhibition of serotonin and norepinephrine reuptake by neurons.

It’s important to emphasize that these drugs were discovered before we understood how they worked. In fact, our early understanding of how the brain regulates mood was largely informed by these drugs. Their efficacy suggested that increasing monoamine availability in synapses (particularly serotonin) helped to alleviate depression, whereas decreasing availability worsened it. Subsequent antidepressant development built off of that. By the 80's, researchers were no longer just discovering drugs by accident; they were engaged in deliberate drug design. That is, they were starting with a biological target in mind and developing candidate drugs that specifically modulate that target. That's how fluoxetine (Prozac) was created, the first selective serotonin reuptake inhibitor (SSRI). SSRIs were found to be equally effective compared to MAOIs and tricyclics, but had far fewer side effects. Importantly, they had negligible effects on other monoamines. That suggested serotonin dysregulation was the primary culprit in depression.

Subsequent research has broadened, deepened, and confounded our understanding of what causes depression and how these drugs work. The short version is: it’s complicated! No, really. We’re teasing apart a really gnarly hairball and haven’t gotten very far yet. It’s unfortunate that the popular conception of serotonin = happy has taken root in the public consciousness, but it was never the whole story, just a very simplified version of an early hypothesis. And yes, it was certainly used to sell drugs, but the massive marketing campaign for the SSRIs (remember the sad Zoloft ovoid?) had another important effect: it contributed to the public’s understanding of depression as a medical condition that results from biological dysfunction, as opposed to being a personal failing.
posted by dephlogisticated at 9:34 AM on July 26, 2022 [19 favorites]

They’re working for me but it’s profoundly uncomfortable to feel that doctors don’t know why. I’m a neurotic and they dull the tiny lightning strikes of anxiety that I used to have in my chest while driving and at work, and make my lows less low. Problem is I’ve experienced a family death fairly recently and I feel a chemical wall between me and the grief that I feel I have a right to and a psychological need for, but it’s also allowing me to hold other family members up and stay functional.
posted by Selena777 at 9:39 AM on July 26, 2022 [8 favorites]

Sapolsky lecture on depression, 2009

He keeps setting up theories and knocking them down, though it looks as though there's an underlying pattern. Even then, it was known that whatever the problem was, it wasn't a single neurotransmitter.
posted by Nancy Lebovitz at 9:44 AM on July 26, 2022 [3 favorites]

please lets NOT DO THIS THING we do on Metafilter all the time where our personal experience means we condemn something beneficial to many.

posted by cinchona at 9:48 AM on July 26, 2022 [6 favorites]

Someone I know went on a combination of Zoloft and some other drug for anxiety (I don't know what) circa January. She's already pretty medically fragile anyway and apparently the drug combination literally incapacitated her--she couldn't walk, lost her job, couldn't do anything--for months on end. And then she had to taper off them. I finally saw her for about an hour a few weeks ago and she said she'd finally tapered off it all a month ago and gotten her ability to walk back after 2 weeks. She said to GET GENETIC TESTING (even if it's out of your pocket) before going on meds because then if someone had done that, she wouldn't have had this happen to her because apparently this being bad for her would have shown up. If anyone has any idea where that gets done, I'd love to hear it (never did find out from her where she went).

I do agree that depression meds are easily handed out like candy, without medical professionals seeming to have much of any idea as to why it works or won't work. I find that deeply scary. Another friend of mine just went on the meds and she has been very scared about doing so, and talking it out with her doctor didn't reassure her AT ALL and she originally said "this talked me OUT of wanting to do them." Unfortunately her husband just got diagnosed with cancer and that's officially so bad that she's feeling like she'll have to resort to meds even if she has misgivings. Of course she said side effects kicked in within a few hours of starting them and she's afraid to drive, but it'll take weeks to know if it works...

I'd be much more willing to consider medication if genetic testing was being done, or if there was anything that wasn't "we're just trying this blind to see what happens." Ironically, after years of people telling me I should be on meds, my HMO doesn't think so :P I know they both help a lot of people AND can end up surprise causing things that can mess you up for life, but it sounds like a complete crap shoot as to which one of those you end up being. I honestly don't think I'd be willing to try psych meds unless anything improves with the "pig in a poke" situation. I'm not judging those who do or do not, but I find it truly terrifying that nobody really seems to have any idea what's going on other than "hey, it works for some people and we don't know how or why! Good luck, give it a try!"
posted by jenfullmoon at 10:15 AM on July 26, 2022 [7 favorites]

Deep and abiding thanks to those of you posting information on here helping me understand the context, especially Jpfed

But it really does not help the discussion when people make vague generalisations about the effects of the *medication I am taking right now* for crippling anxiety and I know I'm not the only one reading this and wincing .

Have a bit of compassion. If you have information to share, do so. But please leave the scaremongering out of it.
posted by Zumbador at 10:39 AM on July 26, 2022 [19 favorites]

I admit I skip a lot of FPPs that seem fraught, but I can't remember a thread that had so much stridently ignorant advice that could literally lead to someone's death. Could we please rein that in a bit?
posted by Ookseer at 11:00 AM on July 26, 2022 [10 favorites]

I'm alive right now because of antidepressants. That's just a fact. I know they can be awful, I know there are a lot of other things that help. I'm not interested in fighting or minimizing other people's experiences. But antidepressants aren't some poison I was hoodwinked into taking. Nothing else worked.
posted by haapsane at 11:01 AM on July 26, 2022 [20 favorites]

*dry* I have often waxed wroth about the lack of attention paid to external and societally mediated stressors here, and especially about the various failures of mental health care when it comes to understanding these stressors.

That said: look, antidepressants are effective for many people, and I will add that I had had considerably more success with managing my very special neurodivergent brain, and the cocktail of mood disorders that spin out of it, with medication than I have ever succeeded at with talk therapy or CBT. SSRIs aren't the only thing I take, but I have been both on and off them for long periods since adolescence, and looking back at the span of my life, I have pretty much inarguably doing better during the periods when they are an active part of my treatment plan.

Folks who have more chronic and longstanding low mood, or mood that fluctuates wildly from day to day, or who have significant anxiety that predates their low mood, have developmental trauma or other adverse childhood experiences, difficulties with frontal lobe functioning like ADHD, or neurodivergent brains, are probably a different kettle of fish and won't necessarily respond to the same kind of treatment. I suspect, but can't confirm, that a lot of the studies on anti-depressants may not have taken these complicating factors into account, hence the lacklustre difference from placebo in randomized controlled studies.

I really think this is an enormous and massive confounding variable in the research we have that hasn't been adequately disentangled for most psychiatric treatments! And I mean, you don't even necessarily have to rely on neuroanatomical or otherwise brain-structure-mediated differences to understand why neurodivergence might create variable experiences with meds: if you're consistently muddying complex trauma (which many neurodivergences will create, by creating various cognitive disabilities without any framework to explain them other than personal failure) with other forms of mood disorders, you're trying to treat a heterogeneous population with a uniform treatment. This meta-analysis doesn't really do anything about that, though, or disentangle at all whether there are populations for whom SSRIs are a reliable and beneficial treatment and populations for whom it's unlikely to be effective, both of which score highly on a depression diagnostic scale. We do so badly about understanding neurodivergence as a common form of variation that appears in a lot of adults of various functioning levels or complex trauma (or even chronic stress) as, again, common experiences to wide groups of people in our societies. Insofar as we try to disentangle these effects, we usually wind up reducing it to socioeconomic status, which is itself a pretty broad brush to paint with.

I guess, insofar as honesty from psychiatry is desired... I don't know, I've had a number of psychiatrists of varying skill over the years, but I don't think I've ever had anyone tell me that they knew for sure what a med would definitely do to me, side effects have always been an open topic of conversation (although sex drive and weight gain, perhaps unsurprisingly, have been the main topics of focus), and I was always definitely warned about the suicidality effect with SSRIs. Maybe the guy when I was twelve? That one's kind of fuzzy. Is the gaslighting about SSRI side effects a larger problem with people who are being prescribed them through GPs?
posted by sciatrix at 11:08 AM on July 26, 2022 [11 favorites]

the drug combination literally incapacitated her--she couldn't walk, lost her job, couldn't do anything--for months on end. And then she had to taper off them.

Aha! I'm not the only one with weird SSRI issues. Lexapro really screwed me up. My psychiatrist was really bemused by the not-able-to-walk bit and I had to drop most of my classes that semester. I've given up on SSRIs--I tried a couple that didn't help me and had terrible side-effects, so I've concluded that they're not a good solution for me (though I do have friends who have found them helpful). I wish the genetic testing was covered by insurance. It would also be nice if we had a better understanding of how these drugs work, but I'd settle for just being able to reliably predict which drugs are most likely to work.

The fact that they just give you some meds and wait to see if they help is incredibly disruptive. It's hard to just bounce back from several weeks of having your brain scrambled, especially if you have a job and/or family members that rely on you. Things more or less worked out for me when I was younger because I was too screwed up to really function to begin with (and I got lucky and the first meds I tried worked reasonably well--things went badly when they tried to change my meds later to address some other issues, but I was able to go back to my previous med regimen).

I've been taking psychiatric medication for almost 14 years, and it's helped me a lot overall (so has talk therapy, but I think the stabilizing effects of the meds made therapy more productive that it would have been on its own). I just wish that there was more support, more comprehensive information for patients, and fewer risks around trying new medications.
posted by threecolorable at 11:33 AM on July 26, 2022 [6 favorites]

the massive marketing campaign for the SSRIs (remember the sad Zoloft ovoid?) had another important effect: it contributed to the public’s understanding of depression as a medical condition that results from biological dysfunction, as opposed to being a personal failing.

On that note, I recently read an interesting piece on whether it's true that the SSRI-suggested picture of depression is helpful.

On how other people react to someone they believe has a chemical imbalance: "People who endorsed the chemical imbalance explanation had consistently more negative reactions to the depressed person than those who did not. They were more fearful, angrier and less socially accepting. The same negative pattern held for people who endorsed the brain disease and heredity explanations."

And as far as the depressed people themselves, the piece reviews another study: "Participants in the chemical imbalance group blamed themselves as much as their control group peers. They were also more pessimistic about their chances of recovery and less confident of their ability to manage their depression." (emphasis mine)

I don't want to overstate this especially in a thread which is already a little tense, but I think for some of us for whom these treatments didn't work, the popularized understanding of chemical imbalance can lead to some frustration among our friends and loved ones: You're taking the pill, why aren't you better yet? Treatment resistance becomes a personal failing.
posted by mittens at 11:59 AM on July 26, 2022 [17 favorites]

"Antidepressants even cause suicidal ideation and suicides, which is something you would know if you were educated outside of your own experience."

Liminal, I have a degree in psychology and I WAS educated. I knew exactly what the risks were. My doctor ran down the side effects - every single fucking one, even the rare as fuck ones and it was a calculated risk. If nothing else, the personal assumption that I don't know what I'm talking about is fucking insulting.

Lets ALSO not do the metafilter thing where we insult people and assume they're uneducated and stupid, kay?
posted by FritoKAL at 12:37 PM on July 26, 2022 [21 favorites]

I, too, react badly to SSRIs and SNRIs (and, yes, I've got a neurodivergent brain and a childhood from which lifelong anxiety and depression would not be unexpected). SSRIs/SNRIs make me feel as though I'm about to start tripping at any moment for the entire duration of the dose. I guess it sounds similar to serotonin syndrome. Every time I got a new psychiatrist, there was always a struggle to convince them that I react badly to SSRIs/SNRIs. They would repeatedly tell me it's impossible for the first dose to have any effect. Eventually, I gave up on antidepressants entirely. Then, almost 20 years after my first failed foray into antidepressants, a psychiatrist finally prescribed buproprion. I don't react badly to it, though I know plenty of people that do. It doesn't give me any noticeable side effects. I am certainly still depressed and anxious, but at least I can function. I don't think I've had a single late call-out at a job because I'm too panicked to get out of bed since I started it about 8 years ago.

As someone who has had bad experiences with antidepressants over a long time, someone for whom things were significantly worse while on them, I get the hate for them. There are people that will get no benefit from any antidepressant, people that will get worse because of them. And there are people that do well with the first SSRIs they are handed.
posted by The Great Big Mulp at 12:42 PM on July 26, 2022 [8 favorites]

I will say this for my friend's conversation with her doctor: the only thing the doctor said that was somewhat reassuring was "most people respond to the first SSRI, if they don't, then they will probably respond to the second." Though I don't know how true that is, exactly, as that's the first I've heard of it.
posted by jenfullmoon at 1:23 PM on July 26, 2022

Crisis units are capable, in my understanding, of forcing holds in pysch facilities, which are facilited or enforced by law inforcement. I am not sure that this model makes people safer.

Consent to treatment is key.
posted by PinkMoose at 1:33 PM on July 26, 2022

I have a lot to say about the neurobiology here but I'm trying to make it home from across the country to see my cat before she dies, and I'm a bit distracted. Suffice to say, no one on the science side has endorsed the naive version of the neurotransmitter imbalance theory of depression for decades. We know SSRIs work, but the mechanism of action is more complicated than that. Clinicians are rarely up to date on the science, but the imbalance theory is a not-exactly-right-but-good-enough simplification that clinicians perseverating on it has done little harm, as in practice it doesn't really cause them to deviate from best clinical practice. Science is full of models that we know aren't exactly right but are still useful for guiding practice; for example, very few engineers ever need to worry about special relativity even though we know that Newtonian mechanics is only approximately true. Clinicians applying the serotonin imbalance theory in prescribing SSRIs isn't exactly in the same category as that, but there are some parallels. Others here have done a good job of explaining why this paper probably shouldn't be a huge revelation to scientists, clinicians, patients, or the general public. SSRIs work, not all of them work for every individual, if you're taking one that works for you keep taking it, and if you and your doctor think you might need one don't be dissuaded from trying it by this article.
posted by biogeo at 2:02 PM on July 26, 2022 [22 favorites]

Suffice to say, I'm going to be relying on my SSRI to help get me through what's going to be a very difficult period.
posted by biogeo at 2:03 PM on July 26, 2022 [6 favorites]

You could just as easily call diabetes a "chemical imbalance". It's also a complicated group of diseases where the body does not process sugar/ insulin well. Fortunately, it's generally amenable to medication and changes in diet and exercise. Chemical imbalance is a popular label for depression, a group of diseases that are poorly understood and sometimes amenable to medication, and possibly changes in diet, exercise, and some form of therapy.

I used tricyclic anti-depressants years ago before Prozac existed. It was not a good experience except that I was more able to function. Prozac had side effects. I've been off and usually on Zoloft for a long time. A pretty small dose works better for me. I've been told it's considered a sub-clinical dose, but I can confidently assert that it is effective for the most part. I went off it for a year fairly recently because I was doing well. Then depression crept back up and I was a hot mess with suicidal ideation, random crying, misery. Back on Zoloft, and I felt dramatically better in a couple weeks.

There's so many studies, lots of conflict. I'm not sure anybody really asks people with depression about it. It can be reactive to events in my life, or quite random. My family was dysfuctional, I've experienced trauma, but I'm also resourceful and used to be pretty resilient. Also, my family was and is dysfunctional because of so much depression and other mental illness. Depression is quite physical for me; slowing my body and making my brain sluggish. There's a fair bit of research suggesting that depression is an inflammatory illness. Stanford has started a Metabolic Psychiatry Clinic, and that will be interesting.

To say human brains are complicated is just the beginning. I think people will look back on this time period as a start, abandoning the ideas of possession by demons, but using meds in an almost scattershot and often heavy-handed approach. People with diseases like schizophrenia take even heavier drugs with long-term consequences. (The Sapolsky lecture on Schizophrenia is excellent and compassionate; the whole series is well worth your time).

It's extremely concerning that few prescribers of anti-depressants deal with ending their use.

There's a special corner of hell for health care providers who say It's just depression, it's a chemical imbalance, take this, and there are a lot of them. We need much, much better cultural understanding and responses to all mental illness, including depression.

biogeo's comment is excellent. and I'm so sorry about your kitty.
posted by theora55 at 2:19 PM on July 26, 2022 [6 favorites]

Antidepressants even cause suicidal ideation and suicides, which is something you would know if you were educated outside of your own experience.

Depression also causes suicides. A *lot* of suicides. Suicide is the leading cause of death in the UK for men between 20 and 49, and women between 20 and 34. 1 in 6 people over the age of 18 experience symptoms of a common mental health problem, such as depression or anxiety, every week, a good proportion of them entirely untreated, for various reasons. And its getting worse.

Are some of these problems caused by societal ills, such as poverty, other medical conditions lingering on an NHS waiting list, abuse by others, or more ephemeral ills like fear of a future that seems to get darker every day? Certainly, and it'd be just great if we could wave a magic wand and fix those, but nobody here has one. Are anti-depressants a very blunt tool, that harms some people more than it helps? Obviously, the evidence of risks are pretty clear, and the side effects are no picnic at all even when they work, though they're less dangerous than the older meds.

Are they still the best tools we have, despite their flaws, to save lives, including those of people in this very thread? Sadly, yes. I wish nobody ever needed to roll that dice again, that we had far better proven treatments for the many illnesses that fall under the umbrella syndromes of anxiety and depression. But the alternative of not rolling that dice at all for many people will be much worse. Adding yet more stigma to mental illness and the available treatments will cause more people to try and tough it out without any help at all. I didn't seek help for years, because I was ashamed, and I was deathly scared of becoming stuck on pills for the rest of my life. I can't speak for others, but my doctor was at great pains to explain the possible side effects, and I was closely monitored for several years to check if they were working and if I was at any risk of suicide. I did receive other therapy alongside fluoxetine (after a few months, admittedly), and was switched to venlafaxine by a specialist when neither really worked. And here I still am, alive. Doing periodic reviews with my GP. Surviving, best I can.

Anti-depressants aren't candy pushed by the devil. They're a flawed tool that's often all many have got in this shitty, shitty world to stay alive. I'd stop taking them tomorrow if the alternative wasn't far fucking worse. Anyone got that magic wand?
posted by Absolutely No You-Know-What at 2:39 PM on July 26, 2022 [29 favorites]

Speaking only for myself, my mind isn't entirely on my side, but it's not as bad as some.

I've tried some anti-depressants that I got on my own. I might be able to recover the names if anyone cares.

I took one before a worldcon. It improved my mood and energy, but when I looked back over the long weekend, I realized I was in several headbanging arguments in a way which wasn't my habit.

One of them screwed up my long term memory for months.

One of them screwed my short term memory, which is kind of pointless, considering that I wanted to get more things done, and now I couldn't even remember them.
posted by Nancy Lebovitz at 3:43 PM on July 26, 2022

As many have outlined, the biochemical theory of depression is not hinged on serotonin levels and has not been for a long time. People can have identical serotonin levels but differences in their serotonergic systems and how that serotonin is used in the brain. There is no question that the serotonergic system is involved in depression; how it is involved is not clear, but no one has thought that the problem is "low serotonin levels" for a long time. Further, there is plenty of evidence for antidepressants and the idea that they aren't better (or only a little better) than placebos is a persistent myth.

I really feel for people regarding the lack of knowledge about what will and won't work for people, and the serious side effects they can cause. It's an awful situation and it causes significant issues in many people's lives. But please understand this is not remotely unique to antidepressants. I've been on a whole lot of classes of meds for my chronic illness and only once have I had the first medication work for me with minimal side effects. Migraine meds, pain meds, nausea meds, GI meds, heart meds, every single one of these has either taken multiple tries to find one that works at all or doesn't come with horrid side effects. They've all required the song and dance of "try this for a couple of months, you might get horrible side effects but they should go away, but if they don't or you get no benefit we need to taper down and start over with something else."

Of the 20+ meds I've been on in my life, only one was an SSRI. And yeah, it had side effects and the withdrawal did suck. But the worst meds I've been on were not psychotropics. Migraine meds have destroyed my sleep, eating, mood, and memory (while doing nothing for my migranes). Blood pressure meds have left me with crushing fatigue. Seizure meds as a kid probably left me with permanent cognitive issues. This is just... how medication for chronic diseases works. God, I wish it was better! I really do! So much! But it's not, and it's not unique to SSRIs and it's not unique to psychiatry and it is so much a part of disabled lives that to claim we should eschew SSRIs for their side effects and uncertain benefit to individuals is to claim we should eschew most all of modern medication and treatment for chronic illnesses.

Also, lifestyle interventions and therapy can come with just as many side effects. Most therapy requires you to feel worse before you feel better, and sometimes you just feel worse and don't feel better. If your lifestyle intervention doesn't match a person's very unique needs, it can also make the situation worse--for example, exercise can make ME/CFS worse, possibly permanently. I tried to treat my GI issues with common wisdom about eating more whole grains, vegetables, and fiber and it made me much worse, because it turns out I actually digest things too quickly so need to avoid those things.

Any sort of change is a roll of the dice. Some are more risky than others, but also everyone's risk calculation is different. I mean, it's extremely obvious in this thread--there's someone who won't take SSRIs but will take an antipsychotic because it's the only thing that works. That is completely their choice! But the permanent, irreversible harm of long-term antipsychotic use is so well-documented that even I would hesitate to go on them. If I were to start anywhere on "maybe this class of psychotropic meds is too risky and too ineffective to continue being prescribed" I would absolutely start with antipsychotics far before SSRIs, personally.

All of that to say that the potential damaging effects of SSRIs are very real, but they are not uniquely so. You play the same game with any number of commonly prescribed medications. It's absolutely your choice not to engage with meds at all, but is disingenuous to single out antidepressants as uniquely risky on a population level (though you are free to decide they aren't worth the risk for you even if you take more "population level risky" meds). There are psychotropic meds whose risk profile might be worth debating (antipsychotics, lithium, high-dose long-term benzodiazepines--though personally I support these as an option as long as the risks are well communicated and carefully monitored), but SSRIs are extremely middle of the road regarding treatment of chronic disease. Like, it sucks that the middle of the road is so bad, but it needs to be considered in the context of all the other meds people take long-term.

Btw, the risk of increased suicidality is only observed in people 18 or younger. No such effect observed in older populations. SSRI use in adolescents is a different conversation and not addressed by this paper.
posted by brook horse at 5:04 PM on July 26, 2022 [32 favorites]

You know, I really enjoy going 24 hours without thinking about how I'm going to kill myself or possibly adding to my complicated suicide countdown timer chart - had to be after the kids are grown, couldn't be near anyone's birthday or a holiday, there were lots of rules I no longer remember. Why do I no longer remember the rules? Because I take generic lexapro, have off and on for years and years. Without it I would almost certainly no longer be here writing about my suicide timer chart because the magic day would have arrived and bye.

I'm currently weaning myself off my SSRI yet again, even though that never works out very well, but I think maybe this time I'm stable enough to survive. I could be wrong! I could slide right back down into the darkness! It's happened before! But if it does I know that I can start taking the damn pills again and in a couple weeks I won't be thinking about killing myself every single hour of every single day.

I don't care if anyone thinks they are dangerous or whatever it is. They probably are. But also yeah, they saved my goddamn life and that matters to me.
posted by mygothlaundry at 5:42 PM on July 26, 2022 [34 favorites]

Mod note: A couple deleted. Don't attack other users; don't make the thread all about yourself / your point of view. (FAQ) Speak for yourself, not others. (Guidelines) It's fine to discuss your own issues and thoughts, negative or positive, but refrain from insisting that your opinion or experience trumps everyone else's. Fine: I had bad / good experience with X, and feel like people should be aware of the possible important negative / positive effects. Not fine: I had bad / good experience with X, therefore X should be outlawed / mandatory, and if you disagree it's because you are stupid, a bad person, etc.
posted by taz (staff) at 11:08 PM on July 26, 2022 [3 favorites]

How did I know this thread would be a shitshow before I even opened it? Here's my bona fides: I've been on and off antidepressants for over a decade. I've tried three that I can remember for significant periods of time (Wellbutrin, Zoloft, and Lexapro). I did not have a hard time detecting their effects on me. I've also, over the last two years, tried out more or less every ADHD medication available, in combination with some of those antidepressants, trying to find a combination that provided meaningful benefit without unacceptable side effects. It has been a roller coaster, to put it mildly.

But I put up with all that because it is better than the alternative. Without medication I mostly just don't want to live. With medication I'm still not that happy about it, but there is at least the prospect of getting somewhere. It's not my imagination; my partner can tell when meds are working for me and when they aren't without actually knowing what I'm taking.

Side effects? Not always great! Withdrawal? Sucks! Perhaps I've had better than average luck with doctors, but every single one of them has been very clear about the risks. So have the warning labels that come with the pills.

Would I consider other approaches? What the fuck kind of question is that? I've tried everything any doctor I've ever gone to has suggested might work. I would do anything not to feel the way I feel. Ketamine treatment would be an expensive pain in the ass given where I live, but I'd try it at the drop of a hat—except that my doctor, who is an actual doctor who knows me and not some dickhead on the internet with an axe to grind, tells me that the effects wear off fairly quickly, and although we are doing pretty well financially we are not doing thousands of dollars a month every month for the rest of my fucking life well, to say nothing of having my partner drive me an hour each way to the nearest clinic that offers it. And you want to talk about marketing and profiteering? Color me a little bit skeptical about the only mental health treatment I've ever seen advertised on fucking billboards.

Bottom line: if you do not know what it is like to want to die every minute of every day, and then to not feel that way because of medical treatment you've received, very seriously consider shutting the fuck up about it.
posted by sinfony at 12:55 AM on July 27, 2022 [12 favorites]

Mod note: A request, please: since most people in this thread are in the same boat, dealing with much the same pain, fear and anxiety, and facing many of the same choices and limited options, perhaps we could not lash out at each other out of general frustration. Why cut off this means of sharing information and helping each other by making it just another source of pain to avoid rather than a place to support and uphold each other?
posted by taz (staff) at 3:01 AM on July 27, 2022 [12 favorites]

May I suggest another little thing to keep in mind when talking about antidepressants being "handed out like candy": antidepressants are prescribed all over the world, but their use varies greatly across different countries, and there are countries where there is still more of a stigma about depression and about seeking help for depression and taking antidepressants at all. So there are places where antidepressants are still underprescribed.
posted by bitteschoen at 5:30 AM on July 27, 2022 [2 favorites]

"Aspirin represents one of humankind’s oldest pharmaceutical agents" and we did not uncover how it works to reduce pain until the 1970s. I won't be alive when the puzzle of depression is finally figured out, which I hope will allow for consistent and reliable treatments (that I am guessing will be personalized, in the future, for the best results). But I'm just a yahoo on (a series of different) meds because my brain is broken. What do I know?

My heart goes out to those who of us who have been damaged by taking meds of any sort; those who needed meds but never got the right ones; those still looking for help but cannot get it; those on medication with lots of side effects. Sending virtual hugs to all who need them. Life is just too hard, way too often. Hang in there.
posted by Bella Donna at 6:20 AM on July 27, 2022 [11 favorites]

I think that some doctors can be a bit dismissive of people for whom SSRIs don't work, just as they can be dismissive of a lot of types of chronic pain; the unsolvable problem makes them uncomfortable, and then (sometimes - I am trying hard not to generalize) that discomfort becomes the patient's fault. It is hard when it feels like the media and the medical mainstream treat depression as a Solved Problem, Except For You, You Weirdo.

It just feels tricky to leave room in the discussion both for people to whom SSRIs are helpful and even necessary, and people who have had to look much further afield for treatment or haven't found something workable yet.
posted by Jeanne at 7:02 AM on July 27, 2022 [13 favorites]

a Solved Problem, Except For You, You Weirdo

(Addendum: except when they're advertising the hot new antidepressant that my insurance does not cover.)
posted by Jeanne at 7:24 AM on July 27, 2022

"So what if it's a placebo, if it helps" actually sounds kinda barbaric to me. Those people are suffering from side-effects that could be avoided if we had better ways of harnessing the placebo effect.
posted by panama joe at 6:46 PM on July 27, 2022 [1 favorite]

That's a good point, panama joe. Also, meds are expensive! Or maybe the expense could contribute to a placebo's effectiveness...?

That's not a happy thought!
posted by Zumbador at 10:19 PM on July 27, 2022 [1 favorite]

Well, we already know that it’s not placebo, because of placebo controlled trials, so that’s fine.
posted by brook horse at 6:46 AM on July 28, 2022 [9 favorites]

The Atlantic: CAN YOU CURE MENTAL ILLNESS? TWO CENTURIES OF TRYING SAYS NO. A new book looks at the long and sordid history of psychiatry and its attempt to help those living with mental illness.

I normally would quote from a paywall article, but most of this is absolutely depressing AF and I will not. But this stuck out:

"As suicide rates among the young remain on the rise and people who suffer from severe emotional disorders continue to need professional help, one wonders whether we have reached a standstill of sorts in the treatment of mental illness—whether our knowledge of how the mind works is too limited to move decisively forward. "
posted by jenfullmoon at 10:22 AM on July 30, 2022 [1 favorite]

Rolling Stone: Who Is the Psychiatrist Behind the Antidepressant Study Taking Over Right-Wing Media? Joanna Moncrieff has spent two decades questioning the efficacy of SSRIs — and more recently, she’s gone after Covid-19 vaccine mandates

To read Moncrieff’s paper and conclude that antidepressants do not work, as many on the right have, is the wrong message to take away from the study. “[The paper] doesn’t undermine the efficacy of antidepressants for those people for whom they work,” says Comaty. “But we just don’t know the biochemical theory of depression.” Such ambiguity may be unwelcome to those looking for definitive answers one way or the other about SSRIs.
posted by Ten Cold Hot Dogs at 5:33 PM on July 31, 2022 [6 favorites]

From the Rolling Stone article:

What is somewhat unusual is that Moncrieff’s work is frequently promoted by an organization called Citizens Commission on Human Rights (CCHR), which touts itself as a “mental health industry watchdog” and was established by the Church of Scientology, which is virulently opposed to psychiatry and medical interventions for mental illness.

I wondered when they were going to show up.
posted by heatherlogan at 6:22 PM on July 31, 2022 [12 favorites]

Good grief.
posted by amanda at 6:49 AM on August 1, 2022

Oh! She also doesn’t believe in adult ADHD.

That explains a lot.
posted by brook horse at 7:45 AM on August 1, 2022 [4 favorites]

I mean, it does make it awkward to argue that ADHD medication for children is an epidemic of overused medication drugging children who are having zero issues whatsoever... when those children grow up to be adults who continue struggling with the same things with executive dysfunction that continue to be alleviated by the same damn meds.
While Aftab may believe it is not an accident that the paper was embraced by the right, Moncrieff is somewhat perturbed by the segment of the U.S. media currently championing her research. “I am perplexed at why this story has been taken up by the right-wing media more than the left,” she says. She believes that treating mental illness with medication constitutes “inappropriately medicalising distress and thereby obscuring the effects of social injustice, poverty, inequality, racism, child abuse etc, [which] should be a major concern for the left.”
I can't quite tell if Moncrieff is uncomfortable with her new right-wing friends or merely mournful that her work isn't getting championed by an even larger audience, but I do think it's worth considering where the hooks she's trying to set are. As with a lot of the conspiratorial theories popular on the alt-right and a lot of other pseudoscientific, grifty, and otherwise harmful ideas, her messages resonate with people whose problems are being exacerbated or even outright caused by broader societal and institutional pressures--and who are reacting, not incorrectly, to the notion that their trauma or exhaustion or whatever can only be solved with a personal, biomedical pharmaceutical intervention.

The problem is that this isn't entirely wrong, but it's not entirely right either. We do need to make social interventions to make life less difficult for many people, especially working class people and people of color. We need to change labor law, intervene in domestic violence, and create a tighter support network for people whose lives are externally struggling. We need to make a lot of very big-picture structural changes to the way that our lives are, collectively, run.

But that doesn't mean that short-term, individual modifications that alleviate some of the very personal problems right now somehow mean that we don't have to address the big structural problems. It is easier, speaking for myself, to figure out how to change my environment in such a way that I can actually benefit from therapy when I have enough energy available to me that I can process and sit with the contents of that therapy. This is one of the reasons that antidepressants like SSRIs work better for people with severer initial depression scores--at a certain point, if you're struggling too hard just to keep afloat, you don't have enough energy left over to actually engage with psychotherapy in a way that will be helpful.

It's not a betrayal of the real need for systematic intervention to seek and accept individual-level help in whatever form you can access it. It is not a betrayal of the glaring enormous problems with our society as it currently exists to seek individual remediations. It does not mean that we do not need to fix them, because we do. And that's really the throughline I'm seeing in many of the similar types of ideas I've seen in left-leaning spaces: if we focus on individual biopsychological interventions as our response to mental health disorders, we'll somehow forget about the systematic inequities and traumagenic stressors that create (some of) those disorders in the first place.

I have a similar fury-reaction to the concept of "mindfulness" as it's often promoted for mental health and wellness, actually, as a direct result of being told to practice more mindfulness by a mental health professional when what I actually needed was support or at least empathy. It's really hard for me to disengage myself from that kneejerk "fuck you for saying my trouble coping is my fault" reaction enough to look at the things that are genuinely useful about mindfulness. A lot of my critiques of it as an intervention--it is intensely popular, especially with HR offices, because it is intensely cheap--remain valid, even if it does contain useful tools.

And it does. There are tools I can take from mindfulness and repurpose to use for myself, even if I have to file the serial numbers off first. They don't fix anything, but they can be useful for small things while I learn how to exist in the world. They are support aids, not panaceas. Just like meds of any stripe; just like psychotherapeutic interventions; just like everything else we do to manage our tired, battered, flailing minds.

I think the greatest protection the left has against these kinds of arguments, then, is the willingness to sit with the real pain that drives our responses to work like Moncrieff's. Sometimes our kneejerk reactions collapse a nuanced, difficult topic into a simplistic black and white story. It takes a lot of time to sit with that and figure out where it's coming from, and it takes more time to sit with those kinds of reactions in our friends and family while we process. But that time protects us from being quite so easily led by frameworks that capture and manipulate our emotional responses, and so generally it is time well and dearly spent.
posted by sciatrix at 10:21 AM on August 1, 2022 [11 favorites]

The Rolling Stone piece is absolutely astonishing garbage, for how it tosses Moncrieff into the partisan meatgrinder, staining her with right-wing associations, without ever probing what the right wing finds palatable about her ideas, and apparently without interviewing any right-wing person who has praised the study. How do you manage to write a story about this topic about bringing up how weird post-COVID American partisanship is, and how the right's long-time affinity with marketing snake oil, combined with its policy of denying Americans healthcare, and yet eagerness to accept big donations from the pharma industry, creates a very tangled knot of confused ideology and politics? I mean, I share Moncrieff's surprise that the study became a talking point on the right because I still have in my head that "right" means "in favor of big business" rather than "whatever coalition of conspiracists and profiteers can pack the room at a given moment."

And how do you let a line like this pass: "the review was largely met with yawns from the psychiatric community." I mean, I guess it's very nice that they've all moved on from the cartoon version of the serotonin theory but maybe they forgot to tell everybody else because this is very, very much still part of how we the public think about depression. How do you not ask a follow-up question about it?
posted by mittens at 12:10 PM on August 1, 2022 [3 favorites]

And that's really the throughline I'm seeing in many of the similar types of ideas I've seen in left-leaning spaces: if we focus on individual biopsychological interventions as our response to mental health disorders, we'll somehow forget about the systematic inequities and traumagenic stressors that create (some of) those disorders in the first place.

I think that is definitely a large part of it, but I think it's also very easy to fall into a kind of trap if you've experienced crippling hardship yourself: I was in contact with mental health services at one point in my life when the stress of being fucking poor was basically killing me, and what I actually needed in that situation was a break - I needed a prescription for money, for a job, for the pressures of poverty to be alleviated. Instead I got offered group CBT sessions and antidepressants. It's so so easy to accidentally generalise too far from personal experience, so it's real easy to look at every antidepressant prescription and say "what they really needed was financial stability" when that isn't necessarily true just because it was for you (or me, in this case - neither antidepressants nor CBT helped me one bit, but eventually finding someone willing to give me money i (n exchange for labour) absolutely did).
posted by Dysk at 7:00 PM on August 1, 2022 [5 favorites]

And how do you let a line like this pass: "the review was largely met with yawns from the psychiatric community." I mean, I guess it's very nice that they've all moved on from the cartoon version of the serotonin theory but maybe they forgot to tell everybody else because this is very, very much still part of how we the public think about depression. How do you not ask a follow-up question about it?

One of the odder things I've noticed during my sojourn to NIH-land is the absence of interest or motivation to engage in public outreach and education as part of professional development. I mean, it's a double edged sword, right; there's too many hats for most working academics to wear as it is without also picking up skill sets in scicomm on top, and fuck knows we're not good at deliberately funding scicomm at the best of times.

But, IDK, I keep finding myself looking at the folks around me and wondering, why aren't you more scared? Maybe it's just that in EEB we're all used to thinking of the public as potentially hostile but potentially interested, such that we'd better get up off our asses and talk to them to justify our collective existences. Education is an important part of public knowledge, but it really does feel like proactive public education on this front has largely been left to pharmaceutical companies.
posted by sciatrix at 9:12 PM on August 1, 2022 [1 favorite]

Quite a few people in this thread have said they would prefer to be told "we're not sure why it works". That's true for me, too. It would not stop me from trying a new medication. Is that true for most people, though?

Is it part of a sort of paternalistic attitude for the medical profession to pretend more surety than they have, in case the complexity of the truth prevents people from making the right decisions for themselves?

This seems a particularly thorny question with mental health meds, where there's a pretty big barrier to people trying them at all, because the stigma of needing meds.
posted by Zumbador at 9:37 PM on August 1, 2022 [1 favorite]

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