Category: Antidepressants effectiveness

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addiction Alternative to mental health treatment antidepressants Antidepressants effectiveness Mental Health pharmaceutical Industry psychiatric drugs psychiatric medications

Are Psychiatric “Medications”Essentially The Same As Recreational Drugs?

Welcome to From Insults to Respect. Today we shall look at a theory that is certain to fire up some mighty strong emotions.

Most advocates within the medical profession say their prescriptions for psychiatric drugs, which they refer to as “medications,” improve the health outcomes for their patients. There are some within the profession that fervently object to this claim and provide extensive research evidence for their position, but nevertheless are clearly a minority. Meanwhile, taking legal and illegal recreational drugs are mostly viewed as distinctly different not only by medical doctors, but a majority of those in the general population.

That said, I do think it is useful for us to look at the case that although there are some differences, essentially they are the same when it comes to opportunities to 1. assess side effects/toxicity as one makes decisions to partake, and 2. what keeps users to continue consuming them.

Assessing Side-Effects and Toxicity

The Food and Drug Administration provides readily available information on the internet, regarding the side effects and toxicity of these substances. Updated research on this information is regularly appearing in the press. For example, we have recently seen stories about how even one glass of an alcoholic beverage can have negative effects on some aspects of health outcomes.

Anyone who wants to delve into a more thorough assessment of health consequences of any of the legal and illegal recreational drugs and psychiatric drugs can do a literature search. I have found Google Scholar fairly easy to use for this purpose. It provides the abstract of the research for free. There is an occasional pay wall that can be modestly costly in order to read the entire paper, but anyone who wants to make a fully informed decision on the risk of partaking can obtain the available evidence at a reasonable cost. Many of the published evidence can be misleading particularly because most studies look at just short-term results, yet many folks take these drugs for much longer. But this is true for recreational and psychiatric drugs, so assessing safety is hardly perfect regardless of what drug is being considered.

The Physical and Psychological Reasons People Continue to Consume These Legal, Illegal, and Psychiatric Drugs Are Essentially the Same.

Let’s begin this theory by using nicotine as an example and by taking a close look at an impressive study in the scientific literature (see HERE).

smoking 5Our body, upon beginning the habit of consuming nicotine, at first fires its receptors more frequently than usual upon each exposure to this drug. This leads to feeling more alert, which some of us experience as rather pleasant. But your body recognizes that if you were to keep firing those receptors at the pace that occurs when you first start smoking, certain functions in your body will end up exhausted. Thus, your body starts to reduce the number of these receptors. In the scientific literature, this process is called “down regulation” or “tolerance.”

For smokers, we see evidence of tolerance in studies that indicate fewer responses than do non-smokers to the same amount of nicotine (Perkins et al. 2001b). More specifically, we see a reduction on measures of subjective stimulation that may be viewed as pleasurable, such as arousal, vigor, and a subjective experience often referred to as “head rush” or “buzz.”

Once the down regulation process is complete, you end up with enough receptors to function fairly well as long as you continue to consume using this drug. withdrawal 2However, shortly after you pause from smoking even for a few minutes, you end up not having enough of these receptors to do what they were originally designed to do. It is this shortage of receptors that occurs when there is not enough nicotine in your system to keep your receptors firing at a rate that would typically occur if you were not regularly consuming the drug that leads to the uncomfortable, sluggish, stressful feelings that lead to a craving for the next cigarette. When you light up, you feel relief because now the reduced amount of receptors are sufficient to carry out your major life functions in a less distressed manner.

The relief that smokers feel each time they give themselves another dose of nicotine creates the powerful illusion that cigarettes help them to deal with stress. Thus, in a study published in the American Psychologist, researchers found the following:

smokingSmokers often report that cigarettes help relieve feelings of stress. However, the stress levels of adult smokers are slightly higher than those of nonsmokers, adolescent smokers report increasing levels of stress as they develop regular patterns of smoking, and smoking cessation leads to reduced stress. Far from acting as an aid for mood control, nicotine dependency seems to exacerbate stress. This is confirmed in the daily mood patterns described by smokers, with normal moods during smoking and worsening moods between cigarettes. Thus, the apparent relaxant effect of smoking only reflects the reversal of the tension and irritability that develop during nicotine depletion. Dependent smokers need nicotine to remain feeling normal. The message that tobacco use does not alleviate stress but actually increases it needs to be far more widely known.

drug withdrwal 1Theoretically, this same process is largely the reason why people become addicted to other substances, such as alcohol, caffeine, illegal drugs, and even the drugs that psychiatrists prescribe, such as the so called antianxiety drugs (anxiolytics), antidepressants, and ADHD stimulants such as Ritalin. They all have the potential of creating for addicted people the illusion that they are functioning better than they did before they started consuming the addictive drug.

Another major part of the addiction process is that the addictive substance often is used as part of a ceremony creating a very pleasant experience. As an example of this, listen to the actor John Cusack explaining his smoking habit:

John Cusack

John Cusack

To me, cigars are a much better situation than cigarettes. Cigarettes are compulsive and cigars are kinda, languid, luminous conversation. Like you’re gonna sit for a couple of hours and talk to somebody. If you gotta smoke, I would say, at least have a long conversation with someone you like, rather than just compulsively sucking down a cigarette. That’s how I’m gonna lie to myself so I can keep smoking cigars.

Although the cigarette habit is not John’s cup of tea, many people have fond associations of sharing a cigarette with others, and drinkers have associations of some very good times hanging out with their buddies. Of course, others have very negative associations with an addictive substance.

Can it be that the same two mechanisms–reduced receptors and pleasant ceremony– that creates the illusion for nicotine users are similar for other drugs that are the other legal, illegal, and psychiatric drugs?
Clearly, regular users of alcohol go through a withdrawal reaction when they don’t get a drink around the time they usually imbibe. We get a delightful sense of this listening to Jimmy Buffet singing about it being five o’clock somewhere and his desire for the relief he needs by taking a swig of his favorite intoxicating drink.

How intense the need can become is powerfully brought home to us during Ray Milland’s Academy Award winning portrayal of Mr. Birnam, an alcoholic in the movie, “The Lost Weekend.”

Ray“Just give me a drink,” says Mr. Birnam with exquisite anguish.
The bartender, in a disbelieving voice: “Mr. Birnam, this is the morning!”
“That’s when you need it most, in the morning,” Mr. Birnam replies with disgust. “Haven’t you learned that yet! At night, it’s a drink, in the morning, it’s medicine!”

Like nicotine, regular consumers of alcohol get a pleasant relief from the sensation of drug withdrawal reactions, and it is often associated with particularly good times.

Often, it is a combination of these drugs that work together to create the illusion that they are a type of “medicine,” relieving stress and feeling an improved sense of being.

Consider Jerry Irby who tells us in his song, One Cup of Coffee and a Cigarette:

IrbyHotlineNow when I get up in the morning
And I’m feeling mighty low
There’s just one thing that will pep me up
And I want you all to know.
Well it happens every morning
No matter where I’m at
I just gotta have a cup of coffee
And a cigarette
Coffee, coffee,
And a Cigarette
Is a habit
That you can’t forget…
There is no doubt that each of the legal, illegal. and psychiatric drugs have powerful withdrawal actions that is relieved when one once again consumes them. The ceremony that medical doctors use to encourage their patients to use psychiatric drugs involves a highly respected professional describing a process in which people often report feeling better as a result of consuming their prescription.

With so called “antidepressants” the withdrawal reaction is referred to as “Antidepressant Discontinuation Syndrome.” It causes a variety of symptoms like nausea, insomnia, fatigue and achiness. Interestingly, prescribing doctors of these drugs, when the patient reports not being helped by the first prescribed drug, often will prescribe others, and even a cocktail of others until the patient reports improvement. During this time the patient might have improved without the drug but attribute feeling better to the drug.

Different people find some drugs pleasant when they first try them while others are not. I know someone, for example, who loves his cigarettes but doesn’t like how marijuana makes him feel. The process that doctors use when trying different prescriptions until one is found that the user happens to feel better on serves this illusion creating process perfectly.

Support for the theory I am putting forth comes from several studies.

People Who Get Over Depression Without “Antidepressants” Do Better Than Those Who Had Taken Them

A recent publication in the journal American Psychologist by Professor Steven Hollon neatly summarizes what I am referring to.

Depression is an inherently temporal phenomenon. Any given episode tends to remit spontaneously even in the absence of treatment but recurrence is common (at least among people seeking treatment). There is reason to believe that depression may be an evolved adaptation (like pain or anxiety) that increases reproductive fitness (the likelihood that one’s gene line will pass on). If so, then any treatment that facilitates the functions that depression evolved to serve is likely to be preferred to one that only anesthetizes the distress.  

After this opening statement, Prof. Hollon provides a more complete description of his theory:

Depression is an adaptation that evolved because it keeps organisms focused on (ruminating about) complex social issues until they can be resolved and that medications work not so much by addressing a nonexistent deficit in neurotransmitters in the synapse as by perturbing underlying regulatory mechanisms to the point that they reassert homeostatic control over those systems. If the latter is true then medications may work to suppress symptoms in a manner that leaves the underlying episode unaddressed and patients at elevated risk of relapse whenever they are taken away. 

So, I hope you will consider this theory of the illusion regarding how helpful these drugs are and please feel free to express your reactions in the comment section below.

My Best,
Jeff
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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional intelligence. To begin at the very first post you can click HERE.
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Antidepressants effectiveness conflict resolution Harmful effects of antidepressants

Do Antidepressants Worsen Depression?

Pills and capsules macro

Welcome to From Insults to Respect. Regular readers know that from time to time I address concerns about the use of antidepressants in our society. Well, as I was thinking about what to write about this week’s post, I learned of a new meta-analysis that was published in the medical journal Lancet that appears to support the claim that antidepressants are effective, at least in short-term studies.

Although well thought out critiques of this analysis soon appeared, the power of the pharmaceutical industry’s media promotion apparatus will lead to the public hearing far more readily a simplified version of the Lancet findings. And so, out of respect for the public’s right to make informed choices, I have decided to provide my readers the link to one of the most thorough and readable critiques (see HERE).

Robert Whitaker

It’s written by Robert Whitaker, a medical writer who started out as a Knight Science Journalism fellow at MIT. Following that, he became director of publications at Harvard Medical School. His most recent book is Anatomy of an Epidemic.

In addition to providing the link to Whitaker’s critique, below I provide a brief summary of his critique’s main objections to the conclusions of the Lancet article. As you will see, there exists substantial evidence that rather than improving outcomes for people dealing with the challenging experiences of depression, antidepressants actually tend to worsen outcomes. The studies I refer to below are fully referenced in Whitaker’s article.

A Brief Summary of Robert Whitaker’s Critique

Whitaker tells us that the Lancet analysis relies on random control trials (RCT) that compared depressed patients taking a placebo with those taking the antidepressants over a mere eight weeks. After eight weeks, symptom reduction, as measured in this study, did favor those in the groups that took the real drug. Should that be the whole story?

Whitaker rightly points out that RCTs are fraught with problems. Most of the studies are industry-funded, thus investigator bias is a worry. The placebo group is composed of patients who have been abruptly withdrawn from antidepressants that they had been taking before the trials got underway, which isn’t a true placebo group at all. Rather, they are a special group of depressed individuals likely to be suffering withdrawal reactions.

Upon looking at the risks versus benefits from this symptom-reduction data, Whitaker tells us that even if we assume that the results are accurate, then:

“12% of patients will benefit from the treatment, while the remaining 88% will suffer the adverse effects of treatment without any additional therapeutic benefit beyond placebo. Those are the odds that a person contemplating taking an antidepressant drug might want to know.”

Whitaker goes on from here to point out that the RCT studies use eligibility criteria to select participants most likely to respond well to the drug. Only about 10% to 30% of real-world depressed patients meet these criteria. Do real world patients respond differently?

In one study that looked at this, only 19% had responded to the treatment at three months, which was one-third the response rate recorded in RCTs. In another study known as the STAR*D trial, this one hailed as the largest antidepressant study, patients who didn’t respond to a first round of treatment could then have a second round with a different antidepressant, and so on through four courses of treatment. The idea was that eventually a treatment would be found that would work. Yet, even with this design, the short-term findings indicated only 38% of the 4041 patients reached meaningful improvement as defined by the researchers.

Whitaker’s conclusion about the effects of antidepressants as determined from the two major short-term studies on real world patients follows:

“Are they better than “natural recovery” rates over the short term? I am not sure there is a good answer to that question in the research literature, but what can be concluded from these two studies is that there is a lack of evidence that antidepressants are effective in the majority of real-world patients, even over the short term. They “work” in only a minority of patients, and it may be that they don’t provide any benefit over natural recovery rates at the end of 6 to 12 weeks.

As interesting as these studies are, it is perhaps even more important to look at the effectiveness of these types of drugs beyond 12 weeks. After all, the goal for people who are depressed is to get well and stay well. In research terms, patients want to experience a “sustained remission.” Whitaker’s critique extensively reviews the studies bearing on this, and the results are troubling.

In one study with real-world patients, 13% were in remission at the end of the year, but only 5% had a “sustained remission” during the year. The outcomes in this study, according to John Rush, the lead researcher in the study, “reveal remarkably low response and remission rates.”

The documented stay-well rate in the STAR*D trial was even worse. At the end of one year, only 108 of the 4041 patients (3%) had remitted and stayed well and in the trial. All of the others had either failed to remit, relapsed, or dropped out of the study.

A Minnesota report on the real-world outcomes of 260,000 patients treated for depression from 2010 to 2013 found similarly low remission rates. At the end of each year, only about 5% of the patients were in remission. Another 10 percent or so were still considered responders to antidepressant treatment.

How does this compare to people who are depressed but don’t take antidepressants? Whitaker describes the following study that seeks to answer this question:

In 2006, Michael Posternak, a psychiatrist at Brown University, studied the one-year remission rate for unmedicated patients. To do his research, he identified 84 patients enrolled in an NIMH study who, after recovering from an initial bout of depression, subsequently relapsed but then did not go back on an antidepressant. He tracked their remission rate over time: 23% percent had recovered by the end of the first month; 67 percent at the end of six months; and 85% at the end of one year.

Posternak summed up his results in this way: “If as many as 85% of depressed individuals who go without somatic treatment spontaneously recover within one year, it would be extremely difficult for any intervention to demonstrate a superior result to this.”

These results are quite startling. In the Minnesota study, only 5% of those taking antidepressants were viewed as recovered at the end of one year while in the Pasternak study 85% of those not taking an antidepressant recovered in the same time period. Although definitive conclusions can not be made from just two such studies, the findings do raise the question, do these types of drugs worsen outcomes for people dealing with depression experiences?

Exploring this issue further, Whitaker takes a close look at the few longer term studies that used real world patients. He tells us:.

  • In a retrospective study of the 10-year outcomes of 222 people who had suffered a first episode of depression, Dutch researchers reported that 76% of those not treated with an antidepressant recovered and never relapsed, versus 50% of those initially prescribed an antidepressant.
  • In a Canadian study that charted outcomes for 9,508 depressed patients for five years, those taking antidepressants were depressed on average 19 weeks per year, versus 11 weeks for those not taking antidepressants.
  • In a World Health Organization study designed to assess the merits of screening for depression, which was conducted in 15 cities around the world, the patients who were diagnosed by their GPs and treated with an antidepressant were twice as likely to be depressed at the end of one year as those who weren’t diagnosed and treated, even though their baseline depression scores were nearly the same.
  • This WHO study also provided some insight into the effectiveness of antidepressants—or their lack of effectiveness—over time. At the end of three months, the patients treated with medications had improved slightly more than the unmedicated group, but after that time they stopped getting better, while the unmedicated group continued to improve throughout the year.
  • In a study of 1,281 people who went on short-term disability in Canada due to depression, 19% of those who took an antidepressant failed to return to work and went on long-term disability, compared to 9% of those who didn’t fill a prescription.
  • An NIMH-funded study assessed the six-year “naturalistic” outcomes of 547 people who suffered a bout of depression, and found that those who were treated for the illness were three times more likely than the untreated group to suffer a “cessation” of their principal social role, and nearly seven times more likely to become incapacitated.
  • The burden of depression in developed countries around the world has dramatically increased since Prozac arrived on the market in 1987.  A 2015 study found that the economic burden from depression in the United States increased from $83 billion in 2000 to $210 billion in 2010.
  • There has been a dramatic increase in the number of people on disability due to mood disorders in developed countries during the Prozac era, with this increase happening in lockstep with the increased prescribing of antidepressants.

Whitaker concludes with these words:

I think it is fair to conclude, based on this data, that antidepressants, as they are used now, can’t be said to “work” for society. Instead, they can be said to cause significant societal harm.

Now, I hasten to point out that for people experiencing depression, their choices are not merely either taking an antidepressant, a placebo, or no treatment at all. Many people report great help from psychotherapy and counseling, although the cost can be unrealistic for many. With regard to learning how to positively deal with the emotional pain that is a central feature of the depression experience, there are several effective approaches that don’t cost any money, such as sensory focus, expressive writing, and meditation. I describe these approaches HERE. Exercise such as walking, yoga, etc, have not only been found in scientific studies to be helpful, but enhance other health outcomes as well.

One of the most frustrating aspects of taking drugs like antidepressants, is that the prescribing doctors often don’t explain how difficult it is for many people, once they begin taking them, to come off them. People can experience severe withdrawal effects that can last for months. Learning how to safely ween off of them can be a challenge. Just stopping them, cold turkey, has the potential to be dangerous for some. There are people, however, who can help you through this challenging experience (see HERE for recommendations).

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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional and social intelligence. To begin at the very first post you can click HERE.