Skepticism

A Guide to Responsible Critiques of Antidepressants

Antidepressants are not cure alls. Duh. They are not perfect. Also duh. They have side effects. The duh-est of the duh.

So why is it that when anyone starts telling another person not to take anti-depressants everyone gets all huffy and says they should fuck off? People are just trying to be helpful and warn them of the evils of anti-depressants, right?

You may be catching some sarcasm here. Good job for picking up on that. Recently, Greta Christina has written a series of great posts about why it’s really and truly obnoxious to tell people that they shouldn’t be taking antidepressants because OMG IT WILL TOTALLY CHANGE YOUR PERSONALITY AND TURN YOU INTO A ZOMBIE.If you have some inexplicable urge to give unsolicited medical advice to random people, then please go read all of her posts right now.

But there is a flip side to the question of antidepressants, which is that they really aren’t perfect and we really should be having a scientifically driven conversation about their benefits and their costs. Many people who have taken antidepressants want to be able to have this conversation, but due to the stigma don’t like to openly discuss their medications, the side effects, and the efficacy. Many doctors who want to support those with mental illness are also hesitant to speak out about potential problems with medications for fear that their words might be misinterpreted as part of the fear-mongering around medicating for mental illness.

So I’m going to throw out some ground rules for what a responsible conversation or critique of antidepressants might look like. None of these are hard and fast, but if we want to have a productive conversation, these might be a good place to start.

The Participants

Everyone is of course entitled to their opinion, but these are guidelines for a conversation that might actually get us somewhere and provide insight. To that end, I’d suggest that the most useful participants for a conversation about medication would be those who have actually taken medications and have firsthand experience of it, and those who study medication/prescribe medication. Potentially those who have considered medication and chosen other routes, or close family/friends of those who took medication could also provide new insights. This is a discussion that should probably be undertaken by those who are actually affected by it. If you really feel the need to have a debate about it and it doesn’t have any bearing on your life, do the rest of us a favor and have that debate in the privacy of your own home.

The Topic and the Style

Again, none of this is to say that no one else is allowed to comment on antidepressants, but I’m going to be perfectly honest here: as someone who has taken 3 different types of antidepressants in the last year alone, I have heard everything that the lay person might have to tell me. I have experienced most of it firsthand as well. I’ve had enough people give me their Very Important Opinion about my medication.If you do find yourself in this kind of a conversation, assume that most of what you know, the person who has a mental illness already knows. If you are worried they’re not taking study x or opinion y into consideration, phrase it as a reminder rather than REALLY IMPORTANT NEW THOUGHTS.

If you do have some hitherto undiscovered piece of information, please don’t shove it in anyone’s face or use it as evidence that THIS PERSON needs to stop taking meds or THAT PERSON really needs to get on them. Present it generally. As Greta has made clear, a person’s mental health is personal and complex. You don’t know what their situation is, and it’s extremely vain to assume that you know the best course of action for someone else to take. The best you can do is present your information and hope that others use that information to make good choices for themselves and others.

Similarly, there are important things to talk about that rightly belong in critiques of medications. Studies of the efficacy or side effects of medications, personal stories about the experience of being on or getting off medication, and stories from doctors who have witnessed a variety of patients reacting to medications are all extremely important to getting a well rounded picture of what medications actually do. All of these perspectives are important because they provide different types of insight. As an example, when I started on my most recent medication (Effexor), I discussed it with my doctor and read the side effects, then felt comfortable to begin taking it. However after missing my dose one day and experiencing some really terrible side effects I did a little Googling and found personal accounts from MANY others who had taken Effexor and found it to be nearly impossible to get off of (inducing such delightful things as hallucinations, dizziness, light headedness, nausea, lack of appetite, extreme anxiety, sensitivity to light and noise, muscle weakness and exhaustion). If I had spoken to others who took the medication, I might have known that Effexor is essentially satan in pill form (no offense to those for whom Effexor has worked). Critiques are clearly important.

The important thing about these critiques is that they should be based either in science or firsthand experience. “I read one time that a doctor said drugs are evil” does not count. It’s also important to remember that offhand comments about “it changes who you are” or other pseudophilosophical bullshit when you haven’t actually been through the experience of being on medications or living closely with someone who is on them is utterly uninformed and unhelpful. Honest and thoughtful opinions on what makes up your essential self and whether that might be altered by medications in a way unlike anything else you ever experience that are backed up with firsthand accounts and science are something completely different.

The general takeaway here is please, if you’re trying to critique antidepressants, don’t do so by preaching. Do so by pointing out specific things backed up with evidence that could cause problems for those who take antidepressants.

The Conclusions

Perhaps most important when we’re criticizing something that has actually saved lives is to remember to be a little bit humble. At this point we don’t have a clear understanding of the brain or how we can affect it. Nearly all of our conclusions are preliminary. The criticisms we do have mostly rest on “we’re not sure but this could turn out to be a big problem”. It’s good to bring up potential problems, but remember that at this point that’s what they are: potential.

We should be skeptical of new medications and new ways of treating mental illness, but our skepticism shouldn’t come at the cost of the health of those who actually are mentally ill. Helping and respecting them should guide our discussions around mental illness and medication.

Olivia

Olivia is a giant pile of nerd who tends to freak out about linguistic prescriptivism, gender roles, and discrimination against the mentally ill. By day she writes things for the Autism Society of Minnesota, and by night she writes things everywhere else. Check out her ongoing screeds against jerkbrains at www.taikonenfea.wordpress.com

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27 Comments

  1. Many of the pop opinions on mood disorders and antidepressants come down to the simple idea that people who are depressed or manic or anxious or whatever need to just SNAP OUT OF IT! I think that’s the most damaging and patronizing aspect of it all. Why is it that if the very nature of a mood disorder is that one is unable to maintain their mood, and yet people are treated like garbage for the very fact that they are unable to maintain control over their moods? We’re learning more with every year that the brain is a complex organ and much of its function goes beyond our active consciousness and immediate control. I can’t wait for the day, if it comes, when we have a clear picture of precisely what happens in the brain’s neurology when a person is suffering from a mood disorder. More objective tests will take a lot of power from the hands of people who simply tell you, “It’s all in your head!” and expect that to help.

  2. I have taken numerous antidepressants. They didn’t work for me. At best, they did the zombie thing to me – no lows, but no highs either, and basically no emotion in my life.

    Turns out this is because I’m not depressed. I have extremely long-cycling bipolar (the cycle typically takes 9-12 months). Getting onto a bipolar med resolved the zombie problem.

    It was my experience that I needed to find a psychiatrist who was willing and able to try many different meds and combinations of meds. A general practitioner just wanted to write a script for Paxil or Prozac and then throw up his hands and give up when neither of those did anything for me. A psychiatrist wanted to put me on Zoloft, and whenever I came back to say that Zoloft was just sucking all of the life out of my life, his answer was more Zoloft. Finally I found a psychiatrist who was willing to mix-and-match meds, and had enough expertise and experience to do this safely, and it was only when he put me onto a bipolar drug that something other than bleeeeeeeeeeeh was produced. My bipolar evaded diagnosis for so, so, so long and it was horrible.

    I’m now on Seroquel, which is essentially addicting. It’s not narcotic-addicting – there’s no high – but it will be extremely difficult if not impossible for me to get off of it. One symptom of withdrawal, which kicks in with as little as one missed dose, is that sleep becomes physically painful. I don’t know how to describe it other than “it hurts, physically, to try to go to sleep” even though I know that sounds like an impossible thing.

    But I’m okay with the addiction. I can say with confidence that this is much better than the alternative. I have mentioned this to people and they are horrified, like, how can I live my life knowing that I am addicted to a drug (and not even a drug that gets me high lol), and don’t understand how completely okay I am with this situation.

    1. Hi, skeith. I’m a pharmacist who has worked in addiction treatment for a while now, and I just wanted to mention that you’re not addicted to Seroquel. Addiction is the continued use of a substance despite adverse physical, psychological or social consequences. Unless you are doing what some of my patients do, and crush Seroquel and snort it to get high, you are using a drug that you need for a medical condition, ergo you are not addicted, even if you have physical tolerance and will suffer consequences if you stop the drug abruptly.

      Perhaps this is a tiny distinction, but I like to clarify because I have encountered people who unnecessarily suffer because they fear being “addicted.”

      And yeah; antidepressants can sometimes make bipolar disorder worse.

  3. Robert Sapolsky made a really good come-back to the “snap out of it” gambit: you would never say to a type-I diabetic that they need to “snap out of it” and stop under-producing insulin, so it makes no sense to say it to someone with e. g. depression (even though depression is obviously more multifactorial than just about brain chemistry).

    1. I actually don’t like that analogy myself because things like blood sugar and insulin levels can be objectively measured. Anyone can accept that the pancreas is all there is, whereas it makes people feel nervous and icky to think that there is nothing to them beyond their brain function. Having a religious frame of mind makes it harder to accept that latter point. Look at what happens when people have traumatic brain injuries or slip into vegetative states… unskeptically-minded people are convinced that there is some measure of “them” still left in there somewhere that’s locked away, even if they do accept that that person will never outwardly be the same again. I think these two ideas stem from an overall societal fear of not being in total control of what makes us US.

    2. Not so long ago, a very good friend of mine broke up with her boyfriend and was very sad. Her doctor put her on anti-depressants. I have no opinion on whether that was the right call or not; she didn’t have depression but she was having trouble functioning at work and such. Still, what she needed was to “snap out of it”; and eventually she did.

      When I was young, my best friend became very sad. Her life sort of fell apart in a way that really only seems to happen in high school; a break up, fake and mean ‘friends’, etc. What she needed was ‘real’ friends and support from her family. What she got was anti-depressants. She spent the last couple of years in high school in zombie mode. It took her a long time to learn to build a life that made her happy, rather than take a pill and pretend she was.

      On the other hand, several members of my family and several close friends suffer from depression and genuinely need anti-depressants.

      Too often anti-depressants are used as a crutch not for the people who need one – but for doctors, parents and friends who would rather offer a pill then work to address real issues. To borrow from the analogy below, it’s like strapping someone into a wheelchair when what they really need is help learning to walk. It’s much easier, but it does more harm in the long run. That’s not to say that anti-depressants, like wheel chairs, aren’t necessary. For those who need them, they’re a god-send*. But frankly I find it difficult to believe a GP who spends 20 minutes with someone every 6 months is qualified to know what’s really needed. We need far better mental health support systems than we have.

      *Blessing? Miracle? For some reason I’m finding it impossible to think of secular ways of expressing this. Being an atheist in a christian culture is weird.

      1. Psychologists definitely do differentiate between different forms of depression. Major depressive disorder and adjustment disorder/situational depression are considered separate maladies and the treatment courses for both are very different. (I do take issue with your description of those people in your anecdote as having “snapped out of it.” Recovery from a depressive episode is often incremental.)

        Unfortunately, I think access to mental healthcare, at least in the United States, is extremely lacking, even when compared to basic general healthcare. Psychotherapy is expensive and takes time and marked commitment. Are doctors just being lazy by prescribing medications? I don’t currently have data on this so I can’t really make any kind of qualified statement… but maybe GPs are doing the best they can in a system where access to regular psychotherapy is not an easy option.

  4. While I’ll recommend antidepressants because they’ve helped me (somewhat), I’ll readily concede they’re not for everyone. Antidepressants aren’t “happy pills”; they’ll make you calmer and more energetic, which can be a bad thing for people with suicidal tendencies or other psychological problems. Even in more-or-less stable individuals antidepressants enable a happier life, but by themselves they won’t make bad situations, bad thoughts, or bad habits go away. And yes, they have side effects which in some people — fortunately not me — are worse than the mood disorder. Also, I’ve changed meds several times because the old ones stopped working. All in all, anyone who portrays antidepressants as a cure-all OR chemical lobotomies are either selling something or scaremongering.

  5. I am a psychiatrist and take medicine for depression. When it comes getting people off of Effexor I use a low dose of Prozac for about a week. Effexor is a short acting medicine so someone is more likely to have withdrawal symptoms. This can be true for Paxil too. Prozac lasts longer in your system so the tapering out of your system takes longer and is more gradual. I have had the best result with Effexor and the fear of withdrawal makes me very compliant. I an interested in people’s experience with generics

  6. I love it how people’s go to comparison is to compare mental health drugs to a crutch. I always imagine a guy politely declining an offered crutch and then trying to remain stoic while walking on his broken leg in defiance of his doctor’s orders. “That wooden leg helper, it’s not me, man. I walk on my own two feet.”

  7. I found the side effects of antidepressants more depressing than the absence of antidepressants in my system. Namely, a near complete lack of sex drive. Fortunately aerobic exercise and adequate sleep have been effective for me.

  8. Having used a number of different antidepressants over a period of about 20 years (including today) I think I am qualified to comment. I’ve struggled with unpleasant side effects and high costs, but since a competent psychiatrist found the right drug my life has been made much better. With all deference to the primary care physicians of the world, my experience has convinced me that if they think a patient needs an antidepressant then a referral to a good psychiatrist is a great place to start. It’s a complicated subject and even the best of specialists don’t always get it right on the first try. I would agree that antidepressants have changed my personality–to one that people can stand to work with, live with, and socialize with, and one that can live and work effectively because my true personality can come out. I’m not a zombie on antidepressants, but at my worst before treatment there were times when I acted like one. If I hadn’t thought that something needed to be different I would never have sought treatment.

  9. I suffer from severe depression. I’ve been prescribed various anti-depressants over the years. In my case, they have all proved ineffective but still had side-effects: primarily weight gain and a diminished libido. Turns out that I have Bipolar Type II. The depression associated with Type II Bipolar is resistant to pharmacological interventions. Finally, I’ve been prescribed an antiseiziure that has at least lifted my mood even thought it has not helped with other symptoms. The depression is a part of my personality. It is not all or even primarily all that I am. How this recovery integrates with the rest of my personality could not be deduced from a an exhaustive scan of my brain just as how depression integrates with the rest of my personality. It is not the drugs that make me a zombie and diminishing my dignity as a human being, it is the depression. The chemistry is one thing, the effects on personality are something else.

  10. also” sertraline kinda turned me into a zombie. I spent three months floating on a little “don’t give a shit about anything” cloud; when your shit-giving is mostly negative and you have anhedonia anyway, that’s actually a vast improvement. Too bad it also lead to not giving a shit about deadlines and that after 3 months I have a huge panic attack that made the clinic take me off sertraline again.

  11. I read Goldacre’s article and the NEJM article and I am not sure what to think. The lack of negative results being published is a problem. Negative results may help figure out which patients benefit from which medication. One conclusion is that the medicine doesn’t work for mild or moderate depression, which I would disagree with. Of course, my data is based on anecdotes. I have had patients get much better with medicine and stay that way. Even if someone has mild depression not due to grief or other significant life events, it is worth trying a medicine.
    I always wondered how much medicine was helping me. I switched to Celexa which did nothing for me and I got more depressed especially in the morning and around 5 pm.
    There is so much to say about anti-depressants, I’m not sure where to start. The serotonin theory is very simplified explanation of depression. Mood is affected by many neurotransmitters and they interact with each other. The makers of Prozac were very deliberate in looking and affecting the serotonin system in making Prozac. It doesn’t just affect serotonin but also norepinephrine. Prozac was revolutionary because it had fewer side effects than older anti-depressants. the drawback of course is that it is prescribed too much in a way.
    But then seeing someone suffer so much you want to try everything and anything, to relieve that suffering.

  12. If an anti-depressant is causing low libido or no libido, sometimes adding Wellbutrin is helpful.
    Zoloft does seem to cause numbed feeling for some people. It is important for the doctor to try another anti-depressant.
    Bipolar disorder can be hard to diagnose and unfortunately, bipolar depression is difficult to treat.

  13. This is an anti-anxiety med not anti-depressant, but I have to be careful with xanax and other benzos because unlike what most people report, they do not lessen my libido — they instead make me very, very horny. Very horny. And manic.

    Ativan is better for me. I don’t risk as much of a chance of becoming really manic.

    But seriously, xanax makes me want to hump everything, and the orgasms it brings on are divine. While xanax can help me sleep, that’s only if I actually relax and go to sleep. Otherwise I just feel REALLY REALLY REALLY nice and I want to be social and hang out with people and get naked.

  14. If and only if I am asked, I will share my experience with antidepressants with a friend or acquaintance: I think they definitely helped, but I am also glad that I no longer take them. I’m fortunate, my depression was episodic, not chronic. Any kind of clinical depression is a real bear, really tough to go through, and antidepressants can help one to avoid the void.

  15. [Note: I live in Alberta, Canada]
    I think Dr.s can be to eager to prescribe anti-depressents not because they don’t care but because other forms of treatment can be hard to access. I was diagnosed with depression by a psychiatrist at a clinic for minors when I was 17, and worked with a counsellor there until I turned 18. From then on counselling was much harder to get – as a student, if your not hallucinating or suicidal Access Mental Health just refers you to the university counselling, which isn’t set up for long term support, and most insurance policies are designed for short term counselling rather than long term maintenance therapy.

  16. Great article. Important words.
    As to participants in this discussion, you said: “To that end, I’d suggest that the most useful participants for a conversation about medication would be those who have actually taken medications and have firsthand experience of it, and those who study medication/prescribe medication.”
    Can we please add other mental health professionals as well? There are tens of thousands of therapist, counselors, social workers and psychologists out there who are not able to prescribe medications, yet work with them on a daily basis.
    In the 20+ years I’ve been a psychotherapist, I’ve seen countless people saved by psychopharmacological interventions (meds). While the meds don’t always work for everyone and we clearly don’t understand why they work; but they are something. Better than nothing, which is basically what we had to offer people for thousands of years prior to the 20th century.

  17. I think part of the problem is that the diagnostic criteria for depression don’t really align with the clinical data for antidepressant response. If you can check at least five symptoms on a list, experience some impairment in life and have had these symptoms for two weeks (or two symptoms for six months for dysthymia) and have never experienced any type of mania or hypomania, you’ve got major depression. That’s a very broad category. The clinical trials would indicate that antidepressants work through the placebo effect for dysthymia and mild to moderate depression. For very severe depression, the drugs are superior to placebo. When you look at melancholic depression, particularly the response to tricyclic antidepressants, the drugs are far better than a placebo. Our current diagnostic system dumps all of those diagnostic groups into a very broad category of depression with optional qualifiers. Because most people with a depression diagnosis have not been diagnosed with very severe depression, one could quite accurately say that antidepressants are just placebos for most people who take them. On the other hand, for someone with melancholia, they can be life-saving and are far superior to a placebo.

    1. Your post is a reasonable summary of the controversies surrounding the release of the DSM-V, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. Many of the psychiatrists I work with feel that there is over-diagnosis and over-treatment, particularly with depression and ADHD. The DSM-V is useful, but in the opinion of many, it over-medicalizes the human condition. Negative human emotions don’t necessarily require a diagnosis and treatment. Sometimes we just need to be sad or angry.

  18. The problem with DSM 5 (they have done away with Roman numerals) is that there is no clear way of connecting the pathophysiology with the diagnosis. Our medical technology just isn’t good enough to really see into what each individual’s brain is doing. So DSM 5 is similar to DSM IV. That being said, they do use research and statistics to determine if the criteria of a diagnosis is valid. There has been somewhat of an uproar of including grief with depression. Grief was added as a comment to depression and basically says that just because someone is grieving doesn’t necessarily preclude depression. Sometimes grief can trigger a depressive episode. It doesn’t mean you need to medicate the patient right away. In any case, the DSM is far from perfect but it is useful for research and if a patient has depression, you have an idea of what kind of symptoms the person may have.
    Depression and ADHD are BOTH over treated and under treated. The key to medicating appropriately is being able to diagnose a patient accurately. Often patients are medicated by primary care providers and they often don’t have time to get into the nuances of a diagnosis. Sometimes a diagnosis is not that obvious so mental health practitioners miss a diagnosis

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