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I’m going to start today’s video with a little mental health pro-tip: if you are taking antidepressants or other pharmaceuticals to aid your mental health under the guidance of a doctor, absolutely do NOT stop taking them without talking to that doctor first and following their advice. I am NOT a doctor, and nothing I’m about to say should supercede what your doctor says.
Also, if you are feeling depressed or suicidal, please speak to your doctor about it. If you don’t have access to a doctor due to a lack of insurance or money, there are community-based health centers that may be able to help you on a sliding scale. Or, if you’re in the US you can get help 24/7 from the National Alliance on Mental Health by texting “NAMI” to 741741.
Okay, on to today’s topic which probably won’t surprise you: antidepressants! Do they work? And if they DO work, then why are a bunch of news outlets (and fake news outlets like the Daily Mail) reporting that a new study says they do NOT work?
All these outlets are referring to a study published last week in the open access peer-reviewed journal PLoS One titled “Antidepressants and health-related quality of life (HRQoL) for patients with depression: Analysis of the medical expenditure panel survey from the United States,” from pharmacologists at King Saud University in Saudi Arabia led by Omar A. Almohammed.
The researchers looked at an existing database of about 17.5 million Americans who were diagnosed with depression over the course of two years and then were followed for the next 11 years, some of whom were prescribed antidepressants and some of whom were not. They concluded, “The real-world effect of using antidepressant medications does not continue to improve patients’ HRQoL over time.”
“HRQoL” stands for “health-related quality of life,” which encompasses both physical and mental health. In this study, they used “SF-12,” which is a 12-question survey that users filled out themselves. The questions are things like “did your physical health prevent you from doing certain activities in the past week,” and “did your MENTAL health limit you in any way,” like did you accomplish less than you wanted? The scoring system is proprietary but you can find a free version online (link in the transcript linked below), which I took and learned that I’m doing better than the average American, which is nice, and for which, I should declare as a conflict of interest, I credit an intensive mental health improvement regimen, which includes SSRIs (an antidepressant medication). But I’ll get back to that.
So, did this study show that antidepressants don’t work? No. The best one can say about this study is that they found a good hypothesis to test – a preliminary look at existing data that might inform how researchers explore this topic in the future. But there are far too many problems to support the authors’ conclusions. Let’s look at a few of the issues I found most glaring.
To start, even the conclusion isn’t “antidepressants don’t work,” it’s “antidepressants don’t continue to improve a person’s quality of life year after year.” As someone who takes SSRIs, that’s not how I expect them to work. My pills more or less ended my severe spikes in anxiety and depression, and that’s enough for me. I don’t need every day to be happier than yesterday. I don’t expect to achieve pure enlightenment after 5, 10, or 15 years of taking these pills. It’s kind of like taking medication for a chronic, incurable physical malady – if I have diabetes, I don’t assume that taking my insulin every day will eventually cure my diabetes. It’s just a thing I have to do every day to get up to “normal.” And that’s fine! It’s better than being an anxious, suicidal mess every day.
I’ve talked openly about my anxiety and my prescription in the past, so you may already know that earlier this year I screwed up and forgot to take my SSRI for several days. I noticed because I woke up in the middle of the night panicking about the inevitable heat death of the universe. And I thought “Wow, I haven’t had an episode like this since before I started taking my SSRI! Oh crap, I forgot to take my SSRI!” In a weird way I’m glad I screwed up my meds because it was a compelling piece of evidence in favor of the idea that I still need the SSRIs because they are still actively improving my life.
(Also by the way, yes, I highly recommend putting timer caps on your meds if you’re like me and are constantly trying to remember whether or not you took them today.)
So: in my opinion, it’s perfectly fine for a medication to improve your life up to a baseline and no further.
There are also a lot of issues with this study based on the data they had available, or more accurately, the data they did NOT have. They had no idea what medications these patients were prescribed, and I don’t just mean “which SSRI are they on, Paxil or Lexapro;” I mean they don’t even know if they were SSRIs, or SNRIs like Effexor, or MAOIs like Nardil (I swear I’m not making these up), or atypical medications like Wellbutrin or Remeron. Further, they didn’t know how MUCH of these medications patients were prescribed. Minimum dose (like me)? Maximum dose? Who knows!
Even further, they had no way of knowing how well the patients stuck to the prescribed medication. Finding the right meds to help depression and anxiety is extremely difficult for a lot of people, and often patients will give up early on because they don’t like the side effects, which can include sexual dysfunction, weight fluctuations, cold sweats, and, perhaps somewhat ironically, suicidal ideation. And don’t forget, this is about Americans, who don’t have easy access to affordable healthcare and prescriptions, so finding the right medication can also be very costly. If a patient loses their job, they lose their healthcare, and can’t even afford to fill the prescription.
None of that is accounted for. Nor do they consider the 30% of patients who have treatment-resistant depression, meaning that none of those drugs will work and they have to seek out different therapies. Oh, and they also have no way to account for the severity of the depression: mild, or severe? Ongoing, or situation-specific? Zero data.
But wait, there’s more! They also couldn’t control for how long patients in their dataset had been on antidepressants prior to the start of the tracking. Take me, for example: if you start monitoring my quality of life right now and on for the next five years as I continue to take my SSRI every day, then yeah, you won’t see any improvement. Because, again, the MASSIVE improvement happened ten years ago when I first started taking it. If I had taken that SR-12 survey prior to my diagnosis and prescription, I would have failed. Like, you can’t fail a mental health survey but I would have failed. “Sorry, you failed so you have to repeat…uh, your entire adult life I guess, until you get it right.” My anxiety and depression negatively affected every aspect of my life, not just in terms of my friendships and hobbies and work but even my physical health, as it caused me severe acid reflux that made me nauseated and unable to eat and sometimes unable to get out of the fetal position from the stomach pain.
And now? I’m frigging great. Life still happens – I went through a very bad breakup 5 years ago and was horribly depressed, so I went to a psychiatrist who tried increasing my SSRI dosage. It didn’t really do anything, so we went back to the minimum and instead she prescribed me a dog, which worked very well actually. Does THAT mean my SSRI isn’t doing anything? No, it just means MORE SSRI didn’t equate to LESS depression when life got really ugly. I needed a little something extra to get me through it, and a lot of people are like that, which is why there are a lot of ways to treat depression. Drugs, support animals, talk therapy, group therapy, exercise, diet changes, electroconvulsive therapy: all of these things have their place.
Depression is a complicated disorder that differs wildly between people and can even change within a person’s life due to what’s going on around them. You can’t look at a dataset of millions of patients and say anything meaningful about how these drugs affect the average person with depression, ESPECIALLY when you don’t know how severe the patients’ depression is, what comorbidities they have, what drugs they were prescribed and in what dosage, when they were first prescribed the meds, and whether or not they filled the prescription and adhered to the program.
So no, this study in no way supports the idea that antidepressants don’t work. Personally, as someone who is extremely antagonistic towards Big Pharma and who prefers to improve my health without medication whenever possible, I’d love to see more studies that look at exactly how different antidepressants work on different people, why some people are treatment-resistant, and how we can improve access to good mental healthcare for the average person. Unfortunately, all this study does is scare the average person away from a therapy that might change their life for the better.