Antidepressants ~ chemical intervention or placebo?
The chemical imbalance theory of depression came about by accident; a serendipitous discovery in the search for drugs to treat completely different disorders. How reliable is this theory of depression, and is this really what antidepressant medications are affecting?
The accidental birth of a billion dollar industry
In 1952, scientists isolated a drug called reserpine from the dried Indian snakeroot plant (which had been used for centuries in India for the treatment of fever and snakebites). It was found to reduce levels of the monoamines in the body (serotonin, dopamine and noradrenalin) and to be pretty good at controlling high blood pressure – the only problem was that it had a tendency to make people sad.
In the same year, researchers noted that a drug given to patients for TB increased the levels of monoamines in the body and made people “inappropriately happy”.
Following this, a hypothesis was formed that depression is therefore due to decreased levels of neural monoamines; particularly serotonin. In the 60 years that followed, the idea that a chemical imbalance causes depression has been repeated like a mantra by public health authorities and become ingrained in popular culture. Pharmaceutical corporations have spent billions of dollars on researching, marketing and advertising medications that promise to cure depression by increasing neural serotonin: but are they selling us a false narrative?
Post hoc, ergo propter hoc: After it, therefore because of it
The immediate and glaring problem with the assumption underlying the development of antidepressants is that of logic: it operates on ex juvantibus reasoning (whereby an inference is made about disease causation from an observed response of the disease to a treatment): just as headaches are not caused by a lack of aspirin, the efficacy of serotonergic drugs is not in itself proof that depression is caused by a lack of serotonin.
The insidious jump was made from an association with increased positive mood, to an inference of causation of increased positive mood. These two relations are in no way the same: we cannot infer causation from correlation.
More to medication than chemicals
The chemical content of antidepressants is not their only potentially relevant variable, for they are also in themselves placebos: many people are prescribed them under the promise that they will improve their symptoms: prescribing physicians say so, the media says so, pop psychology says so… Is simply believing you are taking something which will make you happier enough to make you happier? Is this what pharmaceutical companies are actually selling us?
Kirsch et al (2002) suggest that this may be the case. They found, through analysis of all antidepressant clinical trials submitted to the FDA for approval, that the antidepressant response was matched by 80% of the placebos used. Similarly, Turner et al (2008) reviewed all published literature concerning 12 antidepressants from 1987 to 2004 and showed a 94% success rate, but in the withheld literature there was below 50% success.
Combined, all studies showed 51% efficacy; only 1% above chance, and only 2 points above placebo. There seems to be a publishing bias in which the studies that conform to the predictions of the chemical imbalance theory are most likely to be published: but what we see in journals may not be the full story.
So, the fact that ‘traditional’ antidepressants act to increase levels of serotonin in the brain may just be an accidental property, epiphenomenal to their placebo function. This is supported by several other findings:
The latency of their chemical effects to be translated into increased positive mood (average 6 weeks): surely if depression was due to not having enough neural serotonin, we would all be happier as soon as we took an antidepressant pill, as they increase serotonin levels within minutes.
They are not universally effective: if a chemical imbalance was the true proximal cause of depression, we would expect antidepressant efficacy to be higher than chance, which it doesn’t seem to be.
Spontaneous remission (improvement of a condition without intervention) occurs in many diseases, including depression: how do we know that any improvements we see after antidepressant administration aren’t a result of this?
Tianeptine, which actually reduces available neural serotonin, is clinically efficacious in the treatment of depression, with few side-effects (even alleviating comorbid anxiety without sedation). Based on the pharmaceutical industry’s story about depression, this drug should actually accentuate depressive symptoms.
St. John’s Wort, a herbal intervention, has performed as well as or even better than antidepressants in randomised controlled studies.
CBT: Butler et al (2006) summarised recent meta-analysis literature, demonstrating that CBT efficacy is moderately superior to that of antidepressants for the treatment of depression. Dimidjian (2006) further found that the behavioural activation component of CBT alone is as effective as antidepressant medication. CBT and antidepressants are associated with similar rates of recovery, but evidence suggests that CBT has far fewer cases of relapse.
Group therapy: Leff (2000) found that, for people with depression living with a ‘critical partner’, couples therapy is ‘more acceptable’ than antidepressant drugs and is at least as efficacious if not more so, both in treatment and maintenance phases, and is no more expensive overall.
Mindfulness: Kuyken et al (2008) found mindfulness to be as effective as antidepressants in preventing relapse of depression, and more effective in improving quality of life. It was also proved to be as cost-effective in helping to stay well in the long term.
Taken together, this evidence seems to suggest that, not only are antidepressants not as effective as the pharmaceutical industry would have us believe, but they may even be less effective than non-pharmaceutical interventions. Their chemical content may be secondary to the placebo effects of the industry constructed around them, which tells us that taking certain pills will make us happier. Perhaps that’s all we ever needed to hear.
The House Partnership, 3rd April 2016
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Journalist Phillip Weiss, editor of Mondoweiss, discusses the pressures in modern marriage, especially to do with sex. And how most most studies show, in the US at least, that 25% of married men are unfaithful, and 15% of women.
Steve Hayes, the main force behind Acceptance and Commitment Therapy, is himself a panic attack sufferer in recovery. Panic responds very well to behavioural therapies such as CBT, especially when combined with mindfulness approaches.
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"My pick for the single most effective treatment for managing stress is actually quite a simple one . . . change your thinking style." From Mike Evans, Professor of Family Medicine & Public Health, University of Toronto.
Elizabeth Gilbert-author of Eat, Pray, Love-talks about Schopenhauer's theory about intimacy and relationships and why people are like porcupines. Relationship counselling provides a safe space in which to work through difficulties together.
New psychology research has used brain scans, EEG, and measured antibody production, to reveal the biological processes that underlie the positive changes that people experience after practicing mindfulness meditation as part of psychological therapy.
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Steve Blacknell, 55, used to sneak into the kitchen in the middle of the night to eat in secret. He has been recovering from bulimia for 20 years. At The House, our therapists and counsellors are experienced in helping people overcome issues with food and eating.
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Schema therapy is an integrated psychological therapy, combining elements from a variety of therapies including CBT Cognitive Behavioural Therapy. It aims to challenge and correct some of the deepest maladaptive beliefs that we hold about ourselves and the world.
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By tackling the way we think about ourselves, our bodies, and food, and using this to inform changes in our eating behaviours, CBT provides a powerful method for breaking free from the powerful grip of anxiety, guilt and shame that can control our relationship with food.
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In the current economic climate - when job security is at an all time low - many people are finding that their best course of action when ill is going to work anyway... but what are the costs not only to the economy, but more importantly to our wellbeing?
A man's problems with his wife keep him awake during a whole night. An animation about insomnia, by Marie-Margaux Tsakiri-Scanatovits, promoting the short story 'Night Thoughts' by Helen Simpson, for Granta magazine's issue on feminism.
CBT is an active, collaborative, solution-focussed form of therapy combining techniques that help us to confront and correct biases and problems in the ways we think and feel; leading us to independently pursue a more fulfilling and successful life.
This powerful film by documentary filmmaker Martin Hampton introduces us to the lives of four people struggling with compulsive hoarding; each vignette more uncomfortable that the last.
Levni Yilmazis is an independent film-maker, artist and publisher. In this short animation he provides a wry how-to guide for breaking up . . . in 64 easy steps!
Social anxiety has been part of Jo's life since childhood. In this painful story she describes its pernicious effect and the vicious cycle between feelings of anxiety and sadness. But the story has a happy ending as Jo eventually discovers therapy.
Stress, at an appropriate level and duration, can be a positive influence in the workplace. However, when stressful influences are poorly managed, they can cause us to feel like we are 'treading water'. How can we use workplace pressure to our advantage?
Professor Mark Williams, co-developer of Mindfulness-Based Cognitive Therapy, and research fellow at Oxford University, discusses the science behind why mindfulness works, in calming stress and preventing depression from recurring.
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This film by the charity OCD-UK offers insight into the problems that people with OCD face, and how they experience the condition. OCD responds very well to a combination of CBT cognitive behavioral and mindfulness therapies.
CBT has been consistently shown to aid recovery from OCD in over three quarters of people who undertake it by encouraging them to change the way they think through 'cognitive restructuring', and use this to change the way they behave through 'cognitive management'.
A short video from animator Kelly Bailey on what it's like to live with panic and agoraphobia, containing recorded testimony of real people who have struggled with and overcome these fears.
The focus of mindfulness-based therapy is upon recognising and accepting each moment in the present instead of jumping to hasty and often damaging reactions. This is proving to be greatly beneficial to improving our relationships with others.
Professor Paul Salkovskis, a clinical psychologist and director of the Centre for Anxiety Disorders and Trauma, discusses Cognitive Behavioural Therapy for Obsessive Compulsive Disorder. And Karen reveals how this form of therapy helped her overcome OCD.
Sleep brings a range of benefits to our minds, physical health, and well-being, and insomnia can be extremely disruptive to our lives and functioning. Insomnia and long term, chronic sleeplessness, can be extremely disruptive to our lives and functioning, so what can we do to tackle it?
Depression is three times more common following a heart attack: as many as one in three survivors qualify for a diagnosis of major depressive disorder. Research is beginning to reveal which parts of CBT Cognitive Behavioural Therapy CBT may be most helpful to these patients.
Cutural and religious rituals and many of the behaviours of Obsessive Compulsive Disorder (OCD) show striking similarities: washing, checking, repetition... is OCD a manifestation of a deep human need that has spun out of control?
Kadam Morten Clausen, resident teacher at the Kadampa Meditation Centre in New York, discusses how stress is all about our perceptions of others and of the world. Mindfulness practices, as encouraged at The House Partnership, can help you find a path to a life free of stress.
Iain and Susan are struggling to work out why their sex life has ground to a halt. A short promotional film for the BBC animated documentary: Wonderland: The Trouble With Love and Sex.
Levni Yilmazis is an independent film-maker, artist and publisher. This is his ironic take on the less-than-helpful advice some people give when you're experiencing depression.
Though it has been proposed that food issues such as extreme dieting, anorexia and bulimia are on the rise and influenced by media pressures, analysis of texts about and by many of history's key figures suggests that these problems have been around for centuries.
A clip from the BBC's Weird Nature series showing how Vervet Monkeys in the Caribbean have taken to stealing cocktails from people on the beach. Studies show that they have the same percentage of teetotal and alcoholic individuals as the human population.
