Do Antidepressants Work? Maybe Not.

[Zyprexa_Ho]

"89% of depressed patients are not receiving a clinically significant benefit from the antidepressants that are prescribed for them" Antidepressants and the Placebo Effect

[ixchel]

You cannot do andouble blind RCT for psychotherapy. You can do it with meds. They don't work "really well," they don't work for everybody, and many reports suggest they're equally effective regardless of the monoamines involved.

There is no chemical imbalance. It is ignorant to suggest that based on present research. Posited effects of antidepressants are "downstream" effects of neurogenesis, et al.

I prescribe them everyday with absolutely no anticipation that the patient will return in 4-8 weeks remarkably less depressed. It does happen, and that correlates with meds. I'm not at all convinced it is causative.

So...

Neurotransmitters can simply be imbalanced for schizophrenia, parkinsons, adhd, etc., but not depression? Assuming a person with a healthy and balanced life can't get depressed based on neurotransmitter imbalances is blowing my mind here. Serotonin affects so much in our bodies. How can you discount mood?

[Whispera, MSN, RN]

There's depression that's a tangled mess of neurotransmitters and there's depression that's due to a life that's full of crud. Then there's depression that's some of both.

I've had patients that have happy lives and say they have no reason to be depressed, and yet they were, sometimes so depressed they didn't eat and didn't even get out of bed willingly. Medications have worked for them. Then, when they are stable, therapy might help them to deal with what happened while they were depressed.

Patients whose lives are full of crud aren't likely to be helped by medications, because the medications alter neurotransmitters and their neurotransmitters are doing fine...they just have a life that needs fixing. Therapy is the helpful reagant for them.

Those who have a bit of both, could benefit from both therapy and medications, because we don't know where the neurotransmitter tangle leaves off and the life of crud begins.

[LadyFree28, BSN, LPN, RN]

In some cases (like mine) there isn't so much an underlying issue as there is an altered brain chemistry. Talk therapy, while nice, is not going to convince my neurotransmitters to behave and play nicely. Depression and anxiety is strongly inherited in my family - not all depressive episodes are "triggered" by an event.

Agree.

I went solely to therapy (after years of seeing a therapist and psychiatrist; the psychiatrist moved and I transitioned into another therapist that works with trauma) and lost a job; I went back to what works, and therapist and a psychiatrist for medication management-it saved my life and my career.

Not everyone who is depressed goes on SSRIs; for my depression and anxiety, I am on atypical antipsychotics; the one I am currently on helps a LOT.

Medication management is such an important part in conjunction with therapy; to add, finding the right therapy and therapist is essential as well.

[synaptic]

Yeah "chemical imbalance" is what my mom always used to say I had. Thats ok coming from somebody who isn't a medical professional, but when a medical professional is only able to describe a psychological illness as "chemical imbalance," it just screams they don't know what the F*** they are talking about and are dodging any real knowledge acquisition.

Psych guy addressed this well in a previous post.

[Farawyn]

Yeah "chemical imbalance" is what my mom always used to say I had. Thats ok coming from somebody who isn't a medical professional, but when a medical professional is only able to describe a psychological illness as "chemical imbalance," it just screams they don't know what the F*** they are talking about and are dodging any real knowledge acquisition.

Psych guy addressed this well in a previous post.

I like your mom. :)

[PG2018]

So...

Neurotransmitters can simply be imbalanced for schizophrenia, parkinsons, adhd, etc., but not depression? Assuming a person with a healthy and balanced life can't get depressed based on neurotransmitter imbalances is blowing my mind here. Serotonin affects so much in our bodies. How can you discount mood?

Who is discounting mood?

What is imbalanced in scz, PD, ADHD, et al?

If I give you chlorpromazine or something more fun like quetiapine, what scale am I balancing? This not as simple as "reduce dopamine and suppress hallucinations."

[PG2018]

There's depression that's a tangled mess of neurotransmitters and there's depression that's due to a life that's full of crud. Then there's depression that's some of both.

I've had patients that have happy lives and say they have no reason to be depressed, and yet they were, sometimes so depressed they didn't eat and didn't even get out of bed willingly. Medications have worked for them. Then, when they are stable, therapy might help them to deal with what happened while they were depressed.

Patients whose lives are full of crud aren't likely to be helped by medications, because the medications alter neurotransmitters and their neurotransmitters are doing fine...they just have a life that needs fixing. Therapy is the helpful reagant for them.

Those who have a bit of both, could benefit from both therapy and medications, because we don't know where the neurotransmitter tangle leaves off and the life of crud begins.

Stress Diathesis Model or lack of nurture alters nature.

[PG2018]

There's also a recent study claiming that "talk therapy" is not as effective as people think when publication bias is considered.

A key thing to note from your link is that those 4 antidepressants did prove to have clinically significant effect for those with the most severe depression (compared to placebo).

Then people might want to ask why then are so many people with mild/moderate depression on antidepressant. Frankly I think a chunk of people on antidepressants are prescribed by primary care providers, not specific psych-trained clinicians. They probably should've referred patients to psychotherapy before handing out pills (but many people simply aren't patient enough to follow through psychotherapy).

Those SSRIs/SNRIs also get prescribed for other reasons. Finally, the study includes only 4 (maybe 6) drugs, and I think it's a bit misleading as it implies that all antidepressants. Calling antidepressant a "myth" seems be a little unfair and might keep away those who can really benefit from these drugs.

In the study regarding publication bias, I believe psychotherapy was 25% less effective. Just noting this for others. Thanks for mentioning it.

[PG2018]

If you really want to dive in to a can of worms, look up Dr. Peter Breggin's work. Or MAD in America. It's at the very least an interesting topic.

I have observed antidepressants cause more harm than good to patients, and I have also observed antidepressants serving as a temporary rescue action to help jump start a patient again .

What bothers me the most is observing the prescribing provider switch a few medications at the same time and not follow up for six weeks. IMO, unless a patient is having severe adverse reactions necessitating a "wash out" , one med should be altered at a time and evaluated. I've witnessed way too much polypharmacy in psych .

And any change in medication should be closely monitored, at the very least by phone contact, between provider and patient. A patient can slide downhill quick .

When I worked in psy case management, I would create a simple daily log for my members, each day they had to write a brief summary , listing medications and dosages, times, diet, sleep and amount of stress, and any symptoms. It gave them a sense of involvement (and perspective) into their own medication management. And it was a great tool to present to the provider when it was time to follow up.

Your plan is ideal but there is a national no show rate of 50% in mental health. Sometimes you have to be less conservative and use your "learning" to hit them with a variety of meds in anticipation of a myriad of outcomes. For example, with a blantantly manic, psychotic person you can't normally just start low and go slow, one pill at a time. You can't always get them hospitalized or contained either.

[PG2018]

The meds have their place, but shouldn't the priority be tackling the underlying issues that cause the symptoms in the first place?

If you can devote time and money for that, yes. That is ideal unfortunately not often real.

[PG2018]

In some cases (like mine) there isn't so much an underlying issue as there is an altered brain chemistry. Talk therapy, while nice, is not going to convince my neurotransmitters to behave and play nicely. Depression and anxiety is strongly inherited in my family - not all depressive episodes are "triggered" by an event.

Manual therapy is associated neuroplasticity. Monoamine hypothesis is good but too microscopic in view.

On the short term, there is something to be said for emotional catharsis, learned coping/social/organizational skills, and for many a -oh Geez I'm about to say it- Rogerian approach.

[Farawyn]

Manual therapy is associated neuroplasticity. Monoamine hypothesis is good but too microscopic in view.

On the short term, there is something to be said for emotional catharsis, learned coping/social/organizational skills, and for many a -oh Geez I'm about to say it- Rogerian approach.

I like Carl. He's helped me navigate this site, that's fer sho.