How We Have Been Misled About Antidepressants

By Joanna Moncrieff
Brownstone Intitute

Our umbrella review that revealed no links between serotonin and depression has caused shock waves among the general public, but has been dismissed as old news by psychiatric opinion leaders. This disjunction begs the questions of why the public has been fed this narrative for so long, and what antidepressants are actually doing if they are not reversing a chemical imbalance.

Before I go on, I should stress that I am not against the use of drugs for mental health problems per se. I believe some psychiatric drugs can be useful in some situations, but the way these drugs are presented both to the public and among the psychiatric community is, in my view, fundamentally misleading. This means we have not been using them carefully enough, and crucially, that people have not been able to make properly informed decisions about them.

Much public information still claims that depression, or mental disorders in general, are caused by a chemical imbalance and that drugs work by putting this right. The American Psychiatric Association currently tells people that: “differences in certain chemicals in the brain may contribute to symptoms of depression.” The Royal Australian & New Zealand College of Psychiatrists tells people: “Medications work by rebalancing the chemicals in the brain. Different types of medication act on different chemical pathways.”

In response to our paper finding that such statements are not supported by evidence, psychiatric experts have desperately tried to put the genie back in the bottle. There are other possible biological mechanisms that could explain how antidepressants exert their effects, they say, but what really matters is that antidepressants ‘work.’

This claim is based on randomised trials that show that antidepressants are marginally better than a placebo at reducing depression scores over a few weeks. However, the difference is so small that it is not clear it is even noticeable, and there is evidence that it may be explained by artefacts of the design of the studies rather than the effects of the drugs.

The experts go on to suggest that it does not matter how antidepressants work. After all, we do not understand exactly how every medical drug works, so this should not worry us.

This position reveals a deep-seated assumption about the nature of depression and the action of antidepressants, which helps to explain why the myth of the chemical imbalance has been allowed to survive for so long. These psychiatrists assume that depression must be the result of some specific biological processes that we will eventually be able to identify, and that antidepressants must work by targeting these.

These assumptions are neither supported nor helpful. They are not supported because, although there are numerous hypotheses (or speculations) other than the low serotonin theory, no consistent body of research demonstrates any specific biological mechanism underpinning depression that might explain antidepressant action; they are unhelpful because they lead to overly optimistic views about the actions of antidepressants that cause their benefits to be overstated and their adverse effects to be dismissed.

Depression is not the same as pain or other bodily symptoms. While biology is involved in all human activity and experience, it is not self-evident that manipulating the brain with drugs is the most useful level at which to deal with emotions. This may be something akin to soldering the hard drive to fix a problem with the software.

We normally think of moods and emotions as being personal reactions to the things going on in our lives, which are shaped by our individual history and predispositions (including our genes), and are intimately related to our personal values and inclinations.

Therefore we explain emotions in terms of the circumstances that provoke them and the personality of the individual. To override this common-sense understanding and claim that diagnosed depression is something different requires an established body of evidence, not an assortment of possible theories.

Models of drug action

The idea that psychiatric drugs might work by reversing an underlying brain abnormality is what I have called the ‘disease-centred’ model of drug action. It was first proposed in the 1960s when the serotonin theory of depression and other similar theories were advanced. Before this, drugs were implicitly understood to work differently, in what I have called a ‘drug-centred’ model of drug action.

In the early 20th century, it was recognised that drugs prescribed to people with mental disorders produce alterations to normal mental processes and states of consciousness, which are superimposed onto the individual’s preexisting thoughts and feelings.

This is much the same as we understand the effects of alcohol and other recreational drugs. We recognise that these can temporarily override unpleasant feelings. Although many psychiatric drugs, including antidepressants, are not enjoyable to take like alcohol, they do produce more or less subtle mental alterations that are relevant to their use.

This is different from how drugs work in the rest of medicine. Although only a minority of medical drugs target the ultimate underlying cause of a disease, they work by targeting the physiological processes that produce the symptoms of a condition in a disease-centred way.

Painkillers, for example, work by targeting the underlying biological mechanisms that produce pain. But opiate painkillers may work in a drug-centred way too, because, unlike other painkillers, they have mind-altering properties. One of their effects is to numb emotions, and people who have taken opiates for pain often say they still have some pain, but they do not care about it anymore.

In contrast, paracetamol (so often cited by those defending the idea that it does not matter how antidepressants work) does not have mind-altering properties, and therefore although we may not fully understand its mechanism of action, we can safely presume it works on pain mechanisms, because there is no other way for it to work.

Like alcohol and recreational drugs, psychiatric drugs produce general mental alterations that occur in everyone regardless of whether they have mental health problems or not. The alterations produced by antidepressants vary according to the nature of the drug (antidepressants come from many different chemical classes – another indication that they are unlikely to be acting on an underlying mechanism), but include lethargy, restlessness, mental clouding, sexual dysfunction, including loss of libido, and numbing of emotions.

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Via https://brownstone.org/articles/how-we-have-been-misled-about-antidepressants/

 

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