In the last episode I suggested that depression and anxiety are symptoms rather than diseases, and that for the majority of us they are a symptom of the negative thoughts we are thinking, rather than a symptom of an underlying disease.
When I discuss this alternative approach patients often ask me about serotonin levels. Many people have heard about the serotonin or “neurotransmitter” theory of depression. Namely that feelings of low mood, anxiety and irritability are the direct result of abnormally low levels of serotonin in the brain. It is how I learnt about depression in medical school, and subsequently how I, and many of my medical colleagues, explained these symptoms to patients. If the symptoms are the result of a chemical imbalance in the brain, then only doctors and scientists will have the tools to correct the problem. Surely you can’t just “think your way out” of a chemical imbalance?
A neurotransmitter is a chemical that carries signals between brain cells, allowing the different parts of the brain to communicate with each other. Many of the medications we use to treat depression are aimed at boosting the levels of these chemical messengers in the brain. There are lots of them, adrenaline, noradrenaline dopamine and serotonin to name a few. The most common class of drugs are called Selective Serotonin Reuptake Inhibitors or SSRIs. Examples are Fluoxetine (which is Prozac), Citalopram and Sertraline. These act to boost Serotonin levels in the brain.
However, in truth we have absolutely no idea whether people who are suffering with symptoms of depression and anxiety have lower levels of Serotonin or other neurotransmitters than anyone else. We have no way to measure the levels of serotonin in people’s heads, so we simple don’t know. The only reason the theory of low neurotransmitter levels exists is because we were already using medications that increased neurotransmitter levels to treat depression. It is upside down. We developed the drug, and then invented or imagined a theory to explain its effect. (2)
Using neurotransmitter boosting drugs as a treatment for depression was discovered entirely by accident. In the 1950s scientists were developing new antibiotic drugs to treat TB. They found that one of these antibiotics not only treated the lung infection, but also seemed to make people happier. As a result, psychiatrists started using the antibiotic as a treatment for depressed patients who didn’t have TB, and it became the first antidepressant, although at the time nobody knew how or why it worked. It was later discovered that one of the effects of this medication was to increase the level of the neurotransmitter adrenaline in the brain. After working this out, drug companies wondered if other drugs that targeted neurotransmitters could also influence depression. They started developing and experimenting with a range of chemicals, until eventually they found one that improved symptoms of depression in clinical trials. That drug was the SSRI Prozac.
Since the early 90s when Prozac first came on the market the prescription rates for anti-deprassants have rocketed. In the ten year period From 2007 to 2017 the number of prescriptions for antidepressants in England doubled from 33 million to 67 million prescriptions/year. (3) And as doctors prescribe more and more antidepressants, so they repeat the low serotonin story to justify the use of the medication. The more often a story is repeated the more real it becomes; we forget how it started and start to believe it to simply be true.
The idea that all cases of low mood or irritability are caused by a chemical imbalance in the brain has started to become ingrained in our collective psyche. As a society we are more and more seeing depression and anxiety as physical illnesses, as a medical problem, that is the remit of doctors, psychiatrists and scientists, rather than support from our friends, family and community. As we discussed in the last episode, this leads us to fail to take appropriate responsibility for our own wellbeing, which can have a detrimental impact on our ability to seek helpful solutions to our problems.
Despite the exponential use of antidepressant medications, we are really still no closer to understanding the root causes of depression. We still have no clue about levels of serotonin, or any other neurotransmitter, before or after treatment, or if this correlates with improvement in symptoms. More to the point, as a society, we don’t seem to be much happier. Despite the widespread availability of a medication which has been clinically proven to treat depression there still seems to be a lot of depression and anxiety about. If antidepressants were the whole story, surely we should all be feeling a whole lot happier by now?
There has been much controversy and debate regarding the efficacy of antidepressants. A recent study in the British Medical Journal that pooled together the data from studies from 1990 until 2019 concluded that whilst the studies did show a statistically significant benefit of antidepressants over placebo, the size of this difference was minimal. (4) There is a difference between statistical significance and significance in real life. If something is statistically significant this means that there is an effect that is unlikely to have occurred by chance. However, it tells us nothing about the size of this effect; how significant this effect is on day to day lives, what the actual improvement is in real terms. For example, the difference might be that patients break down in tears an average of 6 times/day without the medication, and this is reduced to 5 times/day with treatment. This might be a statistically significant result, but has the depression really been treated? Does this prove that depression must be caused by a chemical imbalance in the brain? Overall the authors concluded that. Quote, “The benefits of antidepressants seem to be minimal and possibly without any importance to the average patient with major depressive disorder”.
This study was focused on major depressive disorder. When it comes to low grade or mild depression and anxiety, the position is even less clear. The majority of the mental health problems that I see day to day fall into the category of mild or “Sub-threshold” depressive symptoms.
Now, we need to be careful with the terminology here. Mild depression can have a major impact on health and wellbeing. As we said earlier, suffering is not a competition. Depression being classed as mild does not necessarily mean it is any easier to endure. It makes no sense to compare the plight of one person to another, as if the fact that someone else might be more unwell makes our own situation less important or less significant. Just like with trapped wind resulting in severe abdominal pain, mild depression can be a devastating condition. When we say that the depression is mild, what this normally means is that, despite the problem, the patient is still managing to more or less function day to day. They have not completely lost touch with reality. They are still managing to hold down a job or look after family or maintain a home. They are still capable of logical thought and can hold a normal conversation. This does not mean, though, that they might not be suffering a very great deal.
Many of the studies on antidepressant medications were conducted on patients with moderate to severe depression. Patients that were so ill that they needed to be admitted to mental health hospitals for treatment. It is unclear if we can extrapolate the evidence for a treatment from this group of patients to those that seem to be suffering from quite different types of symptoms.
The Royal College of psychiatry does not recommend the routine use of antidepressants for mild depressive symptoms, (3) because there is limited evidence that they are of benefit in this situation, and can potentially have unpleasant and rarely even dangerous side effects. Despite this I see patients every day with low grade symptoms of depression and anxiety that have been started on medication, and many of whom have been on a variety medications for many years.
The use of SSRIs in this way is potentially inappropriate. Essentially, we are treating all mental health issues as if they are the same. We are assuming that all mental health symptoms, regardless of type, severity, trigger or duration, are all fundamentally caused by the same underlying disease, namely low neurotransmitter levels. We use Sertraline to treat patients with depression, anxiety, OCD, personality disorders, anger issues or a prolonged bereavement reaction. It seems unlikely that these wide variety of symptoms are all caused by the same basic underlying problem.
Now, I am not saying that there is absolutely no place for the use of antidepressants in the treatment of anxiety and depression. I still prescribe antidepressants to my patients, although admittedly much less than I used to, and in general I much prefer stopping them than starting them.
But I have patient’s that tell me that their medication has had huge benefits to their lives, and that they simply cannot cope without it. And who am I to doubt them? It is clear that for some patients’ SSRIs can be an effective treatment. Even if this effect is partly placebo, it is still worthwhile using the medication. So long as there are no unpleasant or harmful side effects it doesn’t really matter if its “just placebo”. If a medication works for you then it has worked and I’m all for it.
For me the important thing is to understand how and why we use antidepressants, otherwise I think there is potential for them to become part of the problem, rather than part of the solution. When I prescribe a patient an antidepressant I no longer tell them that they are feeling low because of reduced serotonin levels in their brains, and that my tablet will boost their levels and “cure” the problem. In my view this is an unhelpful, even harmful, message. It means we take the pills and wait to get better. After all, what’s the point in trying when your chemical balance is all screwed up? It stops us from being proactive, of making the changes and undergoing the personal and spiritual growth we need to manage our ever-changing life situation. If you spend your life waiting for good things to happen to you, waiting to be well, you are going to have a long and miserable wait.
Instead SSRIs should be thought of like a painkiller. They are not treating the underlying problem. The underlying problem is the thoughts that we are thinking. SSRIs do not change what we think. What they do seem to do is make us feel slightly less miserable about the bad thoughts that we are currently thinking, but only slightly. They can sometimes give us the boost and the energy that we need to do the work to address the underlying problem. Namely, our thoughts and the way we relate to the world, but they do not actually treat the problem.
Thinking of antidepressants as a painkiller makes a lot of sense to me. It explains why they can be beneficial in a wide range of different mental health problems, but do not seem to be able to cure any of them. What we know is that If we boost levels of neurotransmitters in the brain it can help some people to feel less bad. The mistake is to assume that this means the reason they felt bad in the first place was because they had a deficiency of neurotransmitters. In doing so we are mistakenly believing we are treating a disease, when in fact we are only treating a symptom. The same is true of painkillers. Painkillers can be used to treat a wide variety of problems; headaches, abdominal pain, cuts and broken bones, but they cannot cure any of these. And we do not assume that the headache or abdominal pain is caused by a deficiency of painkiller. If we did this could potentially be very harmful to us.
If you break your leg, taking paracetamol is not going to fix the problem. The leg needs to be properly treated with surgery or a plaster cast. But this does not mean there is no role for paracetamol in the treatment. If you break your leg at the top of the mountain you may well want to take some paracetamol while you make your way to hospital, or to manage pain during your recovery from surgery. However, it would be a problem if you assumed that because paracetamol reduced the pain that it had treated the broken leg, and you continued to walk around on it, taking paracetamol every day. If you try to stop the paracetamol you find the leg is painful again. Maybe you tell yourself that the leg must be painful because of a paracetamol deficiency in the leg. You will stay on paracetamol for the rest of your life, and never address the underlying problem. Maybe if you didn’t have any paracetamol in the first place you might have done more about the leg?
The same goes for antidepressants. Sometimes when people are really struggling, they do not have the motivation or the energy to do the work that needs to be done. I have repeatedly said that this work is challenging and requires dedication and commitment. Antidepressants can help some people find this dedication and commitment, they can help people to get down from the mountain. If we use medications to assist us in addressing the root cause of our problems, then they can be helpful, and may have an important role to play. But if we use them instead of addressing our problems, they will be harmful. They will numb the pain just enough to take away our motivation to get better.
I frequently see patients that have been on a variety of antidepressant medication for years, struggling through life with chronic mental health issues that have never been properly addressed. When they inevitably start to feel low again, because they never addressed the underlying problem, they say, “my antidepressant has stopped working” and wish to increase the dose or be switched to a different one. This is such a shame, and for these people I wonder if western medicine has done more harm than good.
Once again, I want to make it clear that this is not a value judgement. It is not a moral issue. People that use antidepressants, either in the short term, or for many years, are not bad or weak or wrong for using them. They are just people that have been suffering and are trying to find ways to deal with the suffering. This is not a judgement on those people. I’m just saying that maybe its just not a very good strategy for dealing with the pain, and sometimes might even be a harmful one. Every one of us sometimes employs harmful coping strategies to deal with our pain, both emotional and physical. We are not to blame for these, we are just doing the best we can. But learning to recognise our unhelpful habits, in a loving and non-judgemental way, is essential if we are going to change and heal. I am going to be talking a lot more about helpful and unhelpful coping strategies in the New Year.
So, If you are someone that has been on antidepressants for many years, then I really hope that you don’t feel offended, and are not beating yourself up about it. Instead I hope that you are finding these podcasts helpful and empowering. I hope that you are starting to understand that it doesn’t have to be this way, that you have the power and the ability to choose what you want to think and feel, how you want to live, and the person you want to be. There is a beautiful world out there, if only we can learn to open our eyes and see it.
References for episodes 14 and 15:
- Petrie KJ, Faasse K, Crichton F, et al How common are symptoms? Evidence from a New Zealand national telephone survey BMJ Open 2014;4:e005374. doi: 10.1136/bmjopen-2014-005374
- Edward Bullmore: The inflamed mind, A radical new approach to depression, 2018.
- PS04/19: Position statement on antidepressants and depression, Royal College of Psychiatrists, May 2019.
- Jakobsen JC, Gluud C, Kirsch I Should antidepressants be used for major depressive disorder? BMJ Evidence-Based Medicine Published Online First: 25 September 2019. doi: 10.1136/bmjebm-2019-111238