Very nice article! I don’t mean to be the grammar police, but in some instances you have put commas where they don’t belong. This was distracting for me. Good work though!
After reading this article, and from my clinical experience (as a PA in multiple specialties)... I would say the modest effect size of SSRI's is likely explained by confounders. And the side effects + dependency mean that for most patients, these medications probably do more harm than good.
There are other treatments out there that are probably more effective, but I know a lot of people like the idea of taking a pill because it's less effort--the same is true in other areas of medicine.
Thank you for writing this! I’ve just recently learned some of this and it’s very disheartening. I wonder when psychiatrists will advertise other treatments such as Ketamine infusions. It’s finally being approved by some health insurance plans.
Thanks for starting the discussion. Reminds me of a book I just read: The Illusion of Evidence-Based Medicine: Exposing the crisis of credibility in clinical research.
The book goes over in detail two clinical trials of the treatment of adolescent depression, and how these two studies have been misleading. The authors briefly talk about how providing education on disease pathology is part of the pharmaceutical companies marketing strategy, which if I recall correctly, included this chemical imbalance theory.
"Clever metaphors and white lies, no matter how well intentioned can never empower patients to make the right choices for themselves." Quite right. Lying to patients or withholding information from them thwarts their basic psychological need for autonomy by deciding for them what they should or shouldn't know, which may actually worsen symptoms of depression. If we seek to do no harm, we should strive to tell the truth.
Its quite telling that a 50+ year old anesthetic (ketamine) reduces depressive symptoms more quickly and effectively than any 'approved' antidepressant on the market.
About time we put the monoamine hypothesis in the garbage where it belongs.
Excellent explanation for all. Not to veer too much off topic, but it seems that it’ll take another 15-20 years before opiate treatment sees the same clarity about opiate replacement that you eloquently illustrate here with SSRI’s.
I have heard many a psychiatrist state that ORT is “necessary” bc now the “recovering opiate addict is a quart low on endogenous opioids”. Of course this ignores evidence of plasticity…
I totally agree that pharma’s role is huge in the misuse of psychotropic medications. Sadly I also have to “credit“ the American public whose stock in Pharma needs to maintain some semblance of growth. Not necessarily pointing out blame but just giving credit where credit is due, so to speak.
Mostly people don’t think to look at who funds the scientific articles. As soon as Pharma sponsors of scientific article I immediately question the bias associated with it.
With profit driven medicine, rigorous science goes out the window. All this being said I really appreciated the candor with which you wrote your article.
I graduated from medical school. in 1969.All the patients I saw. in my career who took antidepressants were depressed. On the other hand. many of the patients I saw who took medicine for hypertension were normotensive. I have never believed. the chemical imbalance. theory of depression. The only thing worse than that theory in psychiatry was the legacy of Sigmund Freud,
You would have to know whether serotonin is acting as an inhibitor of proteins such as P24 and P40 of Borna virus that can induce depression as to it's efficacy in some cases.
Equally you would have to know if chemical intoxication by n-acetyl and n-nitroso glyphosate that could deplete dopamine in other cases.
Just two scenarios among the myriad potentials.......
How does one have any faith in big pharm anymore. I struggle not be cynical but after “dopesick” and information like this it’s difficult. I guess writing a script for antibiotics, anti hypertensives, anti depressants ,etc does get them out of the office / ER quicker.
Having said that, my appreciation/ admiration for the many wonderful providers trapped in the money making factory we call health care is not lessened.
The field of psychiatry and its eponymous DSM should be binned alongside the field of Phrenology. It's never been evidence-based, nor does ii follow the scientific method. Psychiatry is a system of fads. Every decade a new metanalysis shows psychiatry is a placebo field. All other psychiatric Rx have been shown to be placebo. The field of psychiatry has been and still is responsible for some of the most ghastly such as lobotomy and chopping off body parts and blocking puberty all in the name of some kind of imaginary biochemical brain problem, which NEVER have evidence. Enough. End the entire field.
I clearly remember being taught in my psychiatric rotation in my 3rd year of medical school that the risk of suicide increases when a depressed patient enters early recovery. The thinking was that as the individual begins to shed the lethargy associated with significant depression the energy to act re-emerges. The interesting thing here is that this was taught to me in the 60s, prior to the extensive use of antidepressants.
Good discussion. Alack traditionally studies of anti-depressant efficacy, and suicide epidemiology (especially in youth under 18) have omitted any attention to a serious confounder: The presence or absence of child abuse trauma. This not an accepted DSM diagnosis, so it is neither screened for, appreciated, nor coded. In fact, prior abuse trauma increase the incidence of suicide 300 to 600%.
In the context of SSRI causing suicides in youth: If a troubled youth saw a psychiatrist but his/her abuse history was not appreciated, the patient would already have a higher potential for suicide. On being prescribed an SSRI (known to be relatively ineffective in this population), a suicide might then occur due to the confounding antecedent causal factor of abuse trauma and not the medication. Without attention to this consideration (inattention which is promoted by the DSM) it would appear that med treatment increased the risk of suicide. This is false and tragically wrong reasoning.
Interesting to accompany this essay would be an understanding of how we came to discover anything about SSRIs and their use as antidepressants/panic-quellers in the first place.
Also.... chicken/egg, which comes first? Do chemicals cause thoughts (e.g. suicidal ideation) or do thoughts cause chemical changes or imbalance? CBT is known to be very effective in treatment of psychological dysfunction. This would seem to support the idea that thoughts come before chemical changes as relates to our psychological makeup.
Further: I have not since followed him, but I recall back in the late 1980s or 1990s a Dr. Bruce Perry discussion on the effects of childhood abuse on a child’s brain development (including its chemistry) and something to the effect that up to around age 6 the child’s make-up is maleable, after which it is not (at least not significantly). If environment helps determine our brain chemistry make-up, this would seem to support the idea of trying to “balance” the brain chemistry by exogenous means, i.e. with medication, regardless of which “comes first.” Dr. Perry does have a website which I have not studied, but perhaps this idea can be explored there. https://www.bdperry.com/about
Loved this, thank you.
Very nice article! I don’t mean to be the grammar police, but in some instances you have put commas where they don’t belong. This was distracting for me. Good work though!
After reading this article, and from my clinical experience (as a PA in multiple specialties)... I would say the modest effect size of SSRI's is likely explained by confounders. And the side effects + dependency mean that for most patients, these medications probably do more harm than good.
There are other treatments out there that are probably more effective, but I know a lot of people like the idea of taking a pill because it's less effort--the same is true in other areas of medicine.
Thank you for writing this! I’ve just recently learned some of this and it’s very disheartening. I wonder when psychiatrists will advertise other treatments such as Ketamine infusions. It’s finally being approved by some health insurance plans.
Thank you for your writing. Dana
Thanks for starting the discussion. Reminds me of a book I just read: The Illusion of Evidence-Based Medicine: Exposing the crisis of credibility in clinical research.
The book goes over in detail two clinical trials of the treatment of adolescent depression, and how these two studies have been misleading. The authors briefly talk about how providing education on disease pathology is part of the pharmaceutical companies marketing strategy, which if I recall correctly, included this chemical imbalance theory.
"Clever metaphors and white lies, no matter how well intentioned can never empower patients to make the right choices for themselves." Quite right. Lying to patients or withholding information from them thwarts their basic psychological need for autonomy by deciding for them what they should or shouldn't know, which may actually worsen symptoms of depression. If we seek to do no harm, we should strive to tell the truth.
Its quite telling that a 50+ year old anesthetic (ketamine) reduces depressive symptoms more quickly and effectively than any 'approved' antidepressant on the market.
About time we put the monoamine hypothesis in the garbage where it belongs.
Excellent explanation for all. Not to veer too much off topic, but it seems that it’ll take another 15-20 years before opiate treatment sees the same clarity about opiate replacement that you eloquently illustrate here with SSRI’s.
I have heard many a psychiatrist state that ORT is “necessary” bc now the “recovering opiate addict is a quart low on endogenous opioids”. Of course this ignores evidence of plasticity…
I totally agree that pharma’s role is huge in the misuse of psychotropic medications. Sadly I also have to “credit“ the American public whose stock in Pharma needs to maintain some semblance of growth. Not necessarily pointing out blame but just giving credit where credit is due, so to speak.
Mostly people don’t think to look at who funds the scientific articles. As soon as Pharma sponsors of scientific article I immediately question the bias associated with it.
With profit driven medicine, rigorous science goes out the window. All this being said I really appreciated the candor with which you wrote your article.
I graduated from medical school. in 1969.All the patients I saw. in my career who took antidepressants were depressed. On the other hand. many of the patients I saw who took medicine for hypertension were normotensive. I have never believed. the chemical imbalance. theory of depression. The only thing worse than that theory in psychiatry was the legacy of Sigmund Freud,
You would have to know whether serotonin is acting as an inhibitor of proteins such as P24 and P40 of Borna virus that can induce depression as to it's efficacy in some cases.
Equally you would have to know if chemical intoxication by n-acetyl and n-nitroso glyphosate that could deplete dopamine in other cases.
Just two scenarios among the myriad potentials.......
Interesting
How does one have any faith in big pharm anymore. I struggle not be cynical but after “dopesick” and information like this it’s difficult. I guess writing a script for antibiotics, anti hypertensives, anti depressants ,etc does get them out of the office / ER quicker.
Having said that, my appreciation/ admiration for the many wonderful providers trapped in the money making factory we call health care is not lessened.
The field of psychiatry and its eponymous DSM should be binned alongside the field of Phrenology. It's never been evidence-based, nor does ii follow the scientific method. Psychiatry is a system of fads. Every decade a new metanalysis shows psychiatry is a placebo field. All other psychiatric Rx have been shown to be placebo. The field of psychiatry has been and still is responsible for some of the most ghastly such as lobotomy and chopping off body parts and blocking puberty all in the name of some kind of imaginary biochemical brain problem, which NEVER have evidence. Enough. End the entire field.
I clearly remember being taught in my psychiatric rotation in my 3rd year of medical school that the risk of suicide increases when a depressed patient enters early recovery. The thinking was that as the individual begins to shed the lethargy associated with significant depression the energy to act re-emerges. The interesting thing here is that this was taught to me in the 60s, prior to the extensive use of antidepressants.
Good discussion. Alack traditionally studies of anti-depressant efficacy, and suicide epidemiology (especially in youth under 18) have omitted any attention to a serious confounder: The presence or absence of child abuse trauma. This not an accepted DSM diagnosis, so it is neither screened for, appreciated, nor coded. In fact, prior abuse trauma increase the incidence of suicide 300 to 600%.
In the context of SSRI causing suicides in youth: If a troubled youth saw a psychiatrist but his/her abuse history was not appreciated, the patient would already have a higher potential for suicide. On being prescribed an SSRI (known to be relatively ineffective in this population), a suicide might then occur due to the confounding antecedent causal factor of abuse trauma and not the medication. Without attention to this consideration (inattention which is promoted by the DSM) it would appear that med treatment increased the risk of suicide. This is false and tragically wrong reasoning.
Interesting to accompany this essay would be an understanding of how we came to discover anything about SSRIs and their use as antidepressants/panic-quellers in the first place.
Also.... chicken/egg, which comes first? Do chemicals cause thoughts (e.g. suicidal ideation) or do thoughts cause chemical changes or imbalance? CBT is known to be very effective in treatment of psychological dysfunction. This would seem to support the idea that thoughts come before chemical changes as relates to our psychological makeup.
Further: I have not since followed him, but I recall back in the late 1980s or 1990s a Dr. Bruce Perry discussion on the effects of childhood abuse on a child’s brain development (including its chemistry) and something to the effect that up to around age 6 the child’s make-up is maleable, after which it is not (at least not significantly). If environment helps determine our brain chemistry make-up, this would seem to support the idea of trying to “balance” the brain chemistry by exogenous means, i.e. with medication, regardless of which “comes first.” Dr. Perry does have a website which I have not studied, but perhaps this idea can be explored there. https://www.bdperry.com/about