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.
Are people really justifying ORT based off this kind of weak biological hypothesis? I thought it was more of a practical consideration: It should be safer for addicts if they can get their fix from a doctor than from a dealer. Don’t have to worry as much about OD, about cut product and risk of IV drug use. Also methadone/subuxone don’t have the pure mu agonism that you gets you the euphoria
Yes that is the “Layman’s terms” that a lot of addiction psychiatrist used to explain why an opiate replacement is necessary. The real reason of course is to put the money in pharma’s and the prescribers’s pocket versus the dealers pocket.
Of course it reduces harm. Absolutely no doubt about that. But it keeps a low bar low for the person who has an ability to recover from addiction.
And your last line is another selling point that the drug companies use. This is not a diss towards you at all. It’s just a line that you hear over and over and frankly both methadone and Suboxone are easily abused but they don’t provide the immediate high that mu opioids do. Both drugs are miss used quite a bit. The reason you don’t see as much Abuse with methadone for drug treatment Is because of the tight leash that providers have on distribution. I have always called Suboxone “millennial methadone” because there are really no restrictions on it despite the fact that you need the waiver. One of the “experts“ that pushes the waiver was a big pusher of opiate drugs back in the late 1990s early 2000s. The guy was an absolute joke and full of himself, arrogant as could be. Denied that addiction could happen when treating pain properly. We all know that’s not true. I can go on and on but for today will stop lol!
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.
Right you are. The Justice Dept funded Violence Project has an on line data base of 210+ mass shooters. For 66 of them their childhood history is well established and 60 of them had experienced documented severe child abuse.
This is exactly the problem with the entire "gender" issue. Physical child abuse, religious child abuse, sexual child abuse, all leading to minors being butchered chemically/surgically to "affirm" their imagined brain chemistry.
That would be the case if we were talking about observational data. But I'm pointing to randomized trials, where any such con-founders would hopefully be balanced.
Possible in medication trials, impossible in suicide epi. Also child abuse trauma is both prevalent and not randomly distributed in the genera; population. This detracts from your point.
Oh no I'm not trying to say anything the prevalence and distribution of trauma in the general population. But the data I'm referring to (the 6th reference) is derived from randomized trials. Randomized trials do show that there is an increased risk of suicide in children and adolescents upon starting an SSRI.
Alas some had a huge increased risk of suicide before starting the the RX and the issue of child abuse trauma is not randomly distributed and could confound the results. A good trial would see that controls conformed in, say, age and sex, and perhaps race/ethnicity, and SE class but these are not necessarily good proxies for child abuse trauma. You cannot randomize what you are not looking for.
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
A quick perusal of his website and a web search on his name shows Dr. Perry has continued in this field of research and theories have likely advanced a good deal since my intro to his ideas a couple or three decades ago. If interested, here’s a pubmed abstract,
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.
Are people really justifying ORT based off this kind of weak biological hypothesis? I thought it was more of a practical consideration: It should be safer for addicts if they can get their fix from a doctor than from a dealer. Don’t have to worry as much about OD, about cut product and risk of IV drug use. Also methadone/subuxone don’t have the pure mu agonism that you gets you the euphoria
Yes that is the “Layman’s terms” that a lot of addiction psychiatrist used to explain why an opiate replacement is necessary. The real reason of course is to put the money in pharma’s and the prescribers’s pocket versus the dealers pocket.
Of course it reduces harm. Absolutely no doubt about that. But it keeps a low bar low for the person who has an ability to recover from addiction.
And your last line is another selling point that the drug companies use. This is not a diss towards you at all. It’s just a line that you hear over and over and frankly both methadone and Suboxone are easily abused but they don’t provide the immediate high that mu opioids do. Both drugs are miss used quite a bit. The reason you don’t see as much Abuse with methadone for drug treatment Is because of the tight leash that providers have on distribution. I have always called Suboxone “millennial methadone” because there are really no restrictions on it despite the fact that you need the waiver. One of the “experts“ that pushes the waiver was a big pusher of opiate drugs back in the late 1990s early 2000s. The guy was an absolute joke and full of himself, arrogant as could be. Denied that addiction could happen when treating pain properly. We all know that’s not true. I can go on and on but for today will stop lol!
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.
And to go along with that, child abuse and SSRIs, a look at some recent young men who became shooters might be worth consideration.
Right you are. The Justice Dept funded Violence Project has an on line data base of 210+ mass shooters. For 66 of them their childhood history is well established and 60 of them had experienced documented severe child abuse.
This is exactly the problem with the entire "gender" issue. Physical child abuse, religious child abuse, sexual child abuse, all leading to minors being butchered chemically/surgically to "affirm" their imagined brain chemistry.
That would be the case if we were talking about observational data. But I'm pointing to randomized trials, where any such con-founders would hopefully be balanced.
Possible in medication trials, impossible in suicide epi. Also child abuse trauma is both prevalent and not randomly distributed in the genera; population. This detracts from your point.
Oh no I'm not trying to say anything the prevalence and distribution of trauma in the general population. But the data I'm referring to (the 6th reference) is derived from randomized trials. Randomized trials do show that there is an increased risk of suicide in children and adolescents upon starting an SSRI.
Alas some had a huge increased risk of suicide before starting the the RX and the issue of child abuse trauma is not randomly distributed and could confound the results. A good trial would see that controls conformed in, say, age and sex, and perhaps race/ethnicity, and SE class but these are not necessarily good proxies for child abuse trauma. You cannot randomize what you are not looking for.
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
There was never ANY evidence of biochemical imbalance. It's all a scam.
Oh, for heaven’s sake. Please, this is for serious discussion not off the cuff unsubstantiated blanket accusations of “scam”.
A quick perusal of his website and a web search on his name shows Dr. Perry has continued in this field of research and theories have likely advanced a good deal since my intro to his ideas a couple or three decades ago. If interested, here’s a pubmed abstract,
https://pubmed.ncbi.nlm.nih.gov/31447660/#:~:text=Timing%20of%20Early-Life%20Stress%20and%20the%20Development%20of,specific%20ELS%20experiences%20influence%20specific%20aspects%20of%20neurodevelopment.