Some markers first. I am a committed believer in what may now be a last millennium concept – the medical model. I think antidepressants – the older tricyclics and ECT, not the more recent SSRI and other antidepressants – can save lives. I figure conflict of interest, crucially important in other areas of life, is of minor importance if not irrelevant in science. Although by science I mean something that can only happen in the presence of publicly available data.
I used to sit on training scheme interview panels some years ago. We ended up being told we had to ask exactly the same question of every candidate. By accident I hit on a question and amazed by what I was hearing stuck to it:
Tell me about some mistakes you’ve made and what you’ve learnt from them?
When women were asked this, they immediately looked comfortable and answers tumbled out of them. When men were asked, they looked puzzled and if they could be said to have hopped from foot to foot while sitting on a chair this is what they did.
But of course if SMC are writing a brief for you, whether you are a female or male President of a College, they are unlikely to let you admit to mistakes.
The SMC mantra in the background of the recent Panorama fuss, aside from the weird plug about stigma, and the junk in the background to other artificially created concerns about related issues, is that Antidepressants Work and Save Lives. Millions are benefiting, more and more each year, and its just not right to worry people with Bogeymen. These are the dog-whistles they expect the junkie opinion leaders they have helped create to parrot.
Allen Frances and others now tell us we can’t put DJT’s labeling of inconvenient facts as Fake News down to mental illness. For thirty years the presidents of the American Psychiatric Association and Royal College of Psychiatists (except one), along with Allen Frances, have endorsed a ghostwritten news in all the best journals with zero chance to fact check. Endorsed a News so obviously Fake it beggars belief. They dismiss the inconvenient facts of suicides, homicides and other harms by an appeal to this Fake News. This is not a mental illness.
One of the difficulties here is the word antidepressants. From 1957 to 1987, this meant treatments that could produce a benefit in melancholia. The tricyclic antidepressants and ECT did this and psychiatrists using these treatments judiciously may have saved some lives.
The word has now changed meaning completely. SSRIs and related “antidepressants” are ineffective in melancholia. There are no trials showing they work for what until recently was regarded as depression.
The clinical trial evidence for SSRIs comes from people with much milder conditions, who are at little or no risk of dying if left untreated – as the placebo arm of these studies shows.
There is a myth that SSRIs and related drugs treat severe depression. This comes from the trial data that shows that in people whose rating scale scores are little worse than many of us might have on a Monday morning, it is not possible to show any budge in the rating scale score. You have to head to the severe end of normal to show a budge. This is not severe depression. Its probably not depression. Its certainly not blood test positive depression as in Dexamethasone Suppression Test Positive depression. SSRIs don’t work in people who are DST +ve.
The SSRIs are essentially anxiolytics. People toyed around with words like Serenics in the 1980s, when the drugs were first developed. They adopted the term antidepressant in part because the word didn’t suggest dependence. They adopted this word, knowing SSRIs cause dependence.
Antidepressants Save Lives
If by working we mean save lives, the clinical trial evidence base does not show SSRIs or recent antidepressants saving lives. Quite the contrary. In 2006, FDA called for all trials. They made a curious call that eliminated all data from taper periods, run in periods and had other odd features. Even so they only got some trials. Some other trials in which there were suicides and deaths just didn’t make it to FDA’s offices.
Despite all this, there was an excess of dead bodies in trials that combined involved 100,000 people on antidepressants compared to placebo. These deaths were not just from suicide.
When the regulators finally put a Black Box on antidepressants it was because there was an excess of suicidal acts on these drugs – not because there was some evidence there could be a suicidal act on treatment.
If by working we mean correcting an abnormality in serotonin or other systems, there is no evidence for this and never was. Ideas about abnormalities in serotonin systems were fringe hypotheses before marketing copy transformed them into a biobabble that has degraded clinical encounters.
Antidepressants make people’s serotonin systems abnormal. The longer you stay on them, the more abnormal your serotonin system becomes.
A lot of people seem to sense this, because pharmaceutical company research shows that more than half of those put on antidepressant stop by the end of the first month.
Millions are Benefiting
There is up to a 10% increase in people on antidepressants each year. There are 65 million prescriptions in England per year. What does this mean?
Roughly the same amount of people get put on antidepressants for the first time each year. The increasing number on these pills comes from people continuing on them at the end of each year. Roughly 90% of the people now on antidepressants have been on them for a year or more.
Of this 90%, the bulk continue taking them because they can’t get off.
They may think the pills are saving their lives when they stop and feel awful and go back on them and feel better. And their lives may be saved but they are being saved by a treatment for withdrawal rather than for depression.
This is dependence – addiction in lay language. It’s difficult to know where this story is going to end – probably in a lot people being dismissed as neurotic or psychosomatic. The caravan will move on leaving a lot of dogs barking.
What Antidepressants Do
SSRIs change the genitals of 100% of the people who take them. They do so within an hour of the first tablet. In most cases, this means numbing, but in some cases it may involve the opposite. In almost all cases, except some men (and women) with premature ejaculation (or its equivalent), this leads to sexual dysfunction.
A significant number of people with sexual dysfunction will never recover normal function. A decade after stopping they will not be functioning normally and may not be functioning at all. We don’t in fact know how many people return to full sexual function after an SSRI. It may be less than half of those who have been on treatment for more than a few months.
SSRIs and related antidepressants also produce an emotional numbness in most takers. This is at the core of their therapeutic action. We prefer to talk about these drugs “working” rather “numbing” because numbing doesn’t sound ethically quite right.
But SSRIs were developed to produce precisely this effect – not to correct a serotonin problem.
It would be helpful for people offered them to know this is what is being aimed at, and indeed more honest, even though some people might then say they’d prefer not to go down this route.
Women of Child-Bearing Years
Women of child-bearing years have been the target population for these drugs – even though from before their marketing there were strong warning signs these drugs might cause birth defects.
SSRIs double the rate of birth defects in children born to women who take them during the first trimester. These range from almost all cardiac defects through to spina bifida and other problems.
SSRIs also double the rate of autistic spectrum disorders and developmental delay in children born to women who have been on them in pregnancy.
SSRIs double rates of miscarriage – one of the biggest causes of nervous problems later.
SSRIs trigger alcoholism in a significant number of people, especially women. They can lead to compulsive drinking pregnancy and later Fetal Alcohol Syndrome.
Psychotropic Drugs in Children and Adolescents
Prozac is licensed for depression in adolescents. It doesn’t work. The Prozac trials are indistinguishable from paroxetine and other trials in showing no evidence of benefit and evidence of a great deal of harm.
It remains licensed because regulators are never willing to admit mistakes and the academics involved appear unwilling to come clean. It may be legitimate to talk about a conspiracy to hide its problems.
Children’s mental health is the place with the greatest divide in all of medicine between what the published evidence shows and academics say and what the data in fact shows.
Children’s mental health used to be the clearest place where the magic lay in the doctor rather than the pill. If this were still the case, there would be place for a judicious use of medication even though except for OCD there is not a lot of conventional evidence to support doing this in the case of SSRIs.
But the magic no longer lies in the clinicians. Child Shrinks have become Model Shrinks – where a model means a shrunken replica of the real thing.
Children’s mental health services have become a horror story with children even more likely than adults to end up with a plethora of gateway diagnoses leading to shocking cocktails of treatment – this is in the UK not the US.
And its getting worse. There are proposals to increase the numbers of child psychiatrists to meet an unmet need. This is a nightmare.
The Difference Between…
In response to the interview question above, Women like Blacks vis-a-vis Whites, or Irish vis-a-vis English can spot the mistakes they make. The powerful can’t. Who me? Make a mistake?
The confidence that comes with power leads to a blindness to mistakes. Strangely, it also leads to extreme nastiness when faced with any evidence of a mistake. The powerful feel very threatened by those they subjugate. They worry about death threats. The surprise to me always has been that women and blacks and people whose lives are ripped apart by what was known to be junk information on a drug don’t in fact get violent with the junkies who have robbed and injured them for the sake of a quick fix.
This doesn’t mean that all women and Irish and BMEs are better than WASPs. The Irish have shown themselves at least as capable of bigotry and nastiness as any other group on earth.
But you’d expect shrinks of all people to be aware of psychodynamics and defense mechanisms like this.
Upton Sinclair famously said you can’t depend on a man to understand something if his job depends on not understanding it.
Sinclair was so twentieth century. APA and RCP today don’t seem able to understand things their jobs tomorrow depend on them understanding. If drugs like the antidepressants work wonderfully well and are free of side effects, if it doesn’t require the magic an expert can bring to bring good out of the use of a poison, shrinks are toast. They will be replaced by cheaper prescribers, and Sinclair News (see next post) outfits and SMC will welcome the benefits.
Simon, the train above is about to leave Prague train station and head West. It’s just before other trains start heading East. Pius XII is about to start hearing, seeing and speaking no evil in case the people who produced Beethoven, Mozart and Goethe decide to destroy the Sistine Chapel.
There are more important things than the roof of a Chapel. Children are more important. You know this better than anyone.