Between 2008 and 2009 $743 million was spent on antidepressants in Australia. GPs are prescribing most of these antidepressants (85%) and they have little time to scrutinize the medical journals and publications that provide so-called 'evidence' for the use of these pills in treating depression, not to mention the use of medications in general. So let's explore: do the meds work and what is right and wrong with the supporting evidence for their efficacy.
In short - the answer is no, antidepressants are not the one-stop-shop cure for depression (or anxiety and a host of other disorders). However many people do benefit from the use of antidepressants: the medication needs to be adjusted to, and the person needs to find the right medication. Then a 'window' can be opened to not only help the person feel better, and not so burdened by the cloudy oppressive fog of depression but also to allow them to make the necessary changes in their life for the better, and to seek counselling as well. It really is quite amazing how beneficial counselling and therapy can be to people, so we should not lose sight of this. Medication on its own will never replace good counselling and lifestyle change such as better nutrition, exercise and improved relationship skills. Making changes like switching jobs, going back to school, leaving or starting a relationship can all contribute to the alleviation of stress, anxiety and depression. Conversely, not doing anything about your problems and just masking the uneasiness with medication is clearly the wrong thing to do. This is like throwing a throw rug over a pile of dirty dishes - they will start to smell eventually.
So my view on antidepressants is that we need to be careful and respectful about their use. I have seen many people benefit by using them. Many people have opted not to suicide because they have commenced the right medication - they have been granted some relief and head space to get things done and make positive changes and gotten on with their lives with greater clarity and energy. Why would you not utilize something that helped you??? Whilst antidepressants do not make you happy, they reduce the sharpness of the sting of painful emotions so that you are not suffering or recoiling as much as you otherwise would be. They can alleviate the fog of depressive malaise and you can see a bit more clearly and breathe a bit more easily.
However, in some cases a person cannot take antidepressants as the side effects are intolerable. Side effects for some people on antidepressants include worsening of depression, insomnia, weight gain, bloating, anxiety, panic attacks and even suicidal ideation. People can also lose their sex drive. Clearly there will be serious implications for all of these side effects. In other cases a person will not be affected by such side effects and they will experience tremendous relief. So in my practice, alongside the GP (doctor) I think it is a good idea to try an antidepressant if this is what the patient agrees to and their condition is serious enough to warrant the use of medication, and sometimes this means trialling several and changing dosages to get the right type and level for an individual patient. After 4 weeks if the side effects are making things worse (or sooner in extreme cases) then of course stop taking the drug. If the patient is tolerating the med and their condition is alleviating of course it is a good idea to stay on the med for 6 - 12 months (longer in some cases) and get some positive change and counselling going in this time to really eliminate the depression and help the person return to wellness. Of course sadness, fear, worry and anger will occur at some times but this is the normal human experience; we all go through such emotions from time to time depending on what we are going through in life. So treatment involves helping a person get to a place where they experience such emotions to a normal extent and they are able to tolerate, be resilient and find healthy and constructive ways to deal with their problems. Sometimes this will also mean forgiveness and letting go of things that can't be changed. It may also mean allowing yourself to get angry in a constuctive way and expressing this appropriately and meaningfully. It also means cultivating an enriching, fulfilling and meaningful life where happiness is more likely to be abundant. It may also mean getting courageous and doing something risky and profound. In therapy we can go through all of this and we can also get to the bottom of the individual patient's experience and process of depression, the underlying causes, contributing factors and moderating factors in order to change or comes to terms with these. There are many useful life skills and tools which can be utilized to make huge differences in a person's life. The experience of depression can be turned into a growth experience and the person can learn about him or her self and also about life.
Now on to the topic of medication, and its more sinister side regarding the exploitation of medication and patient's suffering by certain drug companies: It's terrible how an otherwise good thing (certain meds for certain people) can be taken and exploited and turned into a profiteering racket. We have the power of marketing and deregulation by governments, as well as plain old corruption, greed and scandal to blame for this happening. Please bear in mind as you read on that some medications are very helpful for some people. At the same time some people have been put on medication when they should not be, and in other cases the medication is dangerous and improperly used. This article is intended to help open our eyes about the topic of antidepressants so that we can make an informed decision if we use them.
The $743 million dollars spent on antidepressants makes up only 10% of the total amount spent on medications by the Pharmaceutical Benefits Scheme (PBS) in Australia (taken from the Courier Mail which quoted the recent report by the Australian Institute of Health and Welfare). So basically around $7.5 billion is spent on medications annually and financed by...(drum roll)... you guessed it, you and I as tax payers.
Some people who take medications in this country simply do not realize that the amount they are spending on their medications is a fraction of the total expense of the drug. So if patients/consumers are spending more from their pockets on top of the PBS amount, and if we then look at much larger countries with greater populations like the UK and USA, we are talking in the amount of hundreds of billions if not trillions of dollars being spent on medications annually !!! In Australia 12.3 million scripts were written for antidepressants last year alone, and this has increased almost 50% from the number of prescriptions made by doctors only 12 years ago.
This goes hand in hand with the data on mental illness in this country. We are now aware that 1 in 5 people will experience a mental heath disorder of some type in any 12 month period. We also see that mental health is now the number 1 cause of disability in Australia. Not cancer, not traffic accidents, not violent attacks, not heart attacks - but mental illness causes the greatest burden of health problems in our country.
If you go to your doctor suffering from depression or anxiety, or any type of mental illness, you will typically be offered medication to treat the condition. Sometimes this is all you will be offered, but I see some evidence that this is changing now, and that patients are being offered a more comprehensive treatment plan involving psychological counselling. This is very important, especially as the recent Australian of the year, Prof. Pat McGorry has stated that patients should be offered counselling first before they are offered medications for disorders like anxiety and depression. I do wonder if this is the case in our GP clinics or if mainly medications are opted for?
We'd also want to make sure these medications actually worked, wouldn't we? Unfortunately they don't always work and sometimes the so-called supporting evidence in medical journals is bunk. It is paid for by the drug companies themselves. I recently read an article in the free magazine Nova written by Dr. Peter Dingle who is an associate Professor at Murdoch University here in Perth, specializing in Health and the Environment. Dr. Dingle provided quite a harrowing report on how the research that GPs go on to make their prescribing decisions is often contrived by drug companies in the most unscupulous of ways. Dingle quoted the editor of the very prestigious New England Journal of Medicine, Marcia Angell who had 20 years of experience managing the journal; she wrote:
"It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgement of trusted physicians or authoritative medical guidelines.....Over the past two decades, the pharmaceutical industry has gained unprecedented control over the evaluation of its own products. Drug companies now finance most clinical research on prescription drugs , and there is mounting evidence that they often skew the research they sponsor to make their drugs look better and safer" (from M. Angell, the New England Journal of Medicine, 2008).
If anyone knows anything about research and evidence for drugs, Marcia Angell would be an expert. Dingle goes on to describe how the drug companies get away with it. The research in medical journals, which forms the basis of the decision making process for doctors (alongside of the most important factor in my opinion - clinical wisdom) shows discrepancies in:
- Primary research outcomes: if these are not stated before any research is conducted it allows the researchers to invent any reason for doing the study in the first place and this simply is not scientific. So that if the 'right' results weren't found, the researchers could simply say that they were doing the study for another purpose. So, to take a metaphorical parallel, if someone comes to your house to rob you but they see that you are home, they could instead pretend that they were just walking by or they could even drop in to lend you a hand !!!
- Statistical analyses: experimenters can manipulate data to say what they want. Anyone can present data in a way to back up their conclusions by over-emphasising what they want, and there are many statistical devices to aid this.
- Faulty conclusions published in journals compared with the drug trials themselves.
- Ghost authorship: the real author behind the name and the suit in a journal article/ research finding is actually a corporation.
Additionally researchers can inject publication bias depending on who sponsored their research. This is basically because the drug companies pay all the bills. They fund the degree programs and effectively offer bribes in the form of 'honorariums': large cash sums given to apparently respected peers so that they say what the companies want them to say. If someone said to you: 'tell people about the good things this drug does, but no need to bother people by mentioning the bad things please, and we'll give you a million dollars for your time and effort' - what would you do?
There is also blatant data suppression, where funded trials that show a particular drug is harmful or simply does not work are not presented for publication at all. There are also restrictions on access to data. Recently US Congress had to order a drug company to release its data on a drug for cholesterol (named Zetia) that was already on the market, already being prescribed to patients and had grossed $5 billion in sales. In other words the deck was stacked, the game was rigged: the drug companies finance most of the research which gets published in the journals that doctors read to get information about what drugs to prescribe. If the drug companies get unfavourable research they simply don't publish it and even hide it!! Congress finally got the data which actually showed that the $5billion spent on Zetia was a blatant waste of money as the suppressed evidence showed that the drug simply did not work ! So are these medical journals scientific, or are they simply a bastardized form of marketing and advertising for drug companies?
Are you feeling outraged yet? Please let me continue. Back to antidepressants, a report was released by Turner and Matthews, et al., in 2008 published in (our old favourite) The New England Journal of Medicine, vol. 358. This report (clearly amongst the real good guys) analysed what the drug companies had actually been doing with the studies and the data about antidepressants. Turner and Matthews found that: of 74 FDA registered studies (The Food and Drug Administration, a government body much like Australia's Therapeutic Goods Administration, which regulates all products sold to consumers in the USA) of 12 antidepressant drugs involving 12,564 patients, 31% (22 studies involving 3,449 patient results) were NOT PUBLISHED (Dingle, 2010). In addition to this DATA SUPPRESSION, thirty seven studies showing favourable results for the drugs were published, and 11 dubious studies were manipulated to show positive results. This is, of course, out and out BIAS and FRAUD. After selecting the studies they wish to have published, the drug companies are then more than happy to say that the study of a drug was based on the gold standard randomized controlled trial (RCTs) - even though they'd throw the results in the bin if the 'right answer' did not come up in the randomization method. In fact, the results are not random at all as the investigators are very careful with who they select to be a participant in any study (to get the 'right answer') and so generalizing findings to 'all patients' is not appropriate. This is actually EQUIVOCATION of data to be generalised in the clinic, and this is based on abused trust alongside a failure to properly understand the research process by those who nevertheless rely upon it to form the basis of their decisions. Additionally, researchers often FAIL TO DISCLOSE the industry backing and money they are receiving to finance their research.
In actuality, the real, solid hard core 'evidence' stipulating that antidepressants work comes down to this: half and half. The FDA analysis showed that over all studies conducted, only 51% of the drug trials had positive results in ACTUALLY TREATING DEPRESSION, and therefore, 49% had negative results which meant the drug DID NOT HELP DEPRESSION AT ALL.
I remember this well when I was going into post-graduate psychology, it even happens there. A sugar company approached me offering me money in the form of a scholarship to show that their sugar increased brain function, memory and concentration. This was coming at a time when diabetes was about to reach epidemic proportions in Australia.
Put simply this is biased and selective outcome reporting and as doctors we are basing our decisions on extremely faulty information, and as patients and health care consumers we are following advice from doctors who are unfortunately caught up in a system where they have very little time to research the medications available, or indeed to scrutinize the research methods involved in the data reporting. Bare in mind that a doctor is seeing between 30 and 40 patients every single day and then they have documents to read, results to check, phone calls to make, administration matters to oversee, and let's not forget - lunch to eat. And this all before they go home to enjoy or deal with their families and their own personal problems. God bless them - the vast majority of doctors are very caring and professional people and sincerely do wish the best for their patients. But the system they are caught up in is corrupted. I have seen on many, many occasions a pharmaceutical company representative, sexy and smart in a sharp business suit come into a medical practice and put on a lavish spread of lunch, to proceed to talk about their wares with all the apparent appearance of professionalism and science - only to actually be doing something quite different: mixing salesmanship with science. They bandy ridiculous pie charts, bar graphs and line graphs about showing some such drug to be wonderful - but as we have seen, it is often based on bullshit.
So when someone says to you 'it's all based on science', you might want to ask them 'what kind of science?'. Is it real, ethical, honest empirical validation starting from a null hypothesis, a neutral, unbiased and independent position come what may, with any outcome, utilizing genuine RCTs? In other words is it real, genuine, authentic, ethical and honest, or is it bullshit? Because, even as the Editor from the New England Journal of Medicine has stated in her own way '...it is simply no longer possible to believe'.
Now what does all this mean? I am not saying that all antidepressants are bad. From my own clinical experience and wisdom I have personally seen many people enjoy great benefits from such medication. Some people seriously need such medications. However, it needs to be put in perspective and we need to really look at any evidence with greater care. Also, when we talk about psychological counselling as being expensive, considering that so many people (myself included) have gotten so much out of the process if we go to the right counsellor or psychologist, we might want to review this conclusion when comparing it to the billions or trillions spent on medications. What we see is that COUNSELLING ACTUALLY WORKS IN THE TREATMENT OF DEPRESSION, and that antidepressant only help in some cases, so we really should consider counselling as the first port of call in treating people with depression. This should also be the case for us as patients and clients, that we ourselves should consider counselling and therapy before going on a lengthy campaign of antidepressant use that may not only be ineffective, but may also cause a range of unpleasant side effects. We should consider that not all people are the same, just like some people can drink milk and be nourished by it, whereas others are lactose intolerant and need to avoid milk products. Similarly our brains and minds work differently and depression itself is a heterogeneous disorder. This means that it is not always the same thing for different people, even though the same term 'depression' may be used to describe what they are going through. I have seen some people take an antidepressant that caused unpleasant side effects, making the depression worse, to then go on and try another medication which did work. I have seen others not respond in any way at all to a medication. Others still have responded positively almost straight away or over several weeks when they have taken an antidepressant. Some antidepressants, generally speaking, work better and have less side effects than others. Some stimulate you and others sedate you depending on the mechanism of their action. This will often form the basis of what is prescribed, so that if you have insomnia, for example, or mixed anxiety with depression, a sedating type may be used, whereas if the depression is already causing fatigue and somnolence, a stimulating antidepressant may be used.Some people have told me that they haven't liked using antidepressants as it makes them 'not like themselves', that they feel estranged from who they are, dull, flat, lifeless and not really bothered by anything in life like a zombie. So they may not be feeling particularly depressed any more because they don't care about anything any more; they are just 'comfortably numb'. I tend to think that this might be useful for some people, but that if we really want to deal with our issues and make the necessary life changes to improve ourselves and feel better, that we need to be more in touch with what is happening to us, to understand that feelings are important as they provide feedback like a quality control device. Of course feelings can be fickle and we needn't react to them all the time as they do come and go. We do need to rationalize our feelings, and when we do so we have a head-heart connectedness that steers us quite well to where we need to go. Conversely, some people report that their use of an anti-depressant that worked for them settled them down enough to be able to be open to dealing with the life issues that were bothering them, so that it opened up a kind of window and they didn't feel the old cloying darkness of despair that previously stopped them from dealing with things effectively.
I have recently gone through a bout of depression myself, and involved in my health care I:
- took St. Johns Wort (a natural anti-anxiety and anti-depressant herb) that works very well for me
- took Vitamin B (for stress reduction)
- increased the amount of meditation, yoga and exercise I did
- took time off work to reduce my distress
- reduced the amount I said 'yes' to in order to unwind and relax
- spent more time with loving, easy company and less time with non-loving, difficult company
- ate more raw, unprocessed health food
- got more sleep
- bought myself a motorcycle
- spent more time in the sunshine
- got supervision/ counselling with a warm-hearted, professional and wise counsellor who I 'clicked' with.
I chose not to use an antidepressant as I did not want to have to deal with potential side effects of a medication, that this would be the worst time for having to trial and error an antidepressant as I was already having trouble coping. And in response to all the changes I made, guess what happened? That's right chief - I started to feel better !! 😉
Who knows - for other people, doing none of the above, not changing anything in their lifestyles or doing anything to reduce their stress, or doing anything to improve their health, not doing any counselling, and just taking an antidepressant might work for them. But are we really saying that ALL DEPRESSION IS JUST BASED ON SEROTONIN AND OTHER SUCH BRAIN DEFICIENCIES AND HAS NOTHING TO DO WITH THE STUFF WE GO THROUGH AND HOW WE RUN OUR LIVES?????
Personally speaking - I think not.
We as consumers should certainly consider counselling before we consider anti-depressants. Remember folks, as with any product, be a good consumer. You need to find the right counsellor/ psychologist for you - you need to match and you need to feel a connection, and if you don't, simply go see someone else. Obviously if you see say 6 different shrinks and you think they're all 'crap', the problem might be you in the form of an attitude problem or defense mechanism of some kind.... but that's another story.