“Overheard in a brokerage: ‘I worry about economists who are so young that they think the Great Depression was ended by Prozac.’”
— UNKNOWN1
I’ve listened to burned-out colleagues in the healthcare profession wrestle with questions like these: Am I burned out, or do I have a biochemical depression that needs to be treated? Would taking Prozac or an older antidepressant (such as imipramine) help me sleep better and feel more like myself, or would I find it difficult to tolerate like so many of my patients do? I know these drugs are overprescribed, but it can’t hurt to give one a try can it?
In the interest of scientific experimentation—and sincerely hoping to feel better—I asked my family doctor for a Zoloft prescription back in 2001. Within a day I felt distinctly strange, as a kind of buzzing energy seemed to be running through me. Over the next few days, I grew increasingly restless, anxious, and wired— a condition my mother used to describe as “having ants in your pants.” Ten days into the experiment, I honestly felt like I was losing my connection with reality. Suspended in between the totally incompatible extremes of mania and zombification, I no longer felt competent to control my own thinking. When a good friend inquired how I was feeling, the best I could come up with was: “Chemicalized I can feel the drug taking over . . . it’s like being possessed.”
The latter comment is typical of my bizarre sense of humor, by the way, rather than a metaphysical comment suggesting that an exorcism was in order. I was aware of the fact that SSRIs (selective serotonin reuptake inhibitors) can be very hard to tolerate in the first few weeks of treatment, but ten days were enough for this girl. I much preferred to have my old self back again, negative and depressed though she was.
My experience with Zoloft, although not at all unusual, isn’t meant to discourage anyone else from trying it under his or her physician’s careful supervision. There are thousands (perhaps even hundreds of thousands) of people who credit SSRIs with saving their lives.
In the following pages, we’ll explore what antidepressants do and don’t do. They may (or may not) be effective for individuals with severe depression, but can they be of help for those who are experiencing the milder spectrum of depression associated with burning out?
In the interest of educating you on what is and isn’t known about the science of depression and how it’s presented and sold to the public at large, this chapter will take you on a quick tour of the thriving “depression industry.”
Let Them Eat Prozac2
The primary reason why antidepressants are overprescribed in the U.S. is because depression is overdiagnosed. When I decided to undertake my experiment with Zoloft, my reasoning went something like this: I do have a lot of the common symptoms of depression: fatigue, irritability, trouble sleeping, hopelessness, frustration, headaches, body aches, and feeling like a failure. On the other hand, I concentrate well enough and still get pleasure out of skiing, gardening, and being with the kids and grandkids so maybe it’s not biological after all What to do?
That particular monologue involved ticking off the most commonly published symptoms of depression on my own mental checklist. Just Google “depression symptoms,” and self-tests indicating whether you need to seek medical advice will pop up on multiple sites.
The proliferation of online information is due, in large part, to an aggressive campaign on the part of Big Pharma to “educate” doctors and the general public on the epidemic of depression that is supposedly ravishing the nation. It pays to create a market when you have something to sell, even if that something works for unknown reasons and may have serious side effects such as severe anxiety, unmanageable restlessness, sudden weight gain, and obsessive thinking about suicide or homicide (which sometimes leads to terrible tragedy). Yet it can also make a life or death difference to the most severely depressed patients.
Americans use two-thirds of the world’s supply of antidepressants. Let’s stop to do the math: The U.S. population is currently in the vicinity of 309 million souls, and the world population is about 6.8 billion, which means that approximately 4 percent of the entire planet gobbles up 67 percent of the global supply of antidepressants. That’s a veritable river of relief . . . or is it?
The supposed mode of action of the new wave of antidepressants in the SSRI class of drugs is to prevent reuptake of serotonin by synapses in the brain, thus increasing the overall amount of the neurotransmitter available to stimulate neurons. First studied as potential antihypertensive medications, SSRIs (which include Prozac, Zoloft, Celexa, Luvox, Paxil, and Lexapro) were eventually marketed as antidepressants and kicked off a wave of research into a purported link between low serotonin levels in the brain and depression. This is still controversial because low serotonin levels don’t seem to affect mood. Furthermore, there’s a new antidepressant (tianeptine, which isn’t yet available in the United States) that is as effective as the SSRIs, but it actually lowers serotonin levels.
Intrigued by what people “on the ground” might have to report about their experiences with SSRIs, I asked that question on Facebook one evening. By the following morning, more than 60 people had weighed in. About a third of the respondents were extremely grateful for the relief that SSRIs (and other types of antidepressants) provided. A few even credited the drugs with saving their lives. Another third reported a partial response to the drugs, several after switching around to different brands over a period of months or years. The final third stated that side effects (the most common being anxiety, restlessness, rapid weight gain, gastrointestinal problems, and rage) were uncomfortable enough that they discontinued the drugs relatively soon after starting them. A few people reported extremely serious side effects, including suicidal thoughts and attempts to end their lives, which were totally new, never having occurred before taking the drugs.
One FBF who is a doctor of Oriental medicine wrote:
I have had two friends in the last year commit suicide after being put on SSRIs and other antidepressants . . . originally prescribed for pain, not depression. These folks showed no signs of suicidal tendencies beforehand.
These are the kind of cases that finally forced the FDA to implement “black box” warnings about the potentially serious and life-threatening side effects of these drugs.
I’m no stranger to the ways in which drugs affect mood and behavior. While an undergraduate at Bryn Mawr College, I was fortunate enough to take several graduate seminars in psychopharmacology from a Wyeth laboratories research scientist. Their world headquarters was just a short train ride from Bryn Mawr, down the Main Line in Radnor, Pennsylvania. I worked for Wyeth the summer of my junior year and went on to do my honors research there during senior year. Advances in understanding neurotransmitters, brain architecture, and biochemistry; as well as the mechanisms through which drugs affect behavior and mood, were fascinating back in the 1960s, and continue to be so today.
I’m a great believer in the potential of naturally occurring herbal medicines and pharmaceuticals to reduce distress when coupled with healing the whole person— understanding the past, dealing with trauma, becoming more mindful/emotionally intelligent, and implementing a healthy lifestyle.
The majority of Facebook comments agreed with that perspective. Even FBFs who felt that antidepressants had been, or still were, lifesaving, stressed the importance of combining them with therapy, exercise, and what one woman called “over-the-top nutrition.” Poor eating habits—a hallmark of our fast-paced, fast-food nation— can be clearly linked to fatigue, depression, and diseases that range from diabetes and heart disease to a variety of cancers.
My Facebook wall kept filling up with responses to the SSRI question, as did my private-message mailbox, where about 30 people felt safe enough to recount their personal stories in some detail. One of the common threads that ran through those accounts was a history of childhood incest, physical abuse, sexual abuse, or significant trauma and loss as adults. People who had related this type of story believed that traumatic experiences were at the root of their depression. Some of them reported that the drugs were helpful in calming them down so they could explore these issues. But for others, the drug blunted emotions to such an extent that they blocked access to, and healing from, trauma.
The idea that psychological factors might cause depression was rejected strongly by a handful of FBFs. Why stigmatize people by blaming depression on psychological factors when it’s a strictly biological illness, they argued? The metaphor that biological psychiatry commonly invokes—that SSRIs raise serotonin and are needed by depressives in the same way that insulin is needed by diabetics—was cited by two people as proof of the biological nature of the illness.
But it’s not so easy to separate the mind from the body. Significant trauma, for example, can cause a lifelong elevation in levels of the stress hormone cortisol that diminishes immune function, scrambles memory, and shrinks the hippocampus (part of the brain’s emotional and memory system) and can lead to bad dreams, flashbacks, and depression. These biological problems clearly have a psychological root in post-traumatic stress disorder (PTSD). The argument that SSRIs are a biological treatment for a biological disease is based on the fact that these drugs cause new cells to grow in the hippocampus. So, by the way, do exercise and fish oil, which, like SSRIs, are both as effective as antidepressants for some people but not for everyone.
The bottom line is that depression is a complex condition that is still not completely understood. Some severe types, including bipolar disorder (manic-depressive illness), have a genetic component and are clearly biological. In many cases, they respond well to medication. Earlier I mentioned the clinical psychologist Kay Redfield Jamison, who is a world-renowned expert on manic-depressive illness and has also lived with it personally since her young adulthood. Her best-selling memoir, An Unquiet Mind, popularized the disorder and greatly increased public understanding. The problem is that manic-depressive disorder is unlike other forms of depression—apples compared to oranges. Nonetheless, its popularization helped reinforce the idea that all depression is biological and needs to be medicated.
Depression turns out to be a mixed bag, however. Some forms may be biological; but other types are related to grief, burnout, or overwhelming stress. Burnout predisposes individuals to depression, as does trauma. In fact, as we’ll explore in the next chapter, it has been documented that adverse childhood experiences increase adult rates of depression by up to 5,000-fold. So how is a busy family doctor, practicing in a community rather than an academic setting, going to sort all of this out? Who should be medicated, when, and with what? And what other kinds of therapy might be effective?
Wow, What a Beautiful Drug Rep!
The vast majority of physicians are neither psychiatrists nor psychopharmacologists who understand the intricacies of biobehavioral research and treatment. Furthermore, the average physician may have too little time to talk with his or her patients and elicit the story of how their symptoms developed and what has been going on in their lives. A patient may complain of stress, trouble sleeping, aches and pains, or a depressed mood, and simply walk out with a prescription for an antidepressant. So great is the fear of “missing” depression and being sued that “defensive medicine” mandates that it’s better to be safe than sorry, since depression is now widely thought of as a biological disease requiring medicine to treat it.
How do physicians keep up with all the new drugs that hit the market anyway? A primary source of “continuing education” are manufacturers’ representatives (drug reps). These delightful folks appear at the office bearing the modern equivalent of the beads and trinkets with which the Europeans stole Manhattan. They give presentations on new drugs and their usages, and leave the bait in the form of samples. Although it’s expensive to deploy this corps of salespeople, it pays off handsomely. Physicians are much more likely to prescribe drugs that have been left as samples. In fact, the return on every dollar spent in this form of direct sales is a little better than ten to one.
The daughter of a good friend of mine was recruited as a drug rep right out of college, as was my youngest son’s high-school girlfriend. Both of these young women are beautiful, extroverted, bright, kind, and totally engaging. I can see why they would be hard to kick out of your office. Drug reps are generally attractive young people (college cheerleaders are a group that drug companies often recruit).
Carl Elliott, who teaches at the Center for Bioethics at the University of Minnesota and is the author of several books, including Better Than Well: American Medicine Meets the American Dream, wrote an article in The Atlantic in 2006 called “The Drug Pushers.” He describes drug reps in this way:
It is probably fair to say that doctors, pharmacists, and medical-school professors are not generally admired for their good looks and fashion sense. Against this backdrop, the average drug rep looks like a supermodel, or maybe an A-list movie star. Drug reps today are often young, well groomed, and strikingly good-looking. Many are women. They are usually affable and sometimes very smart. Many give off a kind of glow, as if they had just emerged from a spa or salon. And they are always, hands down, the best-dressed people in the hospital.3
Wow, What Impressive Data!
Appealing young people are undoubtedly driving forces in the world of pharmaceutical sales. Articles ghostwritten by science writers working for drug companies are another. The writers prepare articles drawing on the published research of known investigators and combine it with data that is cherry-picked from other studies, reaching conclusions that are favorable to their company’s drugs and which usually discount the possibility of common serious side effects.
When I first read about this practice in the widely lauded book Let Them Eat Prozac by David Healy, M.D., I was outraged. (Healy is a psychiatrist, psychopharmacologist, university professor, frequent expert witness, and the former secretary of the British Association for Psycho-pharmacology.) What happened to medical ethics? How can science writers from companies with vested interests publish “research” that proves the points they want to make yet hides the facts they’d rather forget?
Far from being a critic of psychopharmacology, Healy is one of its most vigorous proponents. He prescribes SSRIs for his own patients when he feels they are a legitimate course of treatment. He has run clinical trials for the manufacturers and has testified for many pharmaceutical companies as an expert witness. He has also been an expert witness for the other side: patients or victims of patients who have been seriously injured by SSRIs.
Currently at the University of Cardiff in Wales, one of Britain’s largest teaching and research universities, Healy has run into some predictable problems as a critic of Big Pharma. His views on ghostwriting, the failure of drug companies to report data from unsuccessful clinical trials and overreporting data from successful clinical trials, their habit of covering up potentially lethal side effects, and paying researchers huge sums of money to give lectures that promote their products have earned him the title of the enfant terrible of psychiatry.
Healy and others have commented upon the modern movement away from what has been called “psychobabble” (a derisive term for the psychological antecedents of mental-health problems) to “biobabble” (an equally derisive dismissal of biological primacy). The truth clearly lies beyond babble—in all of its extremes. Like all of life, human beings are affected by a complexity of interrelated stimuli.
The Movement from “Psychobabble” to “Biobabble”
When I was training to become a clinical psychologist in the late 1970s, some of my scientific colleagues (I was a cancer cell biologist teaching at a medical school when I retrained in psychology) made no bones about suggesting that I’d lost my ever-loving mind.
It’s all psychobabble, completely unscientific, some of them insisted, and made the usual Freudian jokes. “No wonder I’m such a data hound,” one quipped. “It’s all because of my toilet training! I think I’ll call my mother right now and say thanks. Or should I be angry at her instead for making me so obsessive that I’m hard to live with?”
These same colleagues changed their tune gradually over the years. They became fascinated with advances in neurobiology and the emergent understanding that brain circuitry isn’t set in stone—it can be changed by experience and behavior. My stock definitely went up, since scientists like science.
Psychiatry has long been considered unscientific— the impoverished stepchild of the other medical specialties. Modern medicine is based on understanding the etiology (the causation or origin) of illness and offering treatments to correct the underlying causes. The cardiologist can trace high blood pressure to various, mostly treatable, roots. The endocrinologist can prescribe weight loss, nutritional change, and exercise to reverse type 2 diabetes, or insulin to manage type 1 diabetes. The gastroenterologist can diagnose an ulcer and prescribe an antibiotic to knock out the bacteria that caused it. But psychiatry hasn’t had a biological basis until recently.
Freud and Jung, while fascinating and insightful, couldn’t reliably put their finger on a biological cause for anxiety, depression, or psychosis and then prescribe a cure based on evidence acquired from research. Both engaged in what some people derided as psychobabble. And interestingly, some of those individuals are now promoting biobabble, citing research that is inconclusive in order to appear “evidence based,” which is the currency of modern medicine.
The Hippocratic oath, which all physicians take, includes the vow never to do harm. But in the case of drug treatment for depression, most physicians are still unaware of the harm that they may inadvertently cause. Under the sway of biobabble and the convincing tactics of drug companies, they may be unaware of the specific risks and benefits of antidepressants. Therefore, understanding them as a consumer, even if your physician doesn’t, is critically important as you do everything you can to revive from burnout.
Please note: I am not making a case either for or against taking antidepressant medication. That is a decision that only you can make in collaboration with a physician who knows you well and understands your health history, symptoms, and life circumstances. All I urge is that you take the time to find the right physician to work with in managing your depression.
The Unexplained Risks of SSRIs
I hesitated to include this section at first because it’s controversial and disturbing. But for the sake of completeness, I believe it’s vital to address the entire anti-depressant conundrum. Dr. Healy, who was an early adopter of SSRIs, soon noticed alarming side effects in some of his patients, including intense agitation, restlessness, high anxiety, obsessive thinking, and suicidal/ homicidal thoughts and tendencies. There is no longer any question that Prozac and other SSRIs can sometimes cause a small minority of patients at low or no risk of suicide to kill themselves or become homicidal and kill others, often within days of beginning treatment.
While the majority of people on SSRIs will not commit suicide or turn into murderers, even my small, un-scientific Facebook sample of about 60 people revealed the following: one person had to quit Prozac because it enraged her; two suicides were reported by a third party in people taking antidepressants for pain who weren’t even depressed; one woman attempted suicide; one woman reported that her husband became significantly more suicidal than he’d been before treatment on a cocktail of antidepressants; and one woman stated that Prozac put her in what she called a “dangerous state of mind,” saying that “I could see how some people can commit suicide or homicide while on it.”
The SSRI Withdrawal Support Site, which is based in the U.K., is dedicated to compiling incidents of homicides and suicides that may be linked to SSRIs. The site includes dozens of cases such as:
Christopher Pittman, aged 12 (Paxil then Zoloft). Known amongst family as “Pop-Pop’s shadow”, he had always been very close to his grandfather. Shortly after being prescribed Zoloft he shot both his grandparents dead and burned the house down. Imprisoned, he waited 3 years for trial, and was then tried as an adult—a practice acceptable in the USA.4
Such sites are controversial, as is the possible effect of SSRIs on homicides. I Googled Christopher Pittman and discovered a Website created by his supporters, which displays a running clock tracking the days, hours, minutes, and seconds that he has been incarcerated. At the time of this writing, he was 19 years old and still in jail (he’d been given a 30-year sentence). According to the site, before being sent to live with his grandparents, he endured an unstable, chaotic home life and was prescribed Paxil and then Zoloft (apparently at higher-than-normal dosages) after threatening to kill himself. He has recently been granted another trial, and the jury is out as to whether or not the SSRIs provoked his homicidal actions.
Other people have fared somewhat better than this very unfortunate young man, at least in the eyes of the law. The U.K. Website lists several cases that concern seemingly mild-mannered individuals who underwent radical personality transformations, such as the following:
Donald Schell [aged 60] (Paxil). 48 hours after starting Paxil, he killed his wife, daughter, grand-daughter and himself. (Jury found Paxil at cause and ordered GlaxoSmithKline to pay $6.4 million to surviving family members.)
David John Hawkins, aged 76, Australia (Zoloft). Strangled his much-loved wife with no warning. (Judge found: “I am satisfied that but for the Zoloft he had taken, he would not have strangled his wife”.)5
Among the most famous homicidal activity that may or may not be connected with SSRIs involves Eric Harris, one of the teenagers responsible for the Columbine High School murder/suicide tragedy in 1999. Journalist Christopher Bollyn told the story of Mark Taylor, one of the first students shot. Taylor tried to sue Solvay, the international pharmaceutical company that produces Luvox (an SSRI) but was eventually dissuaded by threats of a libel countersuit, according to Bollyn, who also wrote the following:
In early 1998, according to [Mark] Taylor’s lawsuit, [Eric] Harris had taken Zoloft for two months, but soon became “obsessional.” Harris became obsessed with homicidal and suicidal thoughts “within weeks” after he began taking Zoloft. . . . Due to his obsession with killing, Harris was switched to Luvox [the same class of drug], which was in his system at the time of the shooting, according to his autopsy.6
Suicide, Depression, and SSRIs
To reiterate what I said earlier, most people who use SSRIs don’t commit suicide or turn into murderers, and many are helped. But there is still much to be learned about the marketing of drugs and how that market is created and sustained. Since the first reports of suicides linked to SSRIs were made public, drug companies have consistently discounted them in court and in written publications, arguing that those taking them were depressed to begin with and therefore already at a high risk for suicide.
According to Healy, they used data—which is still seen today on many mental-health Websites—stating that the lifetime risk of suicide for a depressive is 15 percent. In fact, I cited that same data in my last book (It’s Not the End of the World: Developing Resilience in Times of Change). The fear of missing a case of depression or not treating it adequately and having a patient commit suicide is daunting. That 15 percent statistic is compelling for health-care providers and patients. Who would want to forego medication with those odds? And what physician would want to risk a malpractice suit—or much worse, a patient’s suicide—by failing to provide what is widely believed to be “evidence-based” antidepressant drug therapy?
The classic article that generated the scary 15 percent suicide figure was a two-page meta-analysis (a study of studies) of severely depressed hospitalized patients published in The British Journal of Psychiatry in 1970 by Samuel Guze and Eli Robins, working out of Washington University in St. Louis. More recent studies have revised that figure downward substantially. According to a report on suicide prevention by the U.S. Department of Health and Human Services: “Best estimates are that suicide rates among those who had previously been treated for a depressive disorder as inpatients are about twice as high (4.1%) as those who had been treated as outpatients (2%).”7
As Healy notes, hospitalized patients with severe depression are not the ones given Prozac in clinical trials Those patients experienced mild and moderate depression that physicians in family practices are likely to encounter and treat—the kind you may experience in burnout. In an attempt to estimate the rate of suicide in depressed individuals in the community whose illness was too mild to warrant hospitalization, Healy and his colleague Jed Boardman arrived at an estimate of less than 30 suicides per 100,000 patient years for depressives in primary care. That means, for example, that if 10,000 patients were followed for 10 years (equaling 100,000 patients years) there would be 30 suicides in that group.
In contrast, a study of patients on Prozac cited by Healy documented 272 suicides per 100,000 patient years for people in their first month on Prozac. This translates to a ten-times greater relative risk of suicide for people with mild depression being treated with Prozac, which is marketed through the ironic scare tactic that without it . . . depressed patients are much more likely to commit suicide!
Antidepressants vs. Placebos
One of my pharmacology professors at Harvard Medical School in the late 1960s counseled our class to stick with prescribing older drugs whenever possible. A lot of patients respond to new drugs, he opined, due to the “placebo effect,” which is when patients respond to placebos (a “fake” treatment, such as a sugar pill or saline solution) because they believe that their medication will be effective. In other words, they think it will work, so it does. (In studies of individuals given mild electric shocks, for instance, those who believed that they were given a numbing cream beforehand reported that they felt less pain. The pain centers in their brain, highlighted with brain-imaging technology, actually showed less activity. Belief becomes biology.) Furthermore, my professor maintained, the long-term side effects of new drugs are unknown, so it’s best to stick with the tried-and-true.
The economic difficulty with my professor’s practical and reasonable approach, of course, is that drug companies don’t make any money from pharmaceuticals that have outlasted their patents and flood the market as cheap generics. And more and more, economic considerations rule, or at least play a major part, in the big business of medicine. After all, antidepressants were a $9.6 billion business in 2008.
It’s also important to note that some people who pursue lifestyle changes, therapy, and other measures simply aren’t helped. They only respond to antidepressants.
This wide variation in response is why the treatment of depression is far from an exact science. It’s an experiment that proceeds through trial and error. What works for one person may not work for another. And what once worked for a person may quit working altogether in a matter of months or a year or two.
A question that several SSRI researchers have asked is the degree to which a patient’s belief in the efficacy of a drug might influence the results of treatment. When patients trust that a medication will work, 30 to 60 percent get better even if they’re given a sugar pill. This is the placebo effect in action, and it’s a cornerstone of mind-body medicine.
Research scientists, including Healy, have wondered how much of the improvement in symptoms ascribed to SSRIs might occur due to the placebo effect. Healy points out that these drugs are powerful, changing brain chemistry and behavior. I can attest to that. My response to Zoloft was distinctly chemical. But are they really antidepressants, and if so, in which populations do they work—those with mild, moderate, severe, or very severe depression?
In February 2008, the psychologist Irving Kirsch, working at the University of Hull in the U.K., published a study that involved collaborators at several universities in the U.S. and abroad. Together, they fired a shot that was not heard round the world—and may never be. They found that SSRIs were no better than placebos except in the most severe cases of depression. In their abstract, the investigators summarized the impact of unpublished studies that drug companies were required to report to the FDA by law, but had never released to the academic community or general public. (Now you can understand why Healy insisted that not including such studies is bad science that masks poor results.) This is the conclusion that Kirsch and his co-authors made:
Meta-analyses of antidepressant medications have reported only modest benefits over placebo treatment, and when unpublished trial data are included, the benefit falls below accepted criteria for clinical significance. . . .
[Our] findings suggest that, compared with placebo, the new-generation antidepressants do not produce clinically significant improvements in depression in patients who initially have moderate or even very severe depression, but show significant effects only in the most severely depressed patients.8
This study wasn’t Kirsch’s first salvo. Back in 1998, he and colleague Guy Sapirstein of the University of Connecticut analyzed data from 38 manufacturer-sponsored studies, which showed significant improvement in 3,000-plus patients taking SSRIs and other types of antidepressants. Patients on placebos, however, showed almost the same level of response. Even after their findings were published, though, the romance with antidepressants continued. Over the next decade, the number of people taking them actually doubled.
Shortly after I finished drafting this chapter, the cover of the February 8, 2010, Newsweek announced “The Depressing News About Antidepressants.” Newsweek’s crackerjack science editor Sharon Begley began her article with these words: “Studies suggest that the popular drugs are no more effective than a placebo. In fact, they may be worse.” (The bolding is Newsweek’s, not mine.)
Begley’s article begins with a moral conundrum that has been bothering me since I first decided to include this chapter in the book. Can reports that antidepressants are no more effective than a placebo (at least for all but the most severely depressed patients) do harm?
If your depression is responding well to medication and then you find out that the result is due to your belief in the efficacy of the drug rather than the drug itself, will your depression return? No one knows the answer to that, but my bet is that those helped by the drugs won’t be bothered by the data on the placebo response.
When I discussed this subject with a medically astute friend, her jaw dropped. Her husband had been taking Prozac for 15 years and credits it with giving him his life back. I didn’t ask, but I suspect that she won’t be sharing Kirsch’s study or this chapter with him. Why upset the applecart? But even if my friend did, it might not matter. In one study cited by Kirsch, patients who found out that they were responding to a “dummy pill” for pain demanded to keep on taking it. After all, it worked just fine.
A couple of months after Kirsch’s new book, The Emperor’s New Drugs, which delves deep into the effectiveness of antidepressants, was released in 2010, I spoke to another knowledgeable colleague about it. He had heard nothing at all about either the book or the studies. This, of course, is the problem with modern research. There’s a lot of it. And unless you’re a research scientist, or have a particular interest in a topic, relevant studies may not cross your desk for a very long time. Even if they do, you might not have the expertise to vet them or the nerve to act on them.
Sharon Begley ends her article with an intriguing question: Is it more important to know the truth or let sleeping dogs lie? Kirsch thinks that if people know the truth about antidepressants, it might motivate them to try other forms of treatment first. Begley isn’t so sure. Based on the reception that Kirsch’s work got over a decade ago, it may be that people (including physicians) simply don’t pay attention to what they don’t want to know, or what contradicts their observations.
The question that holds the most interest for me, however, is why a placebo can relieve depression. It’s clearly not a direct biological effect, but an indirect one— no less powerful—that is the result of hope. Since depression is, by definition, a disorder of hope (a giving up and letting go of life), it’s remarkable that we can return to life so quickly, only because we believe it’s possible.
Cognitive-behavior therapy (CBT), overall, has a better track record than drugs in treating depression and preventing its recurrence. This practice is aimed at changing patients’ minds and getting them to question the reality of their negative beliefs: Is it really true that your life is worthless and that you’ve run out of options?
University of Pennsylvania psychologist Martin E.P. Seligman, the founder of modern positive psychology, has contended that disputing your pessimistic thought pattern can help lift depression. The National Association of Cognitive-Behavioral Therapists defines the craft in this way:
Cognitive-behavioral therapy is based on the idea that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that we can change the way we think to feel/act better even if the situation does not change.9
Drugs, perhaps, should be reserved for those for whom other treatments such as CBT are ineffective. The problem is, of course, that most people would prefer to pop a pill rather than engage in self-reflection and make lifestyle changes.
Please let me remind you again that if you are depressed and taking an SSRI or other antidepressant, under no circumstances should you discontinue it without consulting with your physician. You may be someone who benefits from the drug. In addition, withdrawal can be severe. Although SSRIs were developed as a response to the addictive potential of benzodiazepines (Valium, for example), they’ve turned out to be even more addictive. These drugs must be tapered off very slowly— and only under expert medical supervision—to avoid potential side effects such as extreme emotional lability, nightmares, severe anxiety, depression, hallucinations, short-term memory loss, suicidal/homicidal thinking, or blackouts.
Exercise as an Antidepressant
If SSRIs don’t always work, what alternatives are there to treating depression? The best are cognitive-behavioral therapy (as previously discussed); regular exercise; and a newer treatment called “hope therapy,” which helps people set goals and take reasonable steps toward accomplishing them.
My favorite alternative treatment is exercise. Studies of individuals with mild to moderate depression— many of whom were doubtless suffering from burnout in the first place—have demonstrated that regular physical activity is superior to SSRIs in ameliorating depression. My personal experience is that if I don’t exercise, I’m much more likely to suffer from moodiness and low-level depression.
In a study comparing Zoloft to working out, volunteer patients who were between the ages of 50 and 77 were divided into three groups. The first group exercised only: they rode a stationary bike, walked, or jogged for 30 minutes three times a week. The second group received the drug alone and didn’t exercise, and the third group exercised and took Zoloft. At the end of 16 weeks, all three groups showed significant and equivalent improvement, suggesting that consistent physical activity can relieve depression all by itself. And its side effects include better health and a longer life.
It’s vital to keep in mind, however, that what alleviates depression in one person may not help you. You need to find out what works best for you, as “Phyllis” did, who is a dear friend of mine and an accomplished artist and philanthropist. Anxious and depressed for most of her life (as was her physician father before her), Phyllis self-medicated with alcohol for many years until addiction finally brought her to AA. Neither antidepressants nor psychotherapy, unfortunately, were of any use in treating her depression, and she could never mobilize herself to exercise regularly. At the end of the day, only my friend’s strong spiritual belief in a Higher Power and working the 12 steps have kept her going.
There are many people like Phyllis for whom unexplained biological factors seem to be the primary cause of depression. But childhood experiences, stress, diet, and different levels of social support can affect the expression of genetic potential for better or worse. Some of the major predictors of both burnout and depression, it turns out, are adverse childhood experiences.
Let’s turn our attention to these, and take a closer look at the ways in which they predispose us to feelings of helplessness and wanting to give up.
