Let’s talk about drugs, placebos, “talk therapy” and new research...
Too many of us are anxious, depressed and stressed these days, with COVID worries piled on top of everyday stressors. We know COVID is here for a while yet, perhaps for a long while. So, how do we cope? Is medication the best answer? New research suggests that other treatments are just as effective, except in the most severe forms of these conditions.
Let’s start with a simplified explanation of anxiety and depression:
Depression is a low mood driven by dwelling on events of the past. Anxiety is a negative mood associated with worry about future events. Mindfulness is focusing on, enjoying and appreciating what’s good about the present moment. Mindfulness, relaxation exercises (like deep breathing), meditation, and “talk therapies” (like phychotherapy, and cognitive behaviour therapy [CBT]) seek to break the cycle of repetitive unpleasant thoughts that, over time, can make us depressed or anxious. The more we focus on these thoughts, the stronger these brain thought pathways become, the more often these thoughts pop into your mind, and the more difficult it can become to enjoy the present moment.
So, this is how psychotherapy (talk therapy) works: It helps you train your brain to block negative thoughts and focus on positive ones. I’m simplifying here, of course. Psychotherapy is a complex science that requires highly trained professionals for ideal results. But it’s important to know that your “self-talk” has an influence on your mood and happiness. It’s something that many of us can learn to control.
How antidepressants work
For decades, health professionals have been taught that low levels of the neurotransmitter, serotonin, were responsible for low mood and depression. I remember learning this at an education program for practicing pharmacists many years ago, probably back in the ‘80s when Prozac first came on the market. The education session was sponsored, I’m sure, by a pharmaceutical company that manufactured a drug that influenced serotonin. Most education sessions were paid for by companies, as our professional associations were not well funded, and it was a common way for manufacturers to educate health professionals about their products in those days.
I remember how they explained that depression was caused by an imbalance in brain chemicals, and antidepressant drugs would rebalance the brain chemistry. Drugs that increase the effects of serotonin have been a mainstay in the medical treatment of depression for decades and they are also used to treat anxiety, obsessive-compulsive disorder, post-traumatic stress disorder and other mental health conditions.
A new study says otherwise...
However, a large new study in the UK found no convincing evidence that low serotonin levels are responsible for mental illness. It seems that this was only one of several theories of the cause of depression proposed in the ‘60s. When serotonin drugs were developed beginning in the 1980s, health professionals (like me!) were taught the serotonin theory as if it were fact, when it was really just one of several unproven theories. The observation that these drugs seemed to help was used as "proof" of the serotonin theory.
But it turns out that half of the studies performed by antidepressant drug manufacturers were never published because they showed a negative result. This is called “publication bias” where study results that don’t give the desired result are simply not published. Science is not a democracy, where the majority of results “win”. In other words, any negative result should be questioned: why is the drug not producing a consistently positive result? In order to make the drug results show a significant improvement over a placebo (or sugar pill) they had to “cherry pick” the studies they published.
Another problem with the studies comparing drugs with placebo, is that they were difficult to “blind”. To make a proper comparison that eliminates bias on the part of patients, doctors and researchers, no-one involved in the study should know who actually received the drug and who took a placebo until it’s completed. But because of the side effects from the drug, it was difficult to blind the gathering of the data properly... another problem with the drug trials that could make the drug look better than placebo.
Added to publication bias, this could easily explain how manufacturers were able to sell their drugs despite the small differences found between drug and placebo in mild to moderate depression. Note that the American Medical Association (AMA) recommends using psychotherapy as first line therapy except in cases of severe depression.
But the drugs seem to work for many people...
But the drugs do work 80% of the time. It’s just that placebos were shown to work almost as well as the drugs in the studies—75% benefitted from the placebo, according to analytical researchers (but not mentioned in drug description monographs). This begs the question: why wouldn’t we use placebos as a treatment for anxiety and depression? They obviously work exceptionally well for mental health conditions, triggering our bodies to heal ourselves in the majority of cases without the side effects that drugs cause.
Note that psychotherapy/counselling has also been found to be equally effective to drug therapy in mild to moderate depression and has a longer-lasting effect than drug treatment. The exception would be in severe suicidal major depression where the emotion-numbing effect of these drugs can make a difference in the person’s safety, reducing suicide risk. Medication has been shown to work better than other therapies in more severe depression.
If you’re interested in reading more about this, check out reference #5 below... an article by Irving Kirsch, a researcher who has been examining the placebo effect for many years.
Back to the UK study...
"It's not an evidence-based statement to say that depression is caused by low serotonin; if we were more honest and transparent with patients, we should tell them that an antidepressant might have some use in numbing their symptoms, but it's extremely unlikely that it will be the solution or cure for their problem," says study author, Mark Horowitz.
This seems to fit with the delay in action of these medications—it generally takes 2 or more weeks for them to start working. One researcher described it this way: emotional reactions are dulled by the drug, and begin to have less impact on mood. Eventually depression or anxiety improves because of lowered negative emotional input.
Interestingly, some experts in the field of psychiatry have stated this is nothing new... that they’ve known for years that low serotonin was not the cause of depression but that it is a complex condition with several contributing factors. However, it seems that this was not communicated to front line workers or patients, and the new study is causing quite a stir in the medical media.
Complex conditions often benefit from a combination of several treatment strategies, so simply handing a patient a prescription and advising a follow-up appointment in several weeks might not be an ideal approach to treatment. Working to change thought input can help to correct the patterns that led to a mood disorder in the first place, and could help to prevent a recurrence.
Brain “plasticity”
Meanwhile, other research into brain function has shown that our brains are much more “plastic” than was previously thought... meaning that we can change our thought patterns and the actual number and strength of connections between neurons (nerve cells in the brain) that connect thoughts, memories and emotions to our consciousness. The old statement that a person can’t think their way out of depression is likely not correct, although it could be difficult in severe depression. This suggests that “talk therapies”, like psychotherapy, cognitive behaviour therapy (CBT) and counselling, may be the preferred approach to mental health instead of medication, with medication added only in more severe cases.
And the American Medical Association (AMA) recommends psychotherapy as the first line treatment for mild to moderate depression. In more severe forms of depression, especially when there is a risk of suicide, they recommend that drugs should be included in the first choice of treatments. But, all too often, doctors reach for the prescription pad when they hear a patient describe even mild symptoms of anxiety or depression.
As well, side effects need to be considered. In addition to a long list of side effects while taking antidepressant medications (including drowsiness or insomnia, nervousness, digestive complaints, anxiety, tremor, dizziness, sexual dysfunction, and more), a rebound effect often occurs when the drug is stopped. This has often been misinterpreted as a return of symptoms of depression in the past, resulting in patients staying on medication for years. Patients are now advised to taper their medication slowly, under the supervision of their doctor to reduce rebound effects when discontinuing antidepressants.
Of course, like any ailment, mental health conditions are best treated early, before they become severe. Just like a house fire, you’re better off putting the flames out before the entire house is on fire. Seeking counselling early can give a person the tools to rewire the brain before the nerve connection pathways to negative thoughts become more strongly entrenched, leading to a more severe depression/anxiety state that has a greater effect on the person’s life and is more difficult to treat. What about natural treatments? Another recent study looked at the use of vitamins B6 and B12 specifically for mild anxiety symptoms. It confirmed that B6 at relatively higher doses than normally consumed in food (100mg daily) could help reduce symptoms of anxiety. Vitamin B12, in comparison, made only a small difference in this study.
“Stress formulations” containing mainly B vitamins have been available for many years on pharmacy shelves. A vitamin B Complex-100 tablet, taken once daily, would also provide the amounts used in this study. For many years I have suggested women try taking this at bedtime (for middle of the night awakening) or at suppertime (for trouble falling asleep) when they have difficulty sleeping due to mild anxiety. Improved sleep has been found helpful in overcoming mood disorders. A final caution: It is important not to stop taking your medication abruptly. Be sure to discuss options with your doctor before making any changes to your medical treatment.
#depression #anxiety #SSRIs #Serotonin
References:
No Evidence Low Serotonin Causes Depression?--Medscape
Analysis: Depression is probably not caused by a chemical imbalance in the brain – new study—University College London
What has serotonin to do with depression?--World Psychiatry
A Popular Theory About Depression Wasn’t "Debunked" by a New Review—Neuroscience News and Research
Antidepressants and the Placebo Effect—PubMed Central
Prozac (official drug monograph) (Note side effects, warnings and the lack of data on effectiveness compared to placebo)
Vitamin B6 may reduce anxiety symptoms, study shows—Medical News Today
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