Why Antidepressants Don't Work

Diagnosing Depression

You go to the doctor complaining that you don't feel like yourself.  You aren't having fun, you are tired, you don't sleep well, you have no appetite and feel pretty worthless about your inability to exercise control over anything in your life.  Sometimes you feel like just ending it all.

Your doc asks whether you have a plan (sometimes you think about how you might do it), if anyone in your family has bipolar (not that you know of) and checks your thyroid and glucose levels.

DSM On Depression -- The Chinese Menu

But before the blood tests come back, your doc has already checked the magic list from the Diagnostic and Statistical Manual of Mental Disorders:

Column A:

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

Column B:

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.

4. Insomnia or hypersomnia nearly every day

5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

6. Fatigue or loss of energy nearly every day

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

Ding, ding, ding.  One from Column A, four from Column B. (Your weight loss has been too gradual to count.)  That is all the doc needs to write out a prescription for an antidepressant.  Zoloft is the latest favorite, being the newest.  But if your drug coverage is lousy, you get fluoxetine -- Prozac in its non-generic incarnation.

Depression As A Chemical Imbalance?

You are not sure you want to take an antidepressant.  But your well-educated neighbor assures you that there is no shame in it.  It's not your fault.  Depression is a chemical imbalance in the brain, and antidepressants fix the imbalance.
 

I call this the chemical stew theory.  Your brain is too bland.  Add some salt and you will be good to go.

What a great marketing technique.  It's simple.  It's morally neutral.  It's even kinda manly, if that's an issue for you -- chemistry, you know.  And your next door neighbor, whose education comes from TV ads, is part of a sales force which has been so effective that one out of every ten people in the United States of America is taking an antidepressant right now.

Too bad it hasn't worked out.

No -- Antidepressants Do Not Fix A Chemical Imbalance

There are a couple reasons (at least) why adding a chemical to the stew does not solve the chemical imbalance.

The first reason is that your brain is not a stew.  If you like the food metaphors (and as you can see, I like the food photos), adding a chemical to your brain is more like adding it to a souffle.  The chemical balance in your brain is finely tuned to a variety of interacting factors.  Changing one of the factors has multiple effects, not all of them intended, and not all of them so good for you.

For example, a souffle has fat in it.  Maybe the problem with your souffle is not enough fat.  But when you mix fat into the egg whites, the whole thing falls flat.

The second reason antidepressants fail to do their intended job is that they do not address the problem at the right location. The theory suggests you can fix the imbalance by increasing the serotonin in your synapses.  But scientists have figured out the problem occurs farther upstream.

Or at least that is what the scientists say who fund their labs with money from the pharmaceutical companies who still want to add a chemical to your brain, just maybe a different chemical than the ones whose patent protections have expired.

The Brain As Machine

The new meds are not going to work either, because they are working with, not a food, but a mechanical metaphor.  So second millennium!

Like this:



If only they can find the right place to change the course of the inevitable falling blade?  I don't think so.  Your brain is not a machine.

The Brain As A Living System

Here we go:

Your brain is a whole world.  Those who would tinker with it need to understand its ecology.

Put the internal combustion machine onto this planet, and the whole rest of it experiences the consequences.

Block serotonin from reentering your neurons, and your tear ducts and intestines dry up.  And your sex life.  Put enough of us on antidepressants and we could become an endangered species.

So if you want to do something about depression, if you have it or love anybody who has it, then you have to pay attention to the ecology.  Your interventions will have complex consequences.

And -- this would be a third reason and most intractable reason why antidepressants don't work -- the planet/body/brain/ecosystem is always working to restore balance to the system.  Up the serotonin in your synapses and eventually another part of the brain adjusts to overcome your interference.  In ecology this phenomenon is called homeostasis.  Psychiatry calls it Prozac Poop-out.

I kept complaining about insomnia, one of my Chinese menu choices that did not go away.  A psychiatrist told me my symptoms were caused by my depression.  Address the underlying depression and eventually the symptoms would be relieved.  Never mind about the symptoms that replace them.  Those symptoms are not on the depression menu, and have nothing to do with the psychiatrist.

A Twenty-First Century Approach To Depression?

But systems theorists tell us that any intervention will move the whole rest of the system.  This works in the environment, the economy, the workplace, the family dinner table.  And in the brain.

So what if we go back to that menu and devise some interventions that are not the equivalent of a chemical sledge hammer?

That brings me back round to last week's post about insomnia, when I promised that the next installment of my sleep series would be:

The Good News About Sleep Deprivation and Suicidality 

The good new is coming next -- implications for treatment of mood disorders and other causes of suicidal thoughts and behavior.

It just took me an extra week to get there.  So what else is new.  It's a Prozac Monologues series.

photo "Loneliness" by  Graur Razvan Ionut, from FreeDigitalPhotos.net 
photo of Chinese menu by Hoicelatina, permission to copy under the terms of the GNU Free Documentation License 
photo of bell by Salvatore Vuono from FreeDigitalPhotos.net 
representation of serotonin in public domain 
 photo of pote asturiano by jlastras and used under the Creative CommonsAttribution 2.0 Generic license 
photo of chocolate souffle by Akovacs.hu at the wikipedia project, who has released it to the public domain
representation of lactic acid in public domain
NASA photo of the Earth in public domain
photo of Anthia goldfish in public domain