For drug companies, antidepressants are one of the great success stories. Starting in the early 1960s, and especially over the past 30 years, drug manufacturers have pulled in hundreds of billions of dollars (that's with a B, and also USD) from these products. Starting from a low base of 1% in about 1990, increasing numbers of adults take these drugs regularly, and generally in the long to very long term. In Australian, it's now about 12% of adults take them but in the UK, it's nearly 16% of adults. What's happened? Have we all turned into sad parodies of The Man from Snowy River or The Drover's Wife, delicately reflecting on our sorry state in life when, in fact, we've never had it so good?

Part of it has been a relentless campaign to convince everybody that

(a) depression is very common,

(b) once you've got depression it's got you and will keep coming back, because

(c) it's a genetic chemical imbalance of the brain for which

(d) drugs are essential, effective and safe.

The campaign has been to change everybody's perception of depression from "Get a grip" to "It's an illness like diabetes so take your tablets." This has been directed at the people who pay for the drugs (mostly the government), the people who prescribe them (overwhelmingly general practitioners), and the people who take them (predominantly women).

The story that depression is a "chemical imbalance" is pure propaganda. For a profession that likes to tell everybody it is "evidence-based," there is not and never has been any convincing evidence that depression can be explained on the basis of a brain disturbance. The so-called "serotonin hypothesis" was finally put to death in July last year when Joanna Moncrieff and her associates in the UK published an extensive survey of the psychiatric literature [1]. They concluded:

The two largest and highest quality studies of the SERT gene, one genetic association study (n = 115,257) and one collaborative meta-analysis (n = 43,165), revealed no evidence of an association with depression, or of an interaction between genotype, stress and depression. The main areas of serotonin research provide no consistent evidence of there being an association between serotonin and depression, and no support for the hypothesis that depression is caused by lowered serotonin activity or concentrations .

That should have settled the matter but it doesn't explain why so many people are taking drugs when they didn't actually have the "chemical imbalance" to start with. Part of the answer is that they may not have had a chemical imbalance when they started the tablets but they very soon did because, as intended, that's what the drugs do, they produce chemical changes in the brain. The trouble is, the brain is a very clever organ. If anybody is unlucky or silly enough to undergo a chemical change, the brain quickly adapts and tries to neutralise that change. This takes a while as the brain has to build up its chemical stores, or maybe grow new extensions to the nerves, which usually takes weeks or even longer. This effect, called habituation, has been known forever. People who regularly drink alcohol are much more resistant to its effects than somebody who hardly touches the stuff. Same goes for morphine and cocaine and other stimulant drugs.

This is the basis of drug addiction. Morphine suppresses brain function, the brain must fight it so it changes physically to deal with the physical assault of the drug. With habituation, drug users become resistant to the drug and need to take more and more to get the same effect. Trouble is, if they then suddenly stop the drug, the brain now has to revert from the drug-induced, abnormal state to its normal or drug-free state. That has a price, and the price is severe physical and mental symptoms caused by the brain undergoing rapid physiological changes. That effect is known as drug withdrawal. Withdrawal can last as long as it likes and is extremely unpleasant and potentially dangerous as it can result in convulsions leading to permanent brain damage or even death. It can also drive people to kill themselves, either in desperation or from psychotic symptoms such as delusions or threatening hallucinations. You may have heard stories of people withdrawing from alcohol getting "the DTs" (delirium tremens) or the rats or the joe blakes, from seeing rats or snakes crawling up the walls. That was real and dangerous.

Withdrawal is so typical of the effect of these drugs that it has been part of the definition of addiction for many years: "Addictive drugs produce euphoria, cravings and drug withdrawal effects." This is not a good definition as tobacco is generally regarded as one of the most addictive drugs known but it doesn't produce euphoria, or a "high." The other point is that once people are truly addicted, they generally don't experience much in the way of euphoria. The search for euphoria gets them addicted, then the addiction is maintained by fear of withdrawal.

And so we come to antidepressants. A week ago, the online paper, The Conversation, published an article by a pharmacist from Brisbane, for people thinking of stopping antidepressants [2]. Considering going off antidepressants? Here’s what to think about first, by Ms Treasure McGuire, from the Mater Hospitals, gave a brief rundown on how to go about stopping these drugs. Rather unusually, the article was republished by the ABC with a link to one of their videos on withdrawing from antidepressants, which was quickly taken down. It's a light read, and briefly mentions that "How antidepressants work is not completely understood." We have to stop here, because this sets the tone of the article: nobody has more than the faintest clue what these drugs do, and most of what they do know comes from rats. This sentence is typical of the material put out by drug companies. It implies that psychiatry has a solid scientific basis when we know it doesn't. Moving on, she says:

Stopping antidepressants (or tapering down the dose) too rapidly can cause antidepressant discontinuation syndrome in around 20 per cent of people.

I don't know where this figure comes from, my experience is that practically everybody who stops the drugs abruptly will suffer moderate to severe withdrawal effects. A 2018 survey in New Zealand by psychologist Prof. John Read and colleagues [3], found 55% of people taking antidepressants suffered withdrawal effects, and 27% considered themselves addicted. None of this is mentioned in McGuire's little article. She continued: "Symptoms typically occur within ten days and usually resolve in two to three weeks." Here, we probably do know where she gets this, the Royal College of Psychiatrists (RCPsych) in the UK. A few years ago, the president of the RCPsych breezily announced:

We know that in the vast majority of patients, any unpleasant symptoms experienced on discontinuing antidepressants have resolved within 2 weeks of stopping treatment [4].

This, I suggest, was simply made up. She certainly didn't get that information from patients. Withdrawal effects, especially from paroxetine (Aropax), fluoxetine (Prozac) and venlafaxine (Efexor), can be severe to disabling and can last many months, up to two years. Would the president of a college of psychiatrists make something up? Sure, why not? When it comes to maintaining the narrative that psychiatric drugs are safe and effective, facts are a nuisance [5]. After a fairly nasty argument, Read and his co-workers managed to get the RCPsych to withdraw that comment and replace it with facts: withdrawal effects can be severe, serious and long-lasting.

As reported last week, the UK NHS plans to start a program to help people withdraw from antidepressants and other addictive prescription drugs. That wouldn't happen if withdrawal effects lasted only two weeks. But note that when talking about the effects of stopping antidepressants, psychiatrists don't mention the W-word, because that means addiction, and addiction only happens to bad drugs (implied but not stated: And only bad people take bad drugs). Instead, they use the twee expression "discontinuation syndrome." That's marketing talk for "Withdrawal."

So this brings us to a crucial point which the article on drug withdrawal very carefully didn't mention: When the suicide rate and the rate of new pensions for depression are going up and up, why are so many people taking antidepressants, and why are they taking them for so long? The answer is that they are addictive. People can't stop them because every time they try, they develop withdrawal effects which firstly, are terrible and can be very frightening and second, they often mimic the original condition. Thus a person suffering drug withdrawal can have the impulse to end it all, which is not taken as a drug effect but is seen as "OMG it's your depression again, quick, get back on the tablets."

When people are given correct information about antidepressants, most will refuse them. If they are told "They're not very effective, they have a huge list of serious side effects including massive weight gain and loss of sexual function which can be permanent, and they're highly addictive, so let's start with a psychologist," the great majority will go for the talking cure. But it definitely isn't in the interest of the drug companies to put people off their products, so why did this article appear, and why did the ABC carry it? I don't know, perhaps the drug companies have realised that denying their products are addictive is no longer working, so they're moving to Plan B: "Addiction? Don't worry yourself about that, storm in a tea cup. Now here's your prescription..."

In the US, deaths from opiate addiction have actually caused their average life span to shrink, which is practically unknown in the developed world. Of course, synthetic opiates were sold as "non-addictive," which is exactly the story that has been put about for psychiatric drugs. The bad news is that addiction is no longer something that happens to all those awful people sleeping rough on the city streets, it also happens to nice people dutifully taking their prescribed tablets. Addiction to prescription drugs is shaping up to be the next pandemic. Denial doesn't seem to work as well as it used to.

And to cap it all, there's a recent report that says running is just as effective in dealing with depression as antidepressant drugs, and it improves general health whereas the drugs cause worsening general health [6]. Now who would have expected that?

References:

1. Moncrieff, J., Cooper, R.E., Stockmann, T. et al. (2022) The serotonin theory of depression: a systematic umbrella review of the evidence. Mol Psychiatry

https://doi.org/10.1038/s41380-022-01661-0.

2.McGuire T (2023) Considering going off antidepressants? Here’s what to think about first. The Conversation, Feb 28th 2023.

Also at: https://www.abc.net.au/news/2023-02-28/going-off-antidepresants-heres-what-think-about/102028506

3. Read J, Cartwright C, Gibson K (2018). How many of 1829 antidepressant users report withdrawal effects or addiction? Int J Mental Health Nursing. doi: 10.1111/inm.12488.

4. Read, J et al (2018) Complaint to Royal College of Psychiatrists re drug withdrawal. March 9th 2018. Available at: http://cepuk.org/wp-content/uploads/2018/03/Complaint-to-RCPsych.pdf

5. McLaren N (2018). Questioning the Integrity of Psychiatry.

https://www.madinamerica.com/2018/05/questioning-integrity-psychiatry/

6. Verhoeven, J. E.,et al (2023). Antidepressants or running therapy etc.

Journal of Affective Disorders. https://doi.org/10.1016/j.jad.2023.02.064