How may antidepressants worsen the long-term outcome of depression?

Robert Whitaker in his latest posting on his Mad in America blog (to which I have referred before) elaborates on the work of Giovanna Fava about the vulnerability to relapse created by taking antidepressants. Fava has produced a recent review in which he builds on his hypothesis that the neurobiological mechanism underlying the increased vulnerability is due to oppositional tolerance. By this he means that the effects of the drug are opposed or counteracted by homeostatic changes in the brain, and when drug treatment ends, these processes may operate unopposed.

I am cautious about calling the effect 'tolerance'. Unlike, for example, alcohol, there is no evidence of the need to increase the dose or concentration of antidepressants to produce the desired effect. Maybe what Fava means is a tolerance-like effect.

More fundamentally, I'm not convinced that looking for an underlying neurobiological explanation is the real way to look at the issue. Surely the problem is psychological dependence. As I've said in a previous post, doctors concentrate too much on the physiological explanation of drug effects. People form attachments to their medication more because of what they mean to them than what they do. It's an identity-altering experience taking antidepressants. Discontinuing them is going to cause all sorts of problems which take time to make sense of.

The official view about mental illness

I was not intending to be personal about the bloggers on Healthy Minds. Heathy Lives. in two of my previous postings (see link to the first and to the second). The reason I've focussed on this blog is because it's published under the auspices of the American Psychiatric Association (APA). It therefore has the official backing of American psychiatry.

I've expressed concern before about the biomedical bias which has developed within the APA (see article). It's not so long ago that the APA was more pluralistic. Although I stand to be corrected, I think the Royal College of Psychiatrists in the UK would be more cautious about tying its ideological understanding of mental illness, at least in official statements, to a biomedical model.

Loren Mosher resigned from the APA in 1998 saying it had become the American Psychopharmacological Association rather than the American Psychiatric Association (see his resignation letter). Will the Healthy Minds. Healthy Lives. blog allow a debate about this situation? I doubt it, which I think is a cause for concern.

More on stigma of mental illness

The psychiatrist, Gariane Phillips Gunter's, MD, latest blog on Healthy Minds. Healthy Lives. has a video of her in which she argues that mental illnesses are "not your fault" because they are “biological illnesses, just like having high blood pressure, diabetes or cancer". She believes her crown as Mrs United States 2008 gave "her a greater opportunity to be a voice across this great nation for patients with mental illness and their families".

Reducing stigma is welcome but should not be based on a speculative biological theory of mental illness. As mentioned in the previous post, such a theory could actually increase stigma, as it doesn't really promote understanding of mental illness. As I keep saying, please do not misunderstand me. Of course, our thoughts, behaviour and emotions have their origins in the brain, but if that's all that Dr Gunter's saying, it's merely tautologous. However, she's making a statement about how we understand the world and it's not right.

Genetic theory not cure for stigma of ADHD

Ben Goldacre, in an article in his Guardian Bad Science column, comments on the Lancet ADHD study (as have I in a previous post). What he emphasises is that in fact a genetic theory of ADHD may actually potentially increase, not decrease, the stigma of the condition by encouraging a social distance from people identified as genetically damaged.

Can there be an open debate about biomedical psychiatry?

Robert Whitaker, in a posting on his Mad in America blog, writes about how he sometimes loses the hope that "our society will ever be able to have a thoughtful, honest discussion about what is truly known about mental disorders, and about the merits of psychiatric medications". I understand the sentiment. However, we do need to remind ourselves that biomedical psychiatry is a cultural system. Like a religion, it expresses a view about the nature of the world that provides what Clifford Geertz called an 'aura of factuality'. This feeling of realness is not easy to upset. People don't want to have their worldview turned upside down.

Whitaker's books The Anatomy of an Epidemic and Mad in America are well worth reading. One of their main themes is the vulnerability created by taking psychotropic medication. Relapse rates when people stop medication are very high. There is also evidence of a loss of benefit emerging with long-term treatment and also on retreatment after discontinuation of treatment. People may actually do better over the long-term if they work through their problems without medication. This is a legitimate scientific hypothesis (eg. Can long-term treatment with antidepressant drugs worsen the course of depression?).

(with thanks to News and Alerts from Mind Freedom International)