Tuesday, February 20, 2024

Overstatement in the critical narrative of antidepressants

I agree with a lot of what Jon Jureidini says in The Conversation (see article) about why so many Australians in particular, and people globally, are taking antidepressants. However, as I've always said about Jo Moncrieff (eg. see my review of her book The bitterest pills), who is one of the principle proponents of the critique of antidepressants expressed by Jon, I do find niggling overstatement in the narrative.

Certainly too much antidepressant prescribing reflects the overmedicalisation of society (see previous post). I think that antidepressants may just be another example of doctors' shameless exploitation of the placebo effect (see another previous post). I also have concern about the misinformation the public are being given about side effects of antidepressants (see yet another previous post).

For example, Jon says that antidepressants are emotionally numbing agents. I’m not sure what he means by this. Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants are generally not very sedative compared to the older tricyclic antidepressants. I agree that antidepressants may prevent people dealing with their problems properly over the longer term. But Jon seems to mean more than this and I’m not clear what he is saying. Certainly people over the longer term report that taking antidepressants often leaves them with a sense of not being themselves (see previous post). They may well say that they experience a flattening of emotional responses. But I don’t think people generally notice that antidepressants on first starting have the physiological effect of emotional numbing, whatever that is.

Of course I’m not denying antidepressants can have a placebo effect. Taking a pill which people are being told improves mood will commonly counteract the demoralisation people generally feel in depression, particularly in those that believe this could be true. As I said, for example, in my OpenMInd article, “Expectation that medication will produce improvement may itself produce apparent benefit”. But, over time, the placebo effect may not last, or may diminish, or may even create other problems, perhaps especially over the very long term. These nocebo, meaning negative placebo, effects also need to be taken into account in assessing the psychological impact of taking medication. Adopting the view that one suffers from a biochemically based emotional illness can be an identity-altering experience (see previous post). 

As Jon says, it’s important to emphasise that maybe as many as half of patients stop antidepressants within weeks. Again as Jon says, and here I think he means those that do continue them beyond several weeks, antidepressants should generally be tapered rather than stopped abruptly. Unlike Jon, though, I would say this is only generally the case. How easy people find discontinuing antidepressants can vary considerably. This is not to deny the importance of withdrawal symptoms with antidepressants (see eg. previous post). 

I also agree with Jon about the importance of social factors in depression, although how depressing people find being poor, for example, does vary considerably. My final quibble is about Jon suggesting overprescribing is symptomatic of the medicalisation of distress. Actually, as I’ve already said, I agree overprescribing is a symptom of the overmedicalisation of distress. But the problem is too much medicine, not medicine itself. Psychiatry needs to be far more psychosocial, rather than biomedical, in its approach to depression and other mental health problems. It needs to stop reducing functional mental illness to brain disease.

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