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Five Reasons to Think Twice About SSRIs

How well do SSRIs work for depression?

Key points

  • One study found SSRIs are no more effective in treating depression than a placebo pill. That means they are 33 percent effective.
  • People with high serotonin levels can be depressed and those with low levels can be happy.
  • Many doctors routinely prescribe not one but two or three SSRIs, says one study. Unfortunately, drugs have dangerous interactions.

For the past five years, and in my recent book Obsession: A History, I have been questioning the effectiveness of Prozac-like drugs known as SSRIs. I've pointed out that when the drugs first came out in the early 1990s there was a wildly enthusiastic uptick in the prescribing of such drugs. Doctors were jubilantly claiming that the drugs were 80-90 percent effective in treating depression and related conditions like OCD.

In the last few years, those success rates have been going down, with The New York Times pointing out that the initial numbers had been inflated by drug companies suppressing the studies that were less encouraging. But few if any doctors or patients were willing to hear anything disparaging said about these "wonder" drugs.

Now the tune has changed.

Reason One: A study in the Journal of the American Medical Association says that SSRIs like Paxil and Prozac are no more effective in treating depression than a placebo pill. That means they are 33 percent effective, which is the percent of patients who will respond well to a sugar pill. The article goes on to say that although SSRIs are effective to some degree in treating severe depression, they don't have any effect on the routine type of depression they are most often used to treat.

Reason Two: A January 4 article in MedPage Today cites a study done at Columbia University and Johns Hopkins. The study says that doctors routinely prescribe not one but two or three SSRIs and other psychopharmacological agents in combination with few if any serious studies to back up the multiple usage. The rationale is that if one drug doesn't work, then perhaps two or three will. Doctors are in essence performing uncontrolled experiments on their patients, hoping that in some scattershot way they might hit on a solution. But of course, drugs have dangerous interactions.

Reason Three: More and more psychiatric disorders are appearing which might be called "lifestyle" diseases. What was called shyness, sadness, restlessness, shopping too much, high sex drive, low sex drive, and so on have increasingly been seen as diseases and many more will appear in the new DSM, the diagnostic manual of psychological and psychiatric disorders. Increasingly the criteria for inclusion in the DSM involve whether the disorder responds to a category of drugs. If response drops to one of the key classes of drugs that has been considered effective, what does that say for the idea that if a condition responds to a particular drug, then it is a particular disease? We have to rethink the whole biological basis for lifestyle disorders.

Reason Four: We're an overmedicated society, and the goal of drug companies is ultimately to have some drug coursing through every individual's bloodstream. It's a lot easier to quickly pop a pill or prescribe one than it is to explore the reasons for a person's distress.

Reason Five: The whole serotonin hypothesis is challenged by these findings. What this new information shows is that there may be some help using SSRIs if there is a severe shortage of serotonin, but the average person's depression cannot simply be related to a "chemical imbalance." The human brain is too complicated. We have no way of measuring serotonin in the brain of a living person, short of cutting open the skull. We have not come up with what a normal level of serotonin should be and below which we can say that you would be depressed and above which we can say you will be happy. People with high serotonin levels can be depressed and those with low levels can be happy. We have to go back to the drawing boards on this one.

What Should You Do?

Think twice, be skeptical, and question a simplistic diagnosis you might receive after discussing your condition for a short time with a rushed practitioner. Drugs may not be the answer for you, and some drugs may not be the answer for almost anyone.

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