Fredric Neuman M.D.

Fighting Fear

The Problem with Antidepressant Drugs

They do not always work.

Posted May 29, 2018

Antidepressants have been around since the mid-1950s.They came into use at the same time as Thorazine and other antipsychotic agents. Mental illness was such a pervasive and devastating problem at that time that every other hospital bed in the country was occupied by a psychiatric patient. Often the hospital stays stretched out for years, sometimes decades, and sometimes until the end of life. Thousands of patients were housed in state hospitals with little more than custodial care.

The drugs changed all that. Nevertheless, there was a professional resistance to these changes, at least in some psychiatric circles. Even when I started training in 1961, some of my teachers claimed that the use of these drugs prevented patients from “getting in touch” with their own feelings. I thought they prided themselves on their ignorance of these drugs. Beginning psychiatric residents had to learn from more senior residents how to prescribe them.

Although everyone who used the antidepressants was convinced of their effectiveness, proving that they worked was difficult. There were two major classes of such dregs: the tricyclic antidepressants, such as Tofranil and Elavil, and the MAO inhibitors, such as Nardil and Marplan. Conducting double-blind studies on the tricyclics, for instance,  was not definitive, since their side effects, such as sweating and dry mouth, made it obvious which was the drug being tested and which was the placebo prescribed as a control. Besides, the benefits only appeared over a period of weeks.

Since then other drugs have been developed, including the so-called serotonergic agents, such as Prozac and Zoloft. These drugs, and still others, have become the first choice of most psychiatrists, although they do not really work any better than those developed initially. However, their side-effects are fewer. Still, in the majority of cases a second and sometimes a third drug has to be added in order to achieve  maximum effectiveness.

The debate about whether or not these agents work has continued into the present. The current consensus is that they work well enough for major depression but not on those that are less severe. I think stating the problem this way misses the point.

Antidepressants work very well against a major depression, which is not simply a severe depression, but rather a kind of illness. Simply feeling sad will not respond to drug treatment. A major depression used to be called an “endogenous depression,” meaning it came spontaneously from within. This was contrasted with a “reactive depression,” which was simply a response to circumstances. Obviously, s drug cannot compensate for the varied inadequacies that human beings may encounter in their lives. In fact, the word, “depression” is used even more imprecisely  most of the time.

“Depression” often refers to a simple sense of sadness, which is part of the human condition.  Sadness per se does not imply an unhealthy or even an undesirable state of mind. Sadness, like any other emotional state, serves to drive certain behaviors. Failure and the resultant sadness motivates an individual to try harder. Loneliness and the sadness that accompanies it drives people toward others. And so on.

But there are depressed states that are so severe they may be considered pathological—problems requiring treatment These are some:

Some men and women have a persistent sadness that grows out of ideas they have developed about themselves and about their environment. Someone told throughout childhood, in one way or another, that he/she is “no good” will grow up feeling incompetent, undesirable, guilty and, often, a failure. And depressed. This sort of depression is low-level, but constant, stretching over the years. It responds, when it does respond, to psychotherapy. Of course, drugs cannot be expected to expunge these ideas, and when they are given to such patients they will not work.

Similarly, virtually everyone is vulnerable to the consequences of a severe loss, such as the death of a parent or child, the loss of a valuable job, the development of a disability, or rejection by a loved one. The resultant depression can be severe, even life-threatening.  If such a patient comes to a psychiatrist talking about suicide, he, or she is likely to be prescribed antidepressants, but they will not work. These are not feel-good pills that work on anyone. The affected individual will only recover when the missing parts of life are recovered. The jilted lover will feel better when someone new appears. The lost job is forgotten when a new one is obtained. Even death can be compensated for over time when new people and new occupations enter into life. Supportive psychotherapy is the indicated treatment for such patients. Sometimes antidepressants and/or tranquilizers may be prescribed largely for their placebo effects.

There are true illnesses that manifest themselves primarily with depression. These can be distinguished from the conditions mentioned above by their signs and symptoms. Putting to one side the depression of bipolar disease, most major depressions are marked by what are called “vegetative symptoms.” These include a very characteristic sleeping disorder. The depressed person usually falls asleep readily, unless there is a life-long tendency towards insomnia, but wakes up at intervals during the night  feeling agitated or panicky, often after a nightmare. Sleep may return but ends finally very early in the morning. This is called, not surprisingly, “early morning awakening.” The affected person wakes up feeling bad, usually depressed, but sometimes agitated and worried. Different people may feel somewhat different. One person is sad and preoccupied by mistakes of the past, another worried about the possibility of future failure, and so on. These terrible feelings recede slowly during the course of the day, so that evenings might not be too awful. This is called a “diurnal variation” of mood. Finally, the depressed person loses appetite to the point usually where there is weight loss. There is also loss of interest in sex. This condition responds very well to antidepressants, although sometimes only in combination and over a period of time. There is something called an “atypical” depression, marked by excessive sleeping, withdrawal, and overeating. This condition, too, responds to antidepressants, although, perhaps, preferentially to the MAO inhibitors.

There are other relevant symptoms of this relapsing and remitting disorder, including a family history.

In short, the drugs are an effective treatment for the serious illness that is referred to an a “major depression” and not to ordinary sadness, no matter how severe.

By the way, there was a recent article suggesting that withdrawal from these drugs may be very difficult. A few days later a response by a number of academic psychiatrists contradicted this statement. For what it is worth, I have never had any significant or long-lasting problems stopping these drugs—and I have been around for a long time. What is true is that many depressed individuals become depressed again within a week or so of stopping the drug; but that is a manifestation of the underlying disease rather than a result of withdrawal. My practice is to keep patients on these drugs permanently if they have had three previous depressive episodes.

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