Antidepressants: A Research Update and a Case Example
What experiences do people have if they take antidepressants?
Posted Dec 20, 2018
This post briefly reviews what researchers have been finding about the effectiveness and also the downsides of antidepressant medications — Zoloft, Prozac, and the like. The post then adds a fascinating case example, a self-description submitted to me by a reader who has experienced both the ups and the downs of antidepressant drugs. First, though, a word about my personal bias: Antidepressant pills definitely do help some people. At the same time, I regard them as vastly over-prescribed for mild to moderate depression and also for anxiety. Other treatment strategies for these situations can be equally or more effective, and without the downsides. In my TEDx talk on lifting depression, for instance, I demonstrate an antidepressant visualization exercise that I have used effectively in my clinical practice for decades. See also the techniques here.
What does the latest research suggest about whether you should take antidepressant medications?
For a particularly comprehensive review of the established medical risks of antidepressants, this article from Harvard Medical School is especially informative. You can find many similar articles with a web search of antidepressant risks.
In addition, a recent comprehensive review article of 522 trials and more than 116,000 patients — a meta-analysis combining the findings of all the available studies — reported on findings regarding 21 antidepressant drugs. This review was described as the most comprehensive analysis of the evidence ever undertaken. The Lancet Psychiatry, which reported the study, also then published a further analysis by the study’s authors. Here are their conclusions:
- Antidepressants can be, on average, an effective treatment for adults with moderate-to-severe major depression in the acute phase of illness.
- Effective as defined in this study means that there was a 50 percent or more reduction of depressive symptoms over an eight-week period. “Effective” did not imply complete remission (removal) of the depression.
- Some patients experienced great benefit from the medication; others gained little or no benefit. In general, the more severe the depression, the more benefits from the antidepressant.
- The average response to a placebo (a sugar pill disguised as medication) was 35 percent. The average response to antidepressants ranged between 42 percent (reboxetine) and 53 percent (amitriptyline).
- For between 47 and 58 percent of subjects, depending on the specific drug, the medication was not effective. That is, they did not experience at least a 50 percent reduction in their depression symptoms.
Note that the depressed clients who did receive relief from taking an antidepressant medication definitely felt better — and yet not necessarily fully healed. Again, "effective" is defined as a 50 percent improvement in symptoms. This definition raises a number of questions:
- What about the remaining effects of depression, if only 50 percent of the symptoms have been relieved by the medication?
- Are antidepressant drugs appropriate to prescribe for milder depression? Or are non-medication therapy techniques just as or more effective? The research deals with only moderate to severe depression. Yet most prescriptions for antidepressants are given for milder to moderate depressive reactions.
- Earlier studies have concluded that the combination of both drugs and psychotherapy has the highest response rate. Both show about equal effectiveness on their own, except that psychotherapy has longer-lasting positive impacts, because it teaches skills and understandings that have long-term benefits. And what about the European research which has found that after people have taken an antidepressant, they become more likely to have subsequent depressive episodes?
- Because of the addictive potential of anti-anxiety drugs, like Xanax and Librium (xxx), antidepressants with sedating side-effect profiles now are prescribed to keep anxiety at bay. What are the effectiveness rates of antidepressants for treating anxiety?
- What about the negative side effects of antidepressants? The Lancet Psychiatry summary article says nothing about these, the most significant of which is drug dependency. Drug dependency means that once people have taken an antidepressant over a significant time period, their body begins to depend on it. The result is that when they try to discontinue taking the medication, their body has a rebound reaction of depression. That depression does not mean that they needed the antidepressant all along. It just means that the drug has caused their body to no longer produce the chemistry of well-being on its own.
A Medications Case Example: Despair, Delight, Disaster, and More
Many thanks to LC, for sharing her antidepressant experiences.
LC: It all started one late afternoon. I was in my car with my toddler-aged son, driving home through typical late afternoon traffic.
Suddenly I smelled the distinct scent of burning. Ahead of me, just five cars away, a plume of neon orange fire was climbing higher and higher. It was so out of place and so sudden that I didn't feel panicked or scared, I just stared for a few seconds, mouth wide open, my brain calibrating a fire on the highway.
Then I saw the people starting to run. And the panic set in. People all around me were jumping out of their cars and running down the highway, away from the gas truck that was literally on fire in front of us. The truck was still mostly intact, and it dawned on me all at once that a larger explosion might be imminent.
I jumped out of the car, pried open the car-seat straps, and then, flinging my son over my shoulder, ran to get as far away from the gasoline truck as possible. There was a BOOM sound, but I didn't look back. I just kept running and saying, "It's OK. We just need to move away from the fire," both to my son, and to myself.
The sirens started. Police and fire-trucks and ambulances somehow made their way through the maze of stopped cars.
A tragic gas leak had killed the driver of the truck. I texted my husband. I called and apologized profusely to my one-year-old's sitter for being so late.
Three hours later, I was on my way home. I had to run to the grocery store, pick up my 4-year-old from preschool, and make dinner. With three young children, I didn't have time to panic, process, or recover. I had to just keep going.
It was only later that night, after 11:00 p.m., that I felt the effects of that experience. My husband tried to calm me down. I was inconsolable. I wanted to scream or cry or run, but I was paralyzed and terrified.
The next day, I couldn't do anything. My anxiety was telling me that I was in danger. I wasn't, but the panic was still there. I was dreading trying to sleep again.
My sister told me to go immediately to a psychiatrist. I did. The psychiatrist talked to me for about 1 minute and then handed me a Xanax (an anti-anxiety pill) and a cup of water: "You are having a panic attack, and you've been in it for almost 24 hours. We need to get you calmed down."
Having a doctor hand me something I could swallow immediately soothed me. I was able finally to speak enough to tell the psychiatrist that I had seen a terrifying accident, and that I had never really suffered from anxiety or panic attacks before. I begged her to please make the anxiety stop.
The psychiatrist prescribed Xanax for a couple of weeks and then Cipralex, a commonly-used SSRI antidepressant that treats both depression and anxiety, to take long-term. She also said that it was imperative that I find a therapist and explore what was going on in my mind. I guess she assumed the trigger was deeper than just seeing a gasoline truck in flames.
Dr. Heitler: Traumatic events can trigger intense panic either during or at some point after the dangerous event has concluded. Eventually, especially with a chance to talk about what happened, the anxiety calms down. In LC’s case however, the parasympathetic nervous system, whose job it is to calm feelings of fear, was not functioning.
Fortunately, the anti-anxiety pill, Xanax, is fast-acting and effective.
Fortunately also, the psychiatrist had suggested that Lia speak with a talk therapist. Talking about the thoughts that were barraging her would enable Lia to digest her thoughts and feelings, both from the recent trauma and from prior events that had troubled her for some time.
Unfortunately, the psychiatrist did not offer non-pill options to calm the intense anxiety reaction. As the saying goes, to a man with a hammer, the world is a nail.
In this case, the hammer was in fact effective. Xanax brought Lia immediate relief. There are, however, non-pill options that can produce the same immediate calming effect. Both acupoint tapping and a visualization called the spinning technique would probably have done the job equally well. In addition, Lia easily could learn to do these techniques on her own at home should the anxiety return.
LC: The thing is . . . I knew that I needed therapy. It had been a long time coming. An unspoken trauma from the past was finding its way out, visiting me in dreams, and violating random moments in my life. I had been doing my best to silence it, shushing it desperately, hoping that it would just go away. So I started therapy. And I started the antidepressant drugs. And I was able to breathe. For a while.
Therapy opened my mind to myself. I had closed it years before. Re-opening it was as if a door had been kicked down. The halls and rooms of my mind were inviting me to explore, to wander, and to get reacquainted with my inner-world.
The SSRI seemed to be working too. I was more calm. I was more at ease. I wasn't barking at my husband about crumbs on the counter or scrubbing toys with bleach every night. I was laughing a little more, yelling a little less, more balanced.
What was from therapy, and what was from the SSRI? I didn’t care. I was just relieved to be breathing normally.
Dr. Heitler: Multiple studies of the treatment of serious emotional distress conclude that the combination of medication and psychotherapy is more potent than either alone. Lia’s case exemplifies this principle. Pills and talk therapy can potentiate each other, that is, cause each other to be more effective than either treatment alone could be.
At the same time, newer therapy techniques, such as the Body Code and Emotion Code, enable a therapist to radically shorten the time and intensity of talk therapy. Within one session or several, an Emotion Code therapist can pinpoint the earlier problem and immediately release trapped negative emotions so that they cease to have impact. With the underground spring that had been feeding anxious, angry and/or depressed feelings turned off, the feelings of vitality and well-being that we call mental health can emerge.
Marriage therapy also might well have helped Lia. My policy is when anyone who is married seeks therapy with me, I encourage them to bring their spouse. In almost all cases, underlying marital issues have been fanning the flames of negative emotions.
The spouse also can have a significant role in fostering a return to mental health. For instance, an anxious or depressed person may have an impulse to spend his evenings isolating and ruminating, saying troubling thoughts over and over to himself. Rumination exacerbates anxiety and depression. If husband and wife enjoy activities together in the evening, they are likely to be able to replace the rumination with pleasant interactions.
LC: I don't regret starting the antidepressant, the Cipralex. I truly feel like that drug saved my mind. It also probably held my marriage together for several more years. But by a year later, I knew that something was off. I knew that it was the medication.
Dr. Heitler: An antidepressant, especially in combination with good talk therapy, can work miracles in enabling people to get back to functioning in a normal emotional zone. The difficulties tend to come with the duration of use.
By prescribing an antidepressant medication and then keeping her on it for more than an initial several months, LC’s psychiatrist had inadvertently invited increasingly negative side effects. The negative side effects which had begun while Lia was taking the pills became even worse when she tried to get off the pills.
LC: At about a year, I started feeling fuzzy, numb, and detached. I would have several-minute episodes of not knowing what I was doing or how I got there. Then the confusion would dissipate, and I would be left thinking that I was just imagining it. But it would happen again. Fleeting, but tangible. Almost leaving a taste in my mouth.
I shared this with my husband, but he was worried about the anxiety returning if I messed with my medication. I waited.
Dr. Heitler: LC’s husband’s concerns had some genuine validity. The difficulty is that after a year of taking antidepressants, anyone who attempts to stop taking them must end their use very slowly. Otherwise, removal of the drugs can precipitate serious depression and/or anxiety.
It’s not that these emotions had been lurking there all along. Rather, antidepressants create drug dependency. The body forgets how to produce the chemicals that sustain well-being when they are being provided artificially by pills.
LC: The side effects worsened. I had no sex drive. I stopped feeling motivated to hang out with friends. I stopped caring about how I looked or what I was wearing. I was sinking. I had been saved from anxiety, and was now slipping into depression.
I made a unilateral decision to go off my meds. It wasn't a wise one. Looking back, I see that it was very much a desperate stand against the many factors in my life that I wasn't in control of — my devastation over my marriage that was quietly but quickly ending, my loss of focus on my passions and hobbies, my overweight and exhausted body, too strict in my religious life . . . the list goes on.
To simply argue that the SSRIs were ruining my life would be short-sighted and most likely wrong. I was ruining my life. But I was absolutely clear that the drug I was putting into my body every day was dragging me down and making it much harder to move forward. I felt very much alone — and for the first time in a while, very clear in my mission.
Dr. Heitler: In addition to creating drug dependency when used for more than several months at a stretch, antidepressants can produce a number of further negative side effects. Weight gain, loss of sexual feelings, emotional numbness, and "brain zapping" are among the most common. LC experienced these, and more.
LC: Going off SSRIs cold-turkey is nothing short of a ride through hell. The physical and emotional effects of suddenly depriving your brain of serotonin is horrific.
I was tormented by anxiety. I experienced electric pulses starting in my head and traveling down my entire body. I found myself in tears over everything. I had so much guilt over the decision. But I couldn't put that pill back in my mouth.
I pushed. It was raw without the drug. My husband and I separated. I said goodbye to God on a park bench and said hello to myself. I sabotaged a friendship — not something I'm proud of. I lost 35 pounds. I started singing out loud. I started running.
I told the psychiatrist what I had done. Even though so many things were better, I was on the verge of another breakdown, and I didn't know what to do.
The psychiatrist prescribed a different drug, this time an SNRI (two chemicals for the brain's "happy" place instead of one). She explained that since I was in the middle of a divorce — a major life-crisis for anyone — it probably wasn't the best time to go off psychiatric drugs.
That night I sat with the new pill in my hand. It took a serious pep talk to swallow it, but I did. I felt like I needed all the help I could get. I had three young children depending on me to keep it together, and I couldn't afford to let emotions destroy me. I had delved extensively into my past and had finally put to rest the lurking earlier trauma. I told myself I would take the drug, and when life settled down, I would get off.
Fast-forward a year and a half. A very similar cycle ensued. At first the SNRI filled me with renewed calm. It was like a rosy tint on life was just a pill away. And then . . . the fog set in. Again, about a year in, I felt that familiar detachment. I stopped caring about the little things. I started to feel like I was being numbed. Like I was underwater. Watching the world from below, too slow to stay actively involved in my own life. My sex drive started dying, and with it, my drive for life deteriorated.
With this new and more powerful drug, I again started feeling physical side effects. If I took the pill a few hours later than usual, I would get extremely nauseous. But if I took it in the morning, I would also get nausea and throw up. On the drug, I was more prone to migraines, I fainted several times that year, and I started gaining weight quite rapidly — despite my strictly healthy lifestyle.
This time around, I was determined to get off the drug safely. I checked in with a doctor. I started by taking off just one-quarter of the dose and did so every four weeks, allowing my brain to adapt each time.
Nonetheless, again it was hard, even painful. Each time I weaned down a dose, I had a week of horrible brain zaps. Even worse, I was much more reactive and impatient with my children. The weaning process took four months.
At the same time, I truly feel like this time around I experienced a beautiful and inspiring rebirth of myself. My senses feel heightened. My experiences are fully my own again.
Dr. Heitler: Paradoxically, ending her use of antidepressants turned out for LC to be the ultimate cure. With the pills no longer compromising her body’s chemistry, LC’s natural vitality eventually returned. So did her sexual feelings, ability to lose weight, eventual loss of the brain zapping, and a return of her former good-humored self.
LC’s conclusions: I'm still forming an objective opinion on the use of SSRIs. The power of these drugs, for better and for worse, is something that shouldn't be taken lightly. Off them now though, for me, heading away from antidepressants is heading in the right direction.
Dr. Heitler’s conclusions: Again, as I said at the outset, for a severe or suicidal depressive episode, antidepressant medications can relieve the intensity of dark thoughts and desperate feelings.
At the same time, Lia’s case illustrates well that antidepressants may:
- Have limited or no effectiveness for almost half of users
- Help somewhat, while many aspects of the depression remain
- Produce problematic side effects, like weight gain, decreased sexual feelings, brain zapping, nausea, clouded thinking, and numbing of feelings of joy as well as of negative emotions
- Create drug dependence when used for longer than a few months, and therefore difficult withdrawal symptoms, including withdrawal-induced depression
- Be prescribed for usages for which they are not intended (i.e., mild depressive reactions and anxiety) and for which non-drug options may be equally effective
- Be prescribed at length, for years rather than months, increasing the difficulties of eventual withdrawal