Around 7.8 million people in England received at least one prescription for an antidepressant between 2019 and 2020. This means that one in six British adults are taking or have taken antidepressants. The effectiveness of these drugs has been tested in studies considering the short term, but long-term effects and the difficulties imposed by chemical dependency are increasingly known.
A new review, published in the journal Drug and Therapeutics Bulletin (“Drugs and Therapeutics Bulletin”, in free translation) by Mark Horowitz, psychiatrist at University College London, and Michael Wilcock, pharmacist with the National Health Service Fund of the Royal Hospitals of Cornwall, UK, suggests that antidepressants should have a reduction in prescriptions and in the term for which they are prescribed.
Horowitz and Wilcock point out that much of the evidence in favor of the two most commonly used classes of antidepressants today comes from placebo-controlled studies that lasted between six and weeks. In one of the few studies with longer duration, involving more than 4,000 patients over a year, only 2.7% improved. The effectiveness of these drugs to combat depression is shown on a scale ranging from zero to 19 points, being 52 the maximum severity of depression: the drugs offer a reduction of two points on the scale. Doctors, however, believe that a reduction that makes a sufficient difference in the clinical status of depressed people should be at least three to five points.
There are dissenting voices among experts, but a general picture, according to the authors, it is that current antidepressants fall short in the treatment of the disorder. Cochrane, which publishes rigorous reviews of medical treatments, has even asked whether antidepressants are worth prescribing, given that some of them actually increase the risk of suicide compared to placebo. The assessment of the European Medicines Agency (EMA) is more optimistic, but the authors of the new review raise doubts about the entity’s methods.
Interestingly, this situation, in which many professionals give their word that these drugs work but fail to pass traditional statistical tests is reminiscent of ivermectin as an early treatment for Covid-19—ironically, an antidepressant , fluvoxamine, passed the test as a treatment for the new coronavirus.
The antidepressants considered in the review by Horowitz and Wilcock are of two main classes: the reuptake inhibitors serotonin and norepinephrine, molecules used as messengers between neurons, that is, neurotransmitters. Serotonin, in particular, is associated with a sense of well-being in some contexts. It is released into a space at the connection between two neurons, the synaptic cleft. The brain has a system that recycles (reuptakes) serotonin from this cleft. These drugs inhibit this system, causing the neurotransmitters to stay more in the cleft, thus reinforcing the message from one neuron to the other and the feeling of well-being — at least that’s what the mechanism of action promises.
Withdrawal and side effects2020
Antidepressants cause a type of addiction that triggers withdrawal symptoms when their use is discontinued — the so-called “weaning”. These symptoms are stronger if weaning is done all at once, rather than tapering off to complete cessation. In some people, abstinence is so strong that weaning is not recommended.
During use, possible adverse effects include sexual dysfunction, an emotional torpor (as in Arnaldo Antunes’ lyrics: “ help, I’m not feeling anything”), drowsiness and lack of sensation of being alert, insomnia, weight gain and agitation, among others. Some of these may persist in some people even after weaning. EMA speaks of “post-antidepressant sexual dysfunction”, for example. The risk of this, however, is low.
Where does depression come from?
Medical thinkers first turned their attention to the so-called “melancholy” around the decade of 19 , as discussed in 2019 in the journal JAMA Psychiatry by psychiatrist Kenneth Kendler of Virginia Commonwealth University. Melancholy was considered a disorder of the intellect and judgment, a “partial insanity” similar to sadness but not always associated with it. In the course of the following century, according to Kendler, there was an inversion: instead of considering depression an intellectual problem that leads to an emotional problem, an inverse causal order was accepted in medicine, from pathological emotions to the intellect affected by them.
There are different biopsychosocial models to explain depression. The World Health Organization characterizes it by persistent sadness and loss of interest in activities normally pleasurable for the individual, accompanied by an inability to perform daily tasks for at least two weeks. One of the explanations for the disorder from a biological approach is the theory of social ranking by British clinical psychologist Paul Gilbert, from the University of Derby. According to him, in social and hierarchical species like ours, depression can be a failure of the adaptive mechanism for accepting defeat and showing submission, as a signal to the dominator that the dominated is not (any longer) a threat. In this way, depressed people would disengage from disputes (which would explain the low activity of many of them), but the exaggerated response of depression leaves them in a prolonged state of stress, a psychological prison from which they see no way out. A corroboration of this theory is that depressed people often have a feeling of inferiority, repressed anger and, in short, defeat. The subjective feeling of defeat is associated with another common symptom of depression, anhedonia — an inability to enjoy pleasure.
If depression is associated with how we see ourselves in a social hierarchy, this would also explain why depressed people plague themselves with constant negative self-evaluations. They perceive themselves as low in the social ranking and torture themselves with it, while denying others that they are feeling bad (a way of not making public their supposed inferiority). According to Gilbert’s theory, therefore, depression is a chronic activation of defense systems to sources of stress that results in a suppression of proactive behavior, especially when people feel defeated, trapped, and try to suppress their negative emotions.
2020
