Let’s not oversimplify depression

Summing up the research conducted on thousands of patients over decades, Joanna Moncrieff, a professor of psychiatry at University College London, didn’t equivocate.

“We can safely say that after a vast amount of research conducted over several decades,” she said, “there is no convincing evidence that depression is caused by serotonin abnormalities.”

The response came in the shape of triumphant yelps of ‘I told you so’ from many scribes who, well, told you so.

The issue attracted their attention in the first place because pharmaceutical companies have built a mighty industry on the theory that low levels of serotonin in the brain cause depression. Medical schools went along, churning out psychiatrists trained to treat depression with, among other drugs, Selective Serotonin Reuptake Inhibitors (SSRIs).

The most popular of them is Prozac. In the first 15 years after it was licensed to treat depression in the US, Prozac was prescribed to 40 million patients worldwide, generating sales of $22 billion. Now, another 20 years later, SSRIs keep many a pharmaceutical company in lucrative business.

This was bound to attract criticism that the industry is feathering its own nest at the expense of patients’ health. The critics had a point, and now they have every reason to feel vindicated. Yet they tend to oversimplify the issue, which does nobody any good.

It’s true that doctors have been dispensing SSRIs and other antidepressants like Smarties, but the question is why. Why do they continue to prescribe Prozac if they suspect, as many have for years, that it’s no more effective than a placebo?

First, placebo effect is still an effect, and doctors aren’t allowed to prescribe a placebo. When a patient presents with depression, doctors, who seldom have more than a few minutes to spend on each appointment, feel they have to prescribe something, especially if the patient was already used to Prozac.

In many cases, the patients report a positive effect, so neither they nor the doctors feel like delving too deeply into the pharmacological nuances. Especially since no one seems to be able to define the phenomenon of depression with scientific precision.

Regulating authorities divide depression into three stages, mild, moderate and severe. This is dubious, and not just for purely medical reasons.

For mild and moderate depression is often indistinguishable from unhappiness, a word that has largely disappeared from our everyday lexicon. Modern people insist on medicalising everything that displeases them, and certainly lousy moods.

They have been brainwashed to expect happiness as an inalienable right, a natural state of life. That is, of course, a fallacy. Suffering is an essential part of the human condition and, in Christendom, the formative part.

Yet most people these days don’t recognise this because they don’t believe in life everlasting. They believe in a paradise on earth, where suffering is something abnormal – an illness, in other words. And illnesses, except the terminal ones, ought to be treatable with drugs.

In parallel, people have been immersed into a sea of psychobabble, courtesy of Freudian quackery. Deprived of anything supernatural, they try to find something superpersonal within themselves, which is a logical impossibility.

Thus they step on a never-ending path leading to assorted therapeutic charlatans and then on to doctors, who can do everything the charlatans do. But they can also prescribe drugs, and most of them feel it’s churlish to refuse. After all, they too have eaten the poisoned fruits of the same tree.

None of this means that genuine, clinical, depression doesn’t exist. It always has, and in the past this condition was called ‘melancholia’, from the Greek for ‘black bile’ (that’s another extinct word, by the way, outshouted by psychobabble).

Patients presenting with melancholia, which would now be called clinical depression, would be hospitalised for several weeks, with their condition studied from every possible angle. They would then be treated with a combination of therapy, drugs, in the old days mostly those boosting the level of noradrenalin, and, in extreme cases, electric shocks.

The critical thing to keep in mind is that, after all the billions spent on assorted genome projects and decades of the brain, we still know next to nothing about the human brain, hardly more than Greek physicians did in the old days.

One thing we don’t know is what causes depression. But we do know that it can be either exogenous or endogenous. The first is caused by external factors, such as bereavement, loss of a job, Joe Biden as the leader of the free world. The second has no such cause. It’s purely internal. It just is.

Exogenous depression has every chance of being mitigated by that great therapist, time, or else disappear altogether when its cause is no longer there.

Endogenous depression, on the other hand, is definitely a medical condition, and it can be extremely serious – made even more so by our ignorance of its cause. Hence it must be treated, not dismissed as a case of self-indulgence.

If SSRIs work, then it doesn’t matter if they are no more effective than a placebo. If they are effective at all and reasonably well tolerated, few doctors will begrudge a prescription to a stricken patient.

Moreover, though melancholia has always been rare, it’s now rarer still, and mainly because doctors reach out for their prescription pads with nonchalant ease. When patients are treated with SSRIs or other antidepressants the moment the first symptoms appear, the progression of the disease may well be slowed down.

Some 16 per cent of the people in such Western countries as the US, France and Britain are regular users of antidepressants. Somewhere within that inordinately large group are those few whose disease would have become severe had they not started popping those pills, placebo effect or no.

Exogenous depression, however, especially when it falls into the mild-to-moderate area for which SSRIs are indicated, isn’t readily distinguishable from that ever-present scourge of the human condition, unhappiness.

A priest, a friend or simply a stiff drink (Laphroaig is my chosen tipple) ought to provide sufficient therapy in most cases, along with some mental fortitude, good taste and refusal to succumb to perverse modern fads.

Yet it’s true that some people genuinely can’t cope with their unhappiness, and if SSRIs help, then few doctors would – or should – refuse to prescribe them on philosophical or moral grounds.

The problem isn’t with prescribing SSRIs, but with overprescribing. And the critics are absolutely right: mountains of Prozac moved on demand, often without the slightest medical justification, add up to an existential catastrophe – and often to a medical one.

For while the beneficial effects of SSRIs are up for debate, the side effects aren’t. Dr David Healy has been writing about them for years, and his book Let Them Eat Prozac (2006) describes the dangers exhaustively.

One such is that an excessive dose of SSRIs can turn depression into a mania. In fact, SSRI users are disproportionately represented in the ranks of American mass murderers, those who shoot up schools or shopping malls just for the hell of it. And some SSRI patients may become not homicidal but suicidal.

If a drug has any effects, it has side effects, and those of SSRIs can be horrendous. That’s why they should be reserved for genuine medical conditions, not to treat bored housewives who fear that hubby-wubby is playing away from home.

However, dogmatic denunciation of all SSRI scripts is as ill-advised as any extremism. Commentators inclined to this failing grossly oversimplify the issue, as all extremists tend to do. Most of the points they make about SSRIs are valid – but their wholesale conclusions aren’t.