What would you do to assess the advisability of taking antidepressants?
I’m trying to advise someone who is receiving conflicting advice; there appears to be plenty of controversy in this area and many factors confound assessing the evidence. Before I point to specifics on evidence that might influence the decision one way or the other I thought I’d ask in the most general way I can. I hope using the Open Thread to play “ask a rationalist” like this isn’t a bad thing!
What would you do to assess the advisability of taking antidepressants?
Antidepressants can be useful but I do note that antidepressants and SSRIs are used more synonymously than they could be. In fact, it is worth asking your doctor about a SSRE (ie. tianeptine). From wikipedia:
SSREs are used as antidepressants for the treatment of depression and anxiety, and are in marked contrast to other antidepressants such as the selective serotonin reuptake inhibitors (SSRIs), which inhibit the reuptake of serotonin instead.[1][10] SSREs have been demonstrated to be as effective as SSRIs against depression, have a much faster onset of action (immediate), and have a much better tolerability profile,[1][10] although interestingly, it has also been shown that the SSRI fluoxetine can substitute for tianeptine in animal studies.[11]
I speak as someone who uses an SSRI and finds it useful so I don’t mean to claim the class has no value for all indications.
In general antidepressants can be useful (even life changingly so) but it does depend on the details of the symptoms and etiology. ‘Depression’ is a somewhat broad symptom cluster and not all cases that fit that diagnosis have the same cause and respond best to the same treatment.
But one note: It is best your own research even when a drug is prescribed. If the research brings up doubts then a second and third medical opinion is vital. There are overwhelmingly large numbers of people who have been prescribed venlafaxine (Effexor) for example who regret not doing their research first. It is an extremely effective drug but the side effects when ceasing usage are brutal. People who have gone through withdrawal for heroin addiction and also withdrawn from Effexor have described the latter experience as worse.
On the one hand, the anti-psychiatry movement and critics of biological psychiatry seem to suffer from really serious problems with thinking straight: they criticize reductionism, they seem to like philosophers like Foucault, and when they try to say that mental illness doesn’t exist they seem to go for the “applause lights” of blaming society over the vivid reality of mental illness.
But on the other hand, there seem to be really serious problems with the science of studying mental illness: a tendency to look where it’s easiest to look rather than where the strongest effects are leading to over-emphasis on easily, cleanly detectable factors, massive distortion through the powerful financial incentives of the pharmaceutical industry including ghost-writing papers for scientists and a bad case of the file-drawer effect, and a century-long history of just making shit up.
It’s incredibly daunting to be faced with the task of cutting through this thicket to make a potentially life-changing decision.
I was prescribed Buproprion (a norepinephrine reuptake inhibitor, not an SSRI) as a smoking cessation aid. With my doctor’s acquiescence, I continue taking it at lower dosage for its beneficial (placebo?) effects on mild depression. If your friend’s depression is associated with anxiety, or with mild addictive personality or “low will power”, I would recommend it, perhaps coupled with an exercise program.
Everything I’ve heard is conflicting; of the people I’ve known who have been on antidepressants, some had great results, and some came out worse. What I know for sure is that psychiatrists are very, very likely to prescribe them for people showing symptoms of depression. If you go to a psychiatrist’s office, you’ll probably leave with a prescription. So don’t go to an appointment thinking “Ho hum, I’ll see what the doctor says.”
Amusingly, Marc Hauser’s group at Harvard has just published a paper saying that use of SSRIs change people’s ethical judgments on trolley problems. Here are accounts from twoblogs
Whether antidepressants (realistically you’re probably talking about SSRIs) do enough better than placebo in moderate cases of depression to be worthwhile is a very tough question.
But from a pragmatic viewpoint, SSRIs and placebo both do much better than nothing. Unless your friend can figure out some way to take a placebo and believe it to be effective, the SSRIs could be worth it.
Some behavioral modifications (e.g. a program of exercise) are widely supposed to do better than nothing—would something along these lines serve as a useful placebo?
I don’t know. But placebos can have some pretty strange properties: if a doctor says a placebo is “extra strength”, the patient will do better, if the pill looks colorful and complicated the patient will do better, if it’s delivered via IV instead of pill the patient will do better, if the doctor wears gloves when handling the placebo because it’s “so strong I can’t even risk skin contact” the patient will do better, et cetera.
So there’s no guarantee something flaky-sounding like “diet and exercise” would be as strong a placebo as a big name like Prozac, even if Prozac did work mostly by placebo effect, which, again, is far from certain. Try the drugs.
Some behavioral modifications (e.g. a program of exercise) are widely supposed to do better than nothing—would something along these lines serve as a useful placebo?
That may be be difficult to test. Normally we introduce controls for ‘placebo effects’. How are we supposed to control for “stuff that actually works”?
Tangential: positive controls are common in e.g. biology experiments, where the efficacy of the experiment to detect an actual effect can be in doubt. (This won’t be the case in treating depression, where successful treatment can be detected by asking the patient.)
Things I’m curious about, but probably won’t investigate in detail: Does the placebo effect really do significantly worse if you don’t “believe” in it, even if you’re (for example) told that it’s been experimentally shown to work even if you don’t believe in it?
I googled “metaplacebo” and found some kind of wiki page, but haven’t looked at it yet.
Things I’m curious about, but probably won’t investigate in detail: Does the placebo effect really do significantly worse if you don’t “believe” in it, even if you’re (for example) told that it’s been experimentally shown to work even if you don’t believe in it?
Or (I assume) we’re not smart enough to find and prove the framing that would maximize the effect’s strength for any given human, honestly or otherwise.
My friend has been pointed at these references on this issue by one source:
Antidepressant Drug Effects and Depression Severity, A Patient-Level Meta-analysis, Jay C. Fournier, MA; Robert J. DeRubeis, PhD; Steven D. Hollon, PhD; Sona Dimidjian, PhD; Jay D. Amsterdam, MD; Richard C. Shelton, MD; Jan Fawcett, MD, JAMA. 2010;303(1):47-53.
Richard Bentall, ‘Doctoring the Mind’ and ‘Madness Explained’
The sorts of antidepressants a psychologist would prescribe tend to be problematic in terms of side effects and success rate, so be sure to investigate low-risk options first. Some cases of depression correspond to micronutrient deficiencies; these can be tested for and addressed all at once using a large-dose multivitamin (the sort which has many times the recommended daily value for all the things that don’t have overdose risk). Also check for insufficient sleep, severely insufficient exercise, and caffeine abuse, all of which can make people miserable in ways that antidepressants won’t solve.
If none of that helps, then try the chemical antidepressants. But don’t stay on something that isn’t working; being depressed makes it hard to upset the status quo, even if that status quo is a medication that isn’t helping or is making things worse. As a defense against this problem, either schedule a particular day on which to reevaluate, or designate a trustworthy observer other than the prescribing psychiatrist. (And if it’s not working, then raising the dose is almost certainly not a good answer).
What would you do to assess the advisability of taking antidepressants?
I’m trying to advise someone who is receiving conflicting advice; there appears to be plenty of controversy in this area and many factors confound assessing the evidence. Before I point to specifics on evidence that might influence the decision one way or the other I thought I’d ask in the most general way I can. I hope using the Open Thread to play “ask a rationalist” like this isn’t a bad thing!
Antidepressants can be useful but I do note that antidepressants and SSRIs are used more synonymously than they could be. In fact, it is worth asking your doctor about a SSRE (ie. tianeptine). From wikipedia:
I speak as someone who uses an SSRI and finds it useful so I don’t mean to claim the class has no value for all indications.
In general antidepressants can be useful (even life changingly so) but it does depend on the details of the symptoms and etiology. ‘Depression’ is a somewhat broad symptom cluster and not all cases that fit that diagnosis have the same cause and respond best to the same treatment.
But one note: It is best your own research even when a drug is prescribed. If the research brings up doubts then a second and third medical opinion is vital. There are overwhelmingly large numbers of people who have been prescribed venlafaxine (Effexor) for example who regret not doing their research first. It is an extremely effective drug but the side effects when ceasing usage are brutal. People who have gone through withdrawal for heroin addiction and also withdrawn from Effexor have described the latter experience as worse.
Very interesting, thank you! According to Wikipedia, Tianeptine isn’t available in the UK.
Here’s why I turn to Less Wrong in more detail.
On the one hand, the anti-psychiatry movement and critics of biological psychiatry seem to suffer from really serious problems with thinking straight: they criticize reductionism, they seem to like philosophers like Foucault, and when they try to say that mental illness doesn’t exist they seem to go for the “applause lights” of blaming society over the vivid reality of mental illness.
But on the other hand, there seem to be really serious problems with the science of studying mental illness: a tendency to look where it’s easiest to look rather than where the strongest effects are leading to over-emphasis on easily, cleanly detectable factors, massive distortion through the powerful financial incentives of the pharmaceutical industry including ghost-writing papers for scientists and a bad case of the file-drawer effect, and a century-long history of just making shit up.
It’s incredibly daunting to be faced with the task of cutting through this thicket to make a potentially life-changing decision.
I was prescribed Buproprion (a norepinephrine reuptake inhibitor, not an SSRI) as a smoking cessation aid. With my doctor’s acquiescence, I continue taking it at lower dosage for its beneficial (placebo?) effects on mild depression. If your friend’s depression is associated with anxiety, or with mild addictive personality or “low will power”, I would recommend it, perhaps coupled with an exercise program.
Everything I’ve heard is conflicting; of the people I’ve known who have been on antidepressants, some had great results, and some came out worse. What I know for sure is that psychiatrists are very, very likely to prescribe them for people showing symptoms of depression. If you go to a psychiatrist’s office, you’ll probably leave with a prescription. So don’t go to an appointment thinking “Ho hum, I’ll see what the doctor says.”
Amusingly, Marc Hauser’s group at Harvard has just published a paper saying that use of SSRIs change people’s ethical judgments on trolley problems. Here are accounts from two blogs
Whether antidepressants (realistically you’re probably talking about SSRIs) do enough better than placebo in moderate cases of depression to be worthwhile is a very tough question.
But from a pragmatic viewpoint, SSRIs and placebo both do much better than nothing. Unless your friend can figure out some way to take a placebo and believe it to be effective, the SSRIs could be worth it.
Some behavioral modifications (e.g. a program of exercise) are widely supposed to do better than nothing—would something along these lines serve as a useful placebo?
I don’t know. But placebos can have some pretty strange properties: if a doctor says a placebo is “extra strength”, the patient will do better, if the pill looks colorful and complicated the patient will do better, if it’s delivered via IV instead of pill the patient will do better, if the doctor wears gloves when handling the placebo because it’s “so strong I can’t even risk skin contact” the patient will do better, et cetera.
So there’s no guarantee something flaky-sounding like “diet and exercise” would be as strong a placebo as a big name like Prozac, even if Prozac did work mostly by placebo effect, which, again, is far from certain. Try the drugs.
That may be be difficult to test. Normally we introduce controls for ‘placebo effects’. How are we supposed to control for “stuff that actually works”?
Tangential: positive controls are common in e.g. biology experiments, where the efficacy of the experiment to detect an actual effect can be in doubt. (This won’t be the case in treating depression, where successful treatment can be detected by asking the patient.)
Yes, that’s a great idea.
Things I’m curious about, but probably won’t investigate in detail: Does the placebo effect really do significantly worse if you don’t “believe” in it, even if you’re (for example) told that it’s been experimentally shown to work even if you don’t believe in it?
I googled “metaplacebo” and found some kind of wiki page, but haven’t looked at it yet.
It still works (but less).
Or (I assume) we’re not smart enough to find and prove the framing that would maximize the effect’s strength for any given human, honestly or otherwise.
My friend has been pointed at these references on this issue by one source:
Antidepressant Drug Effects and Depression Severity, A Patient-Level Meta-analysis, Jay C. Fournier, MA; Robert J. DeRubeis, PhD; Steven D. Hollon, PhD; Sona Dimidjian, PhD; Jay D. Amsterdam, MD; Richard C. Shelton, MD; Jan Fawcett, MD, JAMA. 2010;303(1):47-53.
Richard Bentall, ‘Doctoring the Mind’ and ‘Madness Explained’
a PDF of interview with David Healy) which forms part of the course materials for the Open University module Counselling: exploring fear and sadness (sadly can’t find the PDF online, but Healy’s views on SSRIs appear to be well documented elsewhere)
Bentall’s Wikipedia bio concludes:
The sorts of antidepressants a psychologist would prescribe tend to be problematic in terms of side effects and success rate, so be sure to investigate low-risk options first. Some cases of depression correspond to micronutrient deficiencies; these can be tested for and addressed all at once using a large-dose multivitamin (the sort which has many times the recommended daily value for all the things that don’t have overdose risk). Also check for insufficient sleep, severely insufficient exercise, and caffeine abuse, all of which can make people miserable in ways that antidepressants won’t solve.
If none of that helps, then try the chemical antidepressants. But don’t stay on something that isn’t working; being depressed makes it hard to upset the status quo, even if that status quo is a medication that isn’t helping or is making things worse. As a defense against this problem, either schedule a particular day on which to reevaluate, or designate a trustworthy observer other than the prescribing psychiatrist. (And if it’s not working, then raising the dose is almost certainly not a good answer).
What you say sounds plausible, but I don’t see how to evaluate it against conflicting advice.