Anti Depressants Do you need them?

1. Anti DepressantsDo you need them? Dr. Nic Hooper Middle east technical university (northern Cyprus campus)

2. Henry Hooper

3. Bob Whitaker

4. What if everything you have ever been told is wrong? • Today, I am going to suggest that despite the common sense notion that psycho-pharmaceutical drugs work, in fact, the evidence suggests that many do not. • I am going to argue not only that antidepressants and other psycho-pharmaceutical drugs do not work, but also that they can cause serious damage. • Following this I'm going to look at the reasons why we might take anti-depressants. • And then discuss other ways of managing our thoughts and feelings. • So to begin with, let me tell you a story.

5. 1950’s • In 1955 Chlorpromazine (marketed as Thorazine) was introduced into Asylum medicine. • Following its introduction the number of people inhabiting Asylums gradually began to drop. • And historians typically credit this emptying of state hospitals to this miracle drug. "Chlorpromazine initiated a revolution in psychiatry, comparable to the introduction of penicillin in general medicine" (Shorter, 1997, p . 255). • Other anti-psychotic medications soon began to emerge. Then anti-depressants and anti-anxiety drugs followed. • Psychiatry now had drugs to target specific mental illnesses in the same way that insulin worked to manage diabetes.

6. 1960’s - What did the drugs do? • In the 1960’s many began theorizing that psychiatric drugs work by balancing brain chemistry • Anti-Psychotics (Thorazine) were shown to block dopamine activity. • Therefore researchers began to think that Schizophrenia may be caused by excess amounts of this neurotransmitter. • Tricyclic's (anti-depressants) raised norepinephrine and serotonin levels. • Therefore researchers believed that depression may be caused by low levels of these brain chemicals • This is often referred to as the Serotonin Theory of Depression. • What followed was 40 years of psycho-pharmaceutical drugs used to relieve human suffering • But did they work?

7. The Epidemic • The underlying promise that Psycho-pharmaceutical drugs made to the world was ‘we can reduce mental illness and help people live their lives again’. • So has mental illness been reduced since the inception of these drugs? • In 1955, the US government reported that the number of patients treated for mental illness was 1,028 episodes per 100,000 population. In 2000, patient-care episodes was recorded at 3,806 per 100,000 population . That is nearly a fourfold per capita increase in 50 years. • Since the introduction of Thorazine there has been a 6 fold increase in the number of people receiving disability payment for mental illness. • In 1955 there were 3.38 people per 1000 in public mental hospitals. In 2003 the figure was 19.69 people per 1000. Again a 6 fold increase. • Since 1955 there has been an astonishing rise in the incidence of severe mental illness.

8. New Zealand, Australia, Iceland • NZ 2000  2010; 1 in every 168 to 1 in every 90 on government disability (sickness or invalid benefits) in New Zealand due to psychiatric conditions. • AUSTRALIA 2001  2010; 1 in every 137 to 1 in every 98 on disability due a psychiatric disorder • ICELAND 1992  2007; rise from 84 per 100,000 to 217 per 100,000 population in the new cases of disability annually due to mental and behavioral disorders

9. What about anti depressants specifically? • The number of disabled mentally ill has increased dramatically since 1987, the year Prozac was introduced. • The combined sales of antidepressants and antipsychotics jumped from around $500 million in 1986 to nearly $20 billion in 2004 (from September 2003 to August 2004), a 40-fold increase • During this period, the number of disabled mentally ill in the United States, as calculated by disability payment figures, increased from 3.3 million people to 5.7 million. That is an increase of 149,739 people per year, or 410 people newly disabled by mental illness every day • These drugs meant to be making people better, reducing mental illness? Why were they becoming more prevalent?

10. Maybe our theory was wrong? • Back in the 1960’s researchers came up with theories suggesting chemical imbalances as the reasons for certain psychological disorders. • The evidence at the time was not in place, but they expected it to grow with the years thus proving their theory to be correct. • Unfortunately, the theories never panned out. • Although the public may not know this researchers have not found that those who suffer from schizophrenia have excess dopamine levels. • Or that those who suffer from depression have low levels of serotonin

11. Chemical imbalances? • After 40 years of research, in contradiction to prevailing beliefs, chemical imbalance theories have failed to achieve empirical support. • “Although it is often stated with great confidence that depressed people have a serotonin or norepinephrine deficiency, the evidence actually contradicts these claims” Elliot Valenstein (Professor of Neuroscience, University of Michigan). • Elevations or decrements in the functioning of serotonergic systems per se are not likely to be associated with depression.” --NIMH, 1984. • “…there is no “real” monoamine deficit” Stephen M. Stahl (University of California, San Diego and Creator of The Neuroscience Education Institute). • “We have hunted for big simple neurochemical explanations for psychiatric disorders and have not found them” Kenneth Kendler (Professor of Psychiatry, Virginia Commonwealth University).

12. Chemical imbalances? • After more than a decade of PET scans measuring chemical depletion “There is little evidence to implicate true deficits in serotonergic, noradrenergic, or dopaminergic neurotransmission in the pathophysiology of depression.” Krishnan and Nestler, AJP (2010) • “There is no compelling evidence that a lesion in the dopamine system is a primary cause of schizophrenia.”Molecular Psychiatry, 2002 • “Neurotransmitter-related hypotheses explaining the aetiology of schizophrenia are based purely upon pharmacological evidence, and thus are likely to be incomplete or misleading. … aberrations in these systems do not necessarily underlie psychotic disorders” Nestler, Hyman and Malenka (2009) • As U.S. Surgeon General David Satcher acknowledged in his 1999 report on mental health, the causes of mental disorders "remain unknown" (Satchee, 1999, p. 102).

13. But the drugs do have some impact? • Despite little evidence linking psychological disorders to chemical imbalances, scientists have come to understand how drugs do affect the human brain. • In 1996, the director of the National Institute of Mental Health (NIMH), neuroscientist Steven Hyman, wrote that psycho-pharmaceutical drugs "create perturbations in neurotransmitter functions" (Hyman & Nestler, 1996, p . 153) • For instance, Prozac and other SSRI antidepressants block the reuptake of serotonin. In order to cope with this hindrance of normal function, the brain tones down its whole serotonergic system • The “chronic administration” of the drugs then cause “substantial and long- lasting alterations in neural function.” • Hyman concluded, the patient's brain is functioning in a manner that is "qualitatively as well as quantitatively different from the normal state" (Hyman & Nestler, 1996, p . 161). • In other words, these drugs may cause changes in normal chemical functioning, which may in turn induce pathology. • But this is conjecture, lets look at the evidence……

14. Anti-Psychotics • A top cited study for the use of neuroleptics suggested that 75% of patients who received drugs were classed as ‘much improved’ after 6 weeks. Compared to 23% of the placebo group. • However, 3 years later, much to their surprise, the researchers found that "patients who received placebo treatment were less likely to be re-hospitalized than those who received any of the three active phenothiazines” (Schooler, Goldberg, Boothe & Cole, 1967, p .991) . • This result raised an unsettling possibility: while the drugs were effective over the short term, perhaps they made people more biologically vulnerable to psychosis over the long run.

15. Anti-Psychotics • Following this report the NIMH conducted two further studies. Each one found a positive correlation between drug dosage and relapse rates • Specifically, in the 6 months following the the trial: • 7% of the placebo group relapsed • Patients who received <300mg had a 23% relapse rate • Patients who received 300-500 mg experienced a 54 % relapse rate • Patients who received 500 mg plus had a 65% relapse rate • "Relapse was found to be significantly related to the dose of the tranquilizing medication the patient was receiving before he was put on placebo-the higher the dose, the greater the probability of relapse" (Prien, Levine, & Ssvitalski, 1971, p. 22).

16. Anti-Psychotics • In response to these findings the NIMH conducted further research. • The studies all pointed to the same conclusion: exposure to neuroleptics increased the long-term incidence of relapse (Carpenter, McGlashan & Strauss, 1977; Rappaport, Hopkins, Hall, Belleza, & Silverman, 1978; Bola & Mosher, 2003; Matthews, Roper, Mosher, & Mann, 2003)

17. More research? • Martin Harrow conducted a long term study of Psychotic Patients • He found that those who had taken antipsychotics had: • Worse long term recovery rates • Worse global adjustment • Greater levels of anxiety • Worse cognitive functioning • Higher relapse rates

18. More research? “I conclude that patients with schizophrenia not on antipsychotic medication for a long period of time have significantly better global functioning than those on antipsychotics.” Martin Harrow, American Psychiatric Association annual meeting, 2008

19. Anti-depressants • In the early 1960s, there were two types of antidepressants, monoamine oxidase inhibitors (MAOIs) and tricyclics . • However, MAOls soon fell out of favor because of dangerous side effects and a 1965 finding by the Medical Research Council in the United Kingdom that they were no more effective than placebo (Medical Research Council, 1965). • Four years later, the NIMH concluded that there was also reason to doubt the merits of tricyclics. • After reviewing the medical literature, NIMH investigators determined that in "well-designed studies, the differences between the effectiveness of antidepressant drugs and placebo are not impressive" (Smith, 1969, p . 19)

20. Anti-depressants • With such confusion over the efficacy of tricyclics hanging in the air, the NIMH launched an ambitious long-term study of depression treatments in the early 1980s. • 239 patients were randomized into four treatment groups-cognitive behavior therapy, interpersonal therapy, antidepressant and placebo. • The results were startling: • Patients treated with antidepressants were the most likely group to seek treatment following termination of the initial treatment period, they had the highest incidence of relapse, and they "exhibited the fewest weeks of reduced or minimal symptoms during the follow-up period" (Greenberg & Fisher, 1997, p. 147).

21. Anti-depressants • Once again, the results led to an unnerving conclusion; antidepressants were making people chronically ill. • Other studies deepened this suspicion. In 1985, a U.K. group reported that in a 2-year study comparing drug therapy to cognitive therapy, relapse "was significantly higher in the pharma-therapy group" (Blackburn, Eunson, & Bishop, 1986, p . 67). • In 1994, researchers found that "long-term use of anti-depressants may increase the biochemical vulnerability to depression, and thus worsen the course of affective disorders" (Fava, 1994, p . 127) . • Fava revisited the issue in 2003 . In an analysis of 27 studies, he wrote “A statistical trend suggested that the longer the drug treatment, the higher the likelihood of relapse" (Fava, 2003, p . 124).

22. More research? • Recurrence of depression more likely with those who have taken anti-depressants • Source: E.Weel-Baumgarten,“Treatment of depression related to recurrence,”J Clin Psychiatry & Therapeutics 25 (2000):61-66. • Continuing depression most likely in those being being treated with antidepressants • Source: D. Goldberg. “The effects of detection and treatment of major depression in primary care.”British Journal of General Practice 48 (1998):1840-44. • Medicated patients less likely to return to work, more likely to have long term disability and more likely to quit/be fired • Source: C Dewa.“Pattern of antidepressant use and duration of depression-related absence from work.”British Journal of Psychiatry 183 (2003):507-13. • Medicated patients more likely to leave work and more likely to become incapacitated • Source: W. Coryell.“Characteristics and significance of untreated major depressive disorder.”American Journal of Psychiatry 152 (1995):1124-29.

23. More research? • Medicated patients more likely to relapse and more likely to be depressed at the end of 10 months, in comparison to an exercise alone control group. • Source: Babyak, M. “Exercise treatment for major depression.”Psychosomatic Medicine 62 (2000):633-8. • The famous STAR* D trial, the largest study of depression ever conducted found that only 3% of patients remitted, and stayed well throughout the 12 month period. • Source: Pigott, E.“Efficacy and effectiveness of antidepressants.”Psychother Psychosom 79 (2010):267-79.

24. Anti-depressants • But as previously suggested, the drugs do affect our chemical systems in some way, making the likelihood of side effects quite high. • In Prozac's first 2 years on the market, the FDA's Medwatch program received more ‘adverse event’ reports about this new "wonder drug" than it had received for the leading tricyclic in the previous 20 years. • Prozac quickly took up the top position as America's most complained about drug. These reports suggested that nearly 4 million people in the US had suffered problems, which included mania, psychotic depression, nervousness, anxiety, agitation, hostility, hallucinations, memory loss, tremors, impotence, convulsions, insomnia, and nausea.

25. Anti-depressants • The other SSRIs brought to market caused a similar range of problems, and by 1994, four SSRIs were among the top 20 most complained-about drugs on the FDA's Medwatch list (Moore, 1997). • All of this led the American Psychiatric Association to warn that manic or hypomanic episodes are "estimated to occur in 5% to 20% of patients treated with anti-depressants" (Breggin). • Yale researchers reported that 8 .1% of all admissions to a psychiatric hospital they studied were due to SSRI-induced mania or psychosis (Preda, MacLean, Mazure, (St Bowers, 2001) • Of course once diagnosed with mania patients were then prescribed anti-psychotics to go with their anti-depressants! A drug cocktail that most often led to permanent disability.

26. Why do so many people take them? • Answer 1 – we trust people when we should not! • The psycho-pharmaceutical business is a multi-billion dollar business. • This means that many researchers receive payments from companies to make results as favorable as possible (this was the case with the STAR*D researchers). • To combat this projects like ‘Data Based Medicine’ and ‘RXISK’ have started which aim to scrutinize data investigating drugs. Recently DBM, suggested that many of the risks of anti-depressants are not included in the publications. • They have also scrutinized the way in which medical doctors are targeted with free lunches and clever marketing

27. Why do so many people take them? • Answer 2 – because we want to feel better and this is sold to us as an easy way to do it. • Taking tablets requires much less effort and pain than seeing a psychologist. • Many, including people I know, would prefer to take drugs than to talk about their issues. • But what do we do, now that we know the drugs may not work?

28. The Happiness Game • When we take anti-depressants, we take them because we want to feel better. • In fact, we do many things to try to control how we feel. For example, many people drink, take drugs, problem solve with friends, watch a film, use the internet etc. • We do all of these things because we really don’t want to feel a certain way. And we do all of these things because we feel that we should be happy. • But how have these control techniques worked for us?

29. The Happiness Game • Probably not very well. • And there may be a simple explanation for this; maybe we can’t control our feelings. • In fact, at some level, this makes much sense. If it were possible to control our feelings then everyone in the world would click their fingers and be happy! • But this isn't the case. • Everyone in the world is playing The Happiness Game, where they spend much of their time chasing this fuzzy feeling. • But what if this game is impossible to win, and what if the more you play the game, the worse your life becomes.

30. The alternative • Playing The Happiness Game puts feelings up there as the most important part of our life • As if they are right up here in front of your face. Where we find that our every decision is based around the need to feel good. • The problem with this is that when we are busy chasing feelings and being bullied by feelings, we tend not to be able to see many of the options around us and they tend to stop adaptive behavior. • Maybe the alternative would be to carry feelings around in our pocket, or let them play like a radio in the background. • What if you could live a life where you didn’t have to spend your time and energy battling negative feelings? • Where they could just be there, while you are out there living your life?

31. The alternative • What if you could have the Psychological Flexibility to experience the good feelings and the bad feelings, whilst moving in a direction that is important to you? • These questions form the basis of an approach to human suffering named Acceptance and Commitment Therapy (ACT). • ACT suggests that you don’t have to run away from your feelings, you may not want them but you can still live a valued life whilst they are around! • I'm not going to talk about ACT today but if you would like to read more about it then please Google ACT or read ‘The Happiness Trap’ by Russ Harris. • Nevertheless, here is some advice that might help you to live your lives better

32. Advice • Expect to be unhappy, stressed and anxious sometimes. Feelings come and go like the clouds, they're normal. Be willing to feel those things and control your actions • Live in the present moment. Too many of us are affected by the past or worrying about the future. When we do that we lose touch with the richness that is around us right now. • Keep in contact with your values. At times University is tough, but if you value your education and career then that value will be your guidepost when your feeling down • Hold stories about yourself lightly. Sometimes they can get in the way of you acting in a value consistent manner

33. The take home message • The core message of todays lecture is; • People take anti-depressants because they think that will help them to feel better • But psycho-pharmaceutical drugs may not work in the way you expect them to i.e. they may not help us to feel better and may cause major harm in the long run. • Maybe a radical alternative to controlling our feelings, is being willing to experience them. • This isn't easy and it isn't a quick solution, but it is possible. • The evidence for ACT is growing at an impressive rate, and this may be because ACT allows people to stop playing The Happiness Game

35. Thank you for listening