
The Serotonin Levels-Depression Link Is a 'Marketing Myth,' Psychiatrist Claims - DiabloD3
http://motherboard.vice.com/read/the-serotonin-levels-depression-link-is-a-marketing-myth-psychiatrist-claims
======
ap22213
I can't speak for the depression remedy, but SSRIs have certainly helped my
anxiety issues.

A few years ago, I started having incapacitating panic attacks. They were so
pronounced that I'd end up in the hospital ER several times a month.

Eventually, I was prescribed an SSRI, and the anxiety attacks went away
completely. Maybe it's placebo, but when I tried to stop taking them, the
anxiety attacks came back. (reverse placebo?)

I'm not a big fan of big-pharma, but for me, SSRIs were a literal lifesaver.
It's easy to criticize, but unless one has an alternative solution, it's best
to let things be until better treatments come along.

~~~
letstryagain
I've been taking SSRIs for more than a decade. In the last few years I've
learned that they don't seem to work much better than placebos. That may be
true but it does not matter. They work for me and the side effects are minimal
so I will keep taking them. SSRIs have made a huge difference to my quality of
life. I don't care if I'm just taking a placebo at this point, as long as I'm
getting the results I need.

~~~
sjg007
do or did you drink alcohol? and did you stop or not?

*Edit: The reason I ask is because most SSRIs say do not drink alcohol while taking this medication. It could be discontinuation of alcohol that relieves depression.

~~~
DanBC
To support what you say here's the nice guidance for problem drinking combined
with mental health problems. The guidance is very clear: you treat an alcohol
addiction before you treat the depression because the depression is likely to
become less severe as you treat the problem drinking.

[http://www.nice.org.uk/guidance/cg115/chapter/Key-
priorities...](http://www.nice.org.uk/guidance/cg115/chapter/Key-priorities-
for-implementation)

> For people who misuse alcohol and have comorbid depression or anxiety
> disorders, treat the alcohol misuse first as this may lead to significant
> improvement in the depression and anxiety. If depression or anxiety
> continues after 3 to 4 weeks of abstinence from alcohol, undertake an
> assessment of the depression or anxiety and consider referral and treatment
> in line with the relevant NICE guideline for the particular disorder[3].

So, it's true for the general population. But it's a bit rude to ask one
individual if they had problem drinking or to suggest their illness was
problem drinking.

------
electronvolt
I think it's important to note that although studies of serotonin levels don't
show a connection with depression (i.e. lower serotonin levels = depression),
that doesn't mean that drugs which decrease reuptake/increase (by proxy)
serotonin levels won't improve mood.

It's sort of a red herring to say "Depression isn't caused by a serotonin
deficiency, therefore SSRIs are bunk", which is what this article seems to
veer towards. SSRIs could affect a completely different body system as long as
they wind up showing a statistically significant effect over placebo in a
double blind study, then they are acceptable forms of treatment by our current
scientific/medical standards. (Which apparently they do for most patients--so
I wouldn't rule them out.).

~~~
taliesinb
There seems to be a growing view that inflammation plays an important role in
depression. See for example
[http://www.biomedcentral.com/1741-7015/11/200](http://www.biomedcentral.com/1741-7015/11/200)
.

The idea is that depression could be a feedback loop in which negative life
events cause the brain to become chronically flooded by stress hormones like
cortisol and epinephrine.

These are pro-inflammatory factors whose chronic presence promote run-away
inflammatory responses which kill glial cells, decrease neuroplasticity,
retard neurogenesis, and also contribute to a whole constellation of other
health problems like obesity, diabetes, and heart disease.

What closes the feedback loop is that this inflammation-mediated form of brain
damage, particularly in the hippocampus and amygdala, directly compromise a
person's cognitive ability to deal with life stressors constructively. The
ability to process emotion, fear, and memory degrade.

Speaking a bit poetically, you could say that a severely depressed brain is
one that has rewired itself to be a stress-processing circuit.

SSRIs no doubt work for some people, and the modern thinking is that they
might be promoting neurogenesis through upregulating BDNF and other growth
factors; there are multiple lines of evidence, one fun one is the fact that
the maturation time of new neurons roughly matches the time it takes for SSRIs
to start affecting depression (3-6 weeks).

Exercise also works, seemingly about as well as SSRIs for many people with
moderate depression (Googling will provide examples of studies from the last
few couple decades to that affect). I haven't read much about this but I would
imagine that the metabolic and cellular stresses of a bout of heavy exercise
(in which millions of cells die) promotes the production of growth factors all
over the body, including in the brain.

~~~
wobbleblob
I think "negative life events" are more of a symptom than a cause. Temporary
grief over loss or other genuinely bad things happening in life is normal in
healthy people. What's so different about depression is that the patient seems
to feel bad without a clear cause. You hear them going on about things that to
a healthy person don't seem like such a big deal, or easy to fix, or so long
ago a healthy person would have been over it by now. It's more a sign of the
depressed brain trying to rationalize why it feels bad, and looking for
outside causes to blame.

------
joosters
It's worth reading [http://slatestarcodex.com/2015/04/05/chemical-
imbalance/](http://slatestarcodex.com/2015/04/05/chemical-imbalance/) for a
more balanced take on this issue IMO.

~~~
Alex3917
This entire article is based on a complete mischaracterization of Robert
Whitaker's book/article. How exactly is that balanced?

~~~
FeepingCreature
[See also this follow-up.]([http://slatestarcodex.com/2015/04/18/polemical-
imbalance/](http://slatestarcodex.com/2015/04/18/polemical-imbalance/))

~~~
Alex3917
It's still a complete mischaracterization. What RW is saying, to vastly
simplify, is that pharma companies and psychiatrists are selling drugs that
haven't been proven to work by using the monoamine hypothesis, which is a
largely discredited theory.

What this blog is saying is that when psychiatrists talk about a chemical
imbalance, they are merely saying that brain chemicals are involved in
depression in some way, rather than that a lack of serotonin causes
depression. The latter has literally nothing to do with what Robert Whitaker
is actually talking about. It's just nonsense pharma propaganda designed to
trick people who haven't actually read the original book, which sadly is the
vast majority of people.

~~~
thedufer
How can it be a mischaracterization? RW explicitly argued against the blog
post in question here: [http://www.madinamerica.com/2015/04/psychiatrists-
still-prom...](http://www.madinamerica.com/2015/04/psychiatrists-still-
promoting-low-serotonin-theory-depression/) If he was being mischaracterized,
wouldn't he have said that instead of repeating exactly what he was claimed to
be saying?

> pharma companies and psychiatrists are selling drugs that haven't been
> proven to work by using the monoamine hypothesis

Where's your evidence here? SSRIs do work (I assume this is the class of drug
we're talking about). For sure, they don't work for some people (or some types
of depression; hard to say which is the issue at this point). But they still
beat placebo on average.

In fact, the monoamine hypothesis was _based_ on the fact that SSRIs work. The
cause/effect is the opposite of what it would have to be for your claim to
make sense.

------
whoopdedo
If I eat some bad sushi, the pain in my stomach is not caused by constricted
blood vessels or an excess of COX enzyme. But if I take a Tylenol, a COX
inhibitor, I feel better. Then a few hours later I'm "cured" in that I no
longer have stomach pain, headache or fever.

Did the Tylenol cure what was ailing me? Not at all. What it did is made me
feel more comfortable while the root malady was being taken care of. If the
pain persisted after one or two doses of Tylenol then I'd suspect something
more serious than indigestion were at fault and I'd start looking for a
reason. What I wouldn't do, and what I hope a doctor would be responsible
enough not to do, is to keep taking Tylenol or a more serious pain medication
to cover up the pain without considering the actual cause.

~~~
sjg007
Tylenol, interestingly, has an antidepressant effect.

~~~
magic_beans
Would that have to do with its anti-inflammatory property?

------
DanBC
Depression probably is not a single illness with a single cause

The serotonin hypothesis is probably wrong

There are problems with some of the studies used for SSRIs / SNRIs / etc, as
with many drugs.

Studies show stronger effectiveness of meds for more severe depression

Fromt line treatment for depression and anxiety is not medication but is a
talking therapy or a talking therapy and a medication combined.

None of this is particularly new. IAPT (Improved access to psychologicl
therapy) is the UK national health service programme to help local health
providers implement NICE guidance on depression and anxiety disorders. IAPT
started in 2006.

~~~
zamalek
> The serotonin hypothesis is probably wrong

The serotonin is one _possible_ cause. It sounds like you are suggesting that
SSRIs are incorrectly used as a universal treatment, which I'd agree with
completely.

I think it's important to distinguish between depression and sadness. I've
noticed a very sharp increase in the amount of people (especially youth) who
claim to be depressed. They go to a doctor, get a SSRI prescription and next
thing you know their brain has a dependency on SSRIs to maintain normal
serotonin levels (they are now actually depressed). This is why this is
important:

> talking therapy or a talking therapy and a medication combined.

I was _clinically_ depressed for the longest time. Turns out it wasn't caused
by serotonin but instead a genetic mutation[1] that something like 80% of
human samples have. It can results in a condition is called homocystinuria. In
layman terms your body is unable to activate (turn into usable form) one of
the forms of Vitamin B. Unsurprisingly the symptoms 5-MTHF (the activated
Vitamin B) deficiency can be strikingly similar to depression.

My fix for depression is to simply take a vitamin for the rest of my life. I'm
just lucky that the doctors I went to cared enough to not default to the SSRI
prescription.

[1]: [http://ghr.nlm.nih.gov/gene/MTHFR](http://ghr.nlm.nih.gov/gene/MTHFR)

------
scythe
The editorial is here:

[http://www.bmj.com/content/350/bmj.h1771](http://www.bmj.com/content/350/bmj.h1771)

Some of it I agree with, some I don't; I'm going to bed, but my primary
objection relates to why the tricyclic antidepressants fell out of use. First
of all, they're not gone; if you go to a psychiatrist and ask for
amitryptyline or imipramine, you might just get it. But they're only used in
depression which doesn't respond to SSRIs, because in some patients tricyclics
can cause mania, hallucinations, and muscle twitching in addition to the
infamous weight gain and sexual anhedonia seen on SSRIs. As such they were
rarely prescribed even when they were the only drugs available.

Otherwise I agree, but the question "why don't we use tricyclics?" has a lot
of excellent answers.

------
fsk
There were several drugs I tried where I couldn't stand the side-effects, and
only one that I actually liked.

As a patient, if you feel the drugs aren't helping, you should be prepared to
fire your doctor or even stop taking them. (I know that's a big medical no-no,
but I never would have found someone competent if I didn't fire several
psychiatrists and refuse to take drugs that had harsh side-effects. My first
psychiatrist was so incompetent that I believed that they all were incompetent
and all the drugs were harmful.)

~~~
GabrielF00
If you choose to stop taking an anti-depressant, please be careful and consult
a physician. If you don't taper off the drugs, you can feel some really nasty
effects. This seems to be particularly problematic with Cymbalta.
[https://en.wikipedia.org/wiki/Antidepressant_discontinuation...](https://en.wikipedia.org/wiki/Antidepressant_discontinuation_syndrome)

~~~
alejohausner
You bring up an important point. If you STOP taking an SSRI, you will feel
depressed, because your serotonin levels will drop. What's happening is that
the SSRI has been fighting your body, pushing up your serotonin levels, and
your body has been fighting back. When the SSRI is cut off, your body's fight
continues for a while, pushing levels down. Often patients feel suicidal at
this point.

Healy and Whittaker point out that the clinical studies initially used to
justify the use of SSRIs cleverly took advantage of this effect. Patients on
SSRIs were compared to those who had just been cut off the drug. Of course the
latter group, perversely included as "placebo", fared worse than the ones
taking the drug.

~~~
DanBC
Discontinuation effects are not "feeling more depressed".

~~~
bayesianhorse
But you feel like shit and may try to kill yourself. That's sort of the reason
why stopping medication without external supervision is discouraged.

------
Synaesthesia
We do know that MDMA is an incredibly potent anti-depressant and serotonin
releasing agent. It may be able to cure depression in a single dose.

Unfortunately it was banned by the DEA under very controversial circumstances,
against the recommendation of doctors and scientists, (who wanted it to be
schedule 3) so a promising avenue of research was shut down.

Of course it can be harmful, if abused, but if used correctly it's quite a
benign substance.

We also know from decades of studies that SSRI's don't work very well, often
not at all, and that they also have paradoxical effects such as suicidal
feelings and depression.

------
teammatters
For me and others close to me anti-depressants proved to be a joke/a placebo.

I was on five to six different drugs to cure an odd social anxiety, that went
away as I got older and grew more comfortable in my skin. How in the world can
a drug cure an odd internal social behavior that leads one to feel
anxious/uncomfortable? Answer for me is .. it can't.

Another example being my g/f. We started dating six years ago and up until a
year ago she had been on 4 different anti-depressants each year. Her doctors
would say oh that one isn't working lets try this one and so on. Finally she
realized this stuff isn't helpful, what's the point?

For those it has helped that's good to hear, but for me, my g/f and many
others I know... these drugs are just lining the pockets of the drug
companies.

~~~
gordaco
Anti-depressants didn't ever do anything for me, either. Although I suspect
that the only anxiety attack I've ever had could very well have been caused by
them.

In his awesome book Bad Pharma, Ben Goldacre also hints that the link between
depression and serotonin levels is not very well established. For those of you
that don't know, Ben Goldacre is not some quack that pretends that science is
wrong or something like that; in fact, what he asks for is precisely more
rigorous science (specifically, more rigorous medical trials, all made
public).

On the other hand, apparently there are a lot of people who have had a
measurable level of benefit. My non-educated hypothesis is that there are
several causes of depression and serotonin levels may be only one of them.

~~~
pyre
It's probably best to view depression as a symptom. It could have several
immediate causes (i.e. the physical processes that make you feel that way) as
well as many other root causes (i.e. what leads your body to be in the state
that is causing you to feel depressed).

------
im3w1l
One alternative (maybe fringish, I don't know) theory I've heard for the
action of antidepressants, are that they work by being antimicrobial.

~~~
refurb
That would be pretty easy to test, no? Just put some anti-depressant on
different bacterial cultures and see if they die.

~~~
letstryagain
Oh we know they are anti-microbial, we just don't know how that might affect
your mood

------
jmspring
I can't speak to the drugs or the study, but having had a significant other
showing signs of depression and working with them to get them active
(physically), outside more, and an additional avenue to focus on (in this
case, something in common that happened to be outside activity) helped with
the depression symptoms significantly. Not fully, but definite signs.

Just an observation/data point.

------
martin1975
I didn't even know I was depressive until my mid 30's...when apparently
(according to stats from the shrink I visited) a lot of people manifest
symptoms. Mine were sudden panic attacks, which when they happened first, I
thought I was dying so I called 911 for nothing and was told there's nothing
wrong w/my heart even though I felt chest pains/tightness (a common occurence
w/MDD, but who'd know, right?)...which then got worse over time, despite what
I did, exercise, vitamins, supplements, sleep, drinking, and other things I
won't name, only because I (formerly) despised psychiatry as a profession and
thought it was gobbledy gook.

For reason I won't outline here, someone strongly suggested, after having
fought this unsuccessfully for quite some time and needlessly suffering, that
I visit a psychiatrist because in his view, I had MDD. This is someone I truly
trusted and he apparently dealt with his MDD in the past, so I was like, ok,
I'm at the end of my rope so I'll give the MD a shot.

The best way to describe what happened few months down the road after a few
trial/errors to see which SSRI fits me best (and that's how everyone finds out
- trial/error, any doctor worth his salt will admit this- or they lie to your
face if they say otherwise), is a persistent feeling developed, or I should
say, resurrected only because I forgot how it felt to feel normal since I was
a kid - of being lifted out of a deep hole that I seem to have been in for
years, if not decades.

All the b.s. about sexual dysfunction they petrify guys with - for me was not
true, in fact, it was quite the opposite as I regained control over that
aspect of my life, rather than desensitizing myself with some activities which
may have eventually led to ED, despite some "logic" that was telling me that I
was doing the "right thing" ...

I could focus better at work, I was calmer in general with my wife, kids, and
was more chipper and lit up overall. It's not a high or a dependency...to test
it, I stopped, went through what one might call a "withdrawal", but then the
MDD kicked back in in full force after a few months of being off it.

Since then, I went back on and decided it is much more important to be
productive and focused on an SSRI, than a panic-induced, anxious, crying fits,
lost mess without it.

So do SSRIs work? They worked for me - in conjunction with some therapy. Do
they address the EXACT cause of depression? Unlikely. MDD is multi-causal,
some nurtured by choice, some genetically inherited, no one really knows...
but SSRIs treat it well enough in many cases.

Don't dismiss anything out of hand - would be my advice. Depression (clinical,
not just depression cause you lost your job or gf/bf - which tends to go away)
is real and it is sucks big time. Mine was classified as MDD of moderate to
severe character...and I asked the doc, what's really severe - his response
was, curling up into a ball on the couch and not being able to function. Some
are worse and potentially self-destructive...(i.e. suicide). There is
help...SSRIs are just one of many ways to treat this. Point is to reach out
for help when someone points it out to you - if you trust them, and you've
struggled w/it long enough to the point of unmanageabiility. Study upon study
show high causality between SSRI therapy and major reduction of MDD
symptoms...

good luck!

------
bayesianhorse
I compare this to giving a machine a hit with a wrench. So there is this
cliché about machines which have hickups or stop working and then when you hit
them hard enough, they work properly again.

But that doesn't mean they were designed to only work under continous
beatings. Same thing with serotonin: In depressed brains, SSRIs will "hit" the
brain, and that works surprisingly often, but it doesn't mean the brain was
supposed to only work with high serotonin levels.

~~~
martin1975
ECT hits it harder, and allegedly, in many cases, "reboots" it to a point of
being normal (i.e. non-depressed), if the SSRI hits fail to work.

Wanna hear something even trippier from my shrink's mouth? In cases where ECT
failed - and not many at that - as an alternative, nicotine therapy broke the
depression, restored feelings of normalcy. :)

Obviously, they didn't have the patient take up smoking, since there are other
ways to administer nicotine only without the 4000 byproducts of smoke, but it
made sense, since I believe most of my family is depressed and the whole lot
of them have been decades long smokers, to this day.

Cool stuff huh? Grab that Camel pack now ;)

