But SSRIs do work. Experiment often proceeds theory. Uncertainty about the exact mechanism doesn't change the fact that SSRIs reduce symptoms of anxiety and major depression symptoms in many people. They have drastically improved my life and the lives of many family members and friends.
This is not at all settled, and for the people who believe it wholly, the effects that are claimed are marginal. It's fine to talk about the benefits of SSRIs, although they may be controversial, but to use them as a basis for believing in other things is like 12 steps too far.
> For the people who believe it wholly, the effects that are claimed are marginal
No, the effects are not marginal. Research, the experience of basically all clinicians who prescribe antidepressants, and my personal experience all show they treat depression.
For a given person, an SSRI may significantly relieve their symptoms, have a mild effect, or have no effect. Across the population, studies of SSRIs consistently show they work to treat major depression [1].
Every clinician I've met has observed SSRIs being effective. They see depression symptoms getting better when medication starts, and they observe relapses when medication stops.
When I started taking Escitalopram, I stopped being depressed. When I stopped taking Escitalopram, I became depressed again. When I re-started Escitalopram, I stopped being depressed again.
My grandfather had the same experience. When he went on Citalopram, he became calmer and less irritable than he'd ever been in his life. He stopped taking Citalopram for a few weeks, because of a physical illness that interrupted a prescription refill, and immediately slipped back into a depression. When he went back on Citalopram in the hospital, he was smiling and singing again two weeks later.
The trouble is that the placebo effect has been repeatedly demonstrated to be extremely, profoundly strong for depression and anxiety treatments.
Yes research has found improvements when you put people on SSRIs, but double blind placebo controlled studies generally find that about 80% of the benefits also occur in the placebo group, so the actual benefit over placebo is only about 2 points on the HAM-D scale. [1]
On top of that, SSRIs have well-known side effects that are pretty noticeable for most people, so it’s hard to know how much of their benefit vs placebo is due to loss of blinding and/or the “active placebo” effect.
It is, however, notable that one study found a loss of effect when subjects were deceived and told that the SSRI they were given was an active placebo with similar side effects to an SSRI, and the differences were visible on brain scans, not just in their subjective reports.[2]
> When I started taking Escitalopram, I stopped being depressed.
Ooh, anecdotes, and ignoring your own quoted text, I can do that too!
When I started taking it, I became numb, lost my sex drive, and basically exacerbated my underlying anxiety problem related to the depression. When I stopped taking it, I had extreme, severe withdrawal symptoms, orders of magnitude worse than any other withdrawal I've ever been through. When I stopped taking it, I had been practicing meditation and going to therapy. I also threw in real commitment to the gym for the first time in my life. Took a while for the sexual side effects to wear off too. Needless to say, I have extreme resentment for the doc that put me on that with zero guidance, warning, options, etc. I know have a beta blocker prescribed that I can take to prevent the physical symptoms of anxiety from exacerbating into a mini panic attack, but I basically don't need to take those anymore.
I can find a non-trivial number of studies that (happy to link them, don't want to spam or be over the top right now), either:
1. Show it's barely more effective than a placebo.
2. Show it's barely more effective than a placebo, except for about 15% of those taking it, who had a measurable improvement.
I'm not a doctor but I'm going to sublty imply that there are other treatments for depression, with more impressive statistics, that don't cause bi-minutely head-to-toe "body zaps" when trying to go off it.
> For a given person, an SSRI may significantly relieve their symptoms, have a mild effect, or have no effect.
In other words, SSRIs do not work for everyone who has depression. For some people, they do; for others, they don't. You and your grandfather apparently are in the first group; but there are also plenty of people in the second.
Now comes the obvious next question: is there a way to tell in advance (i.e., without trying the SSRI on the person and seeing whether it works or doesn't) which people are in each category? No, there isn't. That's the impact of not knowing the mechanism: treatments for illnesses like depression are trial and error. If you find a drug that works for you, great! But many people never do.
Problem with SSRIs is: Does depression cause reduced serotonin, or does reduced serotonin cause depression?
A recent paper [0], [1] claims there is no connection between reduced serotonin as a cause of depression.
Which in my book says depression is a software problem more than a hardware problem, even though the software problem can create reinforcing hardware problems.
This is a mischaracterization of the research. Recent research has indicated that Serotonin levels in depressed people are not lower than average. But SSRIs are effective for relieving depressive symptoms - either boosting serotonin levels above average works, or they work through some other pathway that hasn't been identified.
> Which in my book says depression is a software problem more than a hardware problem, even though the software problem can create reinforcing hardware problems.
A human isn't a computer. You can't separate psychology from the biology of the brain. This comment is really unhelpful in actually treating mental illness. Talk therapy helps depression, lifestyle changes help depression, and medication helps depression. Most people recover with some combination of all three.
I've never understood people who seem to take offense to the existence of antidepressants. If you don't want to take them, don't take them, but leave the people who benefit from them in peace.
> Recent research has indicated that Serotonin levels in depressed people are not lower than average. But SSRIs are effective for relieving depressive symptoms - either boosting serotonin levels above average works, or they work through some other pathway that hasn't been identified.
But that is exactly the point. If we don't know why something works, we can't even be sure that it does work.
Also SSRIs are only slightly more effective than placebo. [0]
Quote: "So, when we accessed the public domain data from the U.S. Food and Drug Administration (FDA) archives for the antidepressants approved between 1985 and 1997 (7), it quickly became apparent that many of the assumptions about the relative potency of antidepressants compared to placebo were not based on data from the contemporary trials but from an earlier era. Specifically, it became evident that the magnitude of symptom reduction was about 40% with antidepressants and about 30% with placebo."
Until/unless we can finally understand how the human endocrine system works, on both a broad statistical basis as well as on a predictable individual basis (i.e. in the same sense that statistically we know that X number of people die each year in automobile collisions but we don't know exactly WHICH people will die) we are making guesses.
The level of scientism our society exhibits - in which we cannot just accept that some things don't have answers that we can access at this time, and instead accept any answer "science" gives us - is unfortunate. Research we do is limited by what we look for, and the positivist approach we see in medicine ("Find diseases we can make money on") limits everything.
