Don't listen to Prozac

Probably the most important study that has come out in the last month has gotten surprisingly little media attention. It appeared in the journal Molecular Psychiatry and it calls into question the whole basis on which the SSRI antidepressant phenomenon is based—the low in serotonin theory. Whatever is the real cause of depression, the researchers say, it isn’t “chemical imbalance.” The whole theory on which modern antidepressants (selective serotonin reuptake inhibitors—SSRIs) are based is simply wrong.

Many readers of this newsletter may remember “Listening to Prozac,” a 1993 blockbuster book written by psychiatrist Peter D. Kramer. The book and the class of drugs of which Prozac was the most famous was the beginning of a pharmaceutical rip-off that has continued ever since.

The drugs, (SSRIs) were based on the theory that there was a chemical imbalance in the brains of depressed people which could be cured if you could encourage the brain cells specializing in processing the neurochemical serotonin to do their job.

Right from the start, it was obvious that both the drugs and the book were based on junk science—small limited-in-time studies funded by the various pharmaceutical companies.

Since there wasn’t—and still isn’t—any proven long-term cure for depression and Prozac and its ilk seemed to provide short-term relief, SSRIs became tremendously popular. Patients demanded they be prescribed, and physicians, deeply influenced and often materially rewarded by the drug companies, were only too happy to oblige.

Alicia and I were among the few voices in the wilderness crying that the whole SSRI craze was based on false research. There was no solid proof whatever that they worked other than as a placebo. They also had some nasty side effects which, paradoxically increased their popularity. The drug companies found that people believed in the reality of drugs with side effects more than in those that didn’t. That belief, and the trust that people had in their doctors, were the reason that many people experienced short-term relief from their symptoms.

The drugs had a great secondary benefit for their manufacturers: they were highly addictive and caused acute withdrawal symptoms when people tried to get off them.

A billion, billion, billion-dollar industry was created out of nothing approaching real science.

It never made sense to me that the lack of one neurochemical could be the cause of depression. The disease seemed to have too many quite separate causes and my own growing assumption was that depression was a syndrome—separate ailments with common symptoms.

In 1989 a University of Missouri study found that the rate of depression within the US population was doubling every 20 years. Something else besides serotonin was clearly going on. Why would all these extra people suddenly develop a unique chemical imbalance?

One way of looking at depression is through the lens of evolution. What adaptive purpose does it solve?

I was one of the originators of evolutionary psychology. My passion for the discipline stemmed from the year I spent with hunter-gatherers in the Kalahari. One of the things I noticed was that none of the H-G suffered from long-term depression or anxiety. This is something that has been observed by many subsequent researchers.

Depression in hunter-gatherers, I observed, was reactive and stemmed from a specific event—failure to get the mate one wanted, exclusion from the group etc. The adaptive purpose was to get the loser in the mating conflict to withdraw and therefore prevent societal conflict.

I reasoned that the “something else” which was causing the modern long-term depression pandemic (as well as the equally accelerating levels of GAD—general anxiety disorder—and PTSD) must be to do with our present lifestyle. I developed the theory of human “design specs.” The idea was that we were designed by evolution for a particular lifestyle, and a particular environment. Biologically and neurogenetically we are still hunter-gatherers on the African savannah.

In general terms, that idea is central to both evolutionary psychology, evolutionary psychiatry, and behavioral neurogenetics (my other discipline).

The further we get from that lifestyle and context the more stressed we become. Like any system that exceeds its design specs, ours becomes stressed and at a certain point, it must break. Depression is a symptom of that stress. Alicia and I included this idea in our best-selling 2005 book “Creating Optimism.”

But quite apart from the new way of looking at our biology and psychology, researchers were beginning to look at the antidepressant drugs themselves. They were finding that SSRIs were not as effective as the initial reports suggested and were highlighting flaws in the original serotonin studies.

The first major crack in the SSRI mythology came in 1997 with an article in The International Journal of Risk and Safety in Medicine. In this, the author reviewed all the studies up to that date and concluded that the risks associated with the drugs far outweighed their benefits. Added to that he found that their efficacy was little better than a placebo.

In 1999 a major study by the University of Connecticut confirmed the placebo effect, adding that the reason the drugs worked for some people was that they had such faith in their physicians that their systems worked to make the doctors right. At the same time, a meta-study in the journal Prevention and Treatment looked at the studies supporting the SSRIs and found them very wanting in real evidence of any benefit over placebos.

But what should have been the death blow to the whole SSRI industry came in 2008 when a team led by Irving Kirsch of the University of Hull published a definitive review of all the studies, published and unpublished, and found that SSRIs were, effectively, useless.

And yet the power of the industry is such that the pills keep being prescribed by doctors either unwilling or too pressured to cease handing them out. They were even increasingly being prescribed for adolescents despite warnings by European and US regulators of increased suicides among young people taking them.

And now this new study which I mentioned at the start. The house of cards should now collapse.

There is a deeper question that must now be answered: when did the drug companies realize that their pills were both harmful and useless? It is the same question that the coal and gas industry must answer in relation to climate change and the adverse health effects of the extraction and use of their products.

What does work for depression? In the long term we don’t know. Recent studies have shown, for example, that CBT psychotherapy (cognitive behavioral therapy, the psychology industry standard approach) and other forms of talk therapy aren’t effective for anything except very mild depression.

In the short term, the following have proven to be helpful:

• Religiosity
• Supportive partner, friends and colleagues
• Ketamine infusions
• Psilocybin (the active ingredient in magic mushrooms)
• Dark sugar-free chocolate
• Praise and acknowledgement
• Interesting and diverting work/hobbies (but only when actively engaging in them)