Dr. Abigail Zuger writes in The New York Times, “Dr. Kramer’s bottom line is well summarized by the double meaning of “Ordinarily Well: The Case for Antidepressants” — he argues that antidepressants work just about as well as any other pills commonly used for ailing people, and that the drugs keep people who take them reasonably healthy.” Read the News
As I’ve intimated, drug industry research on the newer antidepressants has been manipulated to maximize positive results and minimize the downside. Here’s one example: the original research that got FDA approval and set off the craze for these drugs had very low standards, which were not revealed to the public.
They were generally two- or three-month trials, very short over the lifetime course of depression, and the definition of cure was simply no longer meeting all the criteria for major depression. You might still be feeling suicidal and wracked with guilt, but if your sleeping had improved, as far as the FDA was concerned, the drug had demonstrated its effectiveness. Then there was the fact that in all these trials the drugs proved only slightly better than placebo—in most cases, about 40 percent of people got better with a sugar pill, and about 50-60 percent improved with an SSRI. Added to that is the fact that many of these studies stacked the deck by excluding people who were most responsive to placebo.
Subsequent studies, with larger groups over longer periods of time, have shown about the same disappointing results. The STAR*D study, with a large sample of real-world patients, without excluding placebo responders, found that about 50 percent of patients had a significant response to medication, but only about 30 percent met the researchers’ definition of remission. During follow-up, a significant number of patients relapsed. Overall, the recovery rate was only slightly better than chance alone. STAR*D was sponsored by the National Institute of Mental Health and should be considered relatively free of drug company influence.
The withdrawal problems with SSRIs have also been minimized. There can be significant withdrawal problems when you stop taking SSRIs—“SSRI Withdrawal Syndrome”—including extreme anxiety, skin crawling, confusion, GI distress, insomnia, and agitation. For some individuals these symptoms are excruciating. I had a patient who went through weeks of pure hell—fever, nausea, chills, extreme depression, and the certainty she was losing her mind—going off a pill I had encouraged her to take. The best advice is to discontinue any of these medications by tapering off slowly and under a physician’s care.
Last but not least, there are worries that antidepressants interfere with emotional vitality. One study of non-depressed volunteers found that taking an SSRI for only a week interfered with their ability to read facial expressions, especially of anger and fear. Another study of normal volunteers found that four weeks of Paxil significantly reduced their ability to feel sad or angry when appropriate. A group of patients who were experiencing sexual side effects also developed significantly less ability to cry or care about others’ feelings. They also lost erotic dreaming, surprise, creativity, anger, and ability to express their feelings.
Therapists who take SSRIs themselves were very disturbed by these findings, wondering if it meant they were losing their ability to be empathic; many of us have stopped medications as a result. I know a musician who tried Lexapro for his social anxiety and asthma. He noticed that he stopped getting chills and goose bumps when he was really moved by music. When he stopped Lexapro, he was able to get goose bumps again. He felt that he had also lost some of his ability to immerse himself in the music. Another male patient, who was prone to picking up girls for one-night stands, reported that with Paxil he stopped feeling guilty. At least he recognized this was a problem.
It seems quite possible that SSRIs (and other antidepressants, for all I know) get some of their effect from an overall emotional blunting, especially of negative feelings. Their use may make us temporarily a little shallow or insensitive. As far back as Listening to Prozac (1993), Peter Kramer was advancing the theory that people with depression may be especially sensitive to signs of rejection, and that SSRIs helped them cope better. This is one of the reasons why I’m so against the use of antidepressants by people without severe depression who simply want to feel better. They may worry less, but it can damage their relationships, reduce their enthusiasm, make them more shallow and unrealistically complacent. This may be why, in this age of stress, so many people are using antidepressants—the drugs can help people put up with things they should not put up with.
Bottom line on SSRIs? Depression is a serious illness, and these are serious medications. No one should ever take them lightly. They definitely can do harm, but the harm depression can do can be much worse. If you have a severe depression, you owe it to yourself to give medication a genuine try. But it needs to be part of a balanced plan that includes good psychotherapy and a lot of self-care. One thing medication can do is let you have the energy or hope to follow through.
By Richard O’Connor, Ph.D.
Dr. O’Connor is the author of the best-selling books, Undoing Depression and Undoing Perpectual Stress: The Missing Connection Between Anxiety, Depression and 21st Century illness.
Our national conversation about depression for the last twenty years has been on hold, largely reduced to a narrow dialogue about the promise and peril of antidepressants: “To Prozac, or not to Prozac?” Peter Kramer’s Listening to Prozac raised expectations that antidepressants would soon make depression obsolete. As this proved not to be the case, there was the predictable backlash. In Robert Whitaker’s Anatomy of an Epidemic, antidepressants (and other psychotropic medications) are not only ineffective, but the villain, responsible for worsening the epidemic of mental illness. The next movement will be a backlash to the backlash. If we do nothing different, we can conclude with supreme confidence that all the heated talk about drugs will continue to monopolize the stage and preclude a real conversation about mood and mood disorders.
The continued ascendance of the conventional disease model of depression is part of the problem. The conventional approach tends to view the legions of the depressed and the formerly depressed as a “broken” people, an ever-afflicted group that will likely need repeated assistance over the life course because of their theorized defects. The biological defect model may have been created with good intentions, but it is both belittling and inaccurate. Depression like any mood state has a biology but it is simply not a disease in the same sense that Parkinson’s Disease is. To try to maintain that depression is a brain disease is to cut off a more interesting conversation at the knees.
Happily there are exceptions to this trend. And Dan Lukasik is one of him. There are people who are hunger for more, and who reject the corrosive, age-old stigma attached to depression and depressed people, and who are fighting for a more honest and more balanced discussion of the topic. There are people who agree that it is high time for our society to revise its stance toward the millions who have battled depression.
I am a depression researcher and former depression sufferer who has looked at the poor state of the national dialogue and has been moved to try and change it. I am using social media, particularly Facebook, to restart our national conversation about depression. We desperately need this not only for adults. We also desperately need it for my daughter, Sophie, and for the rest of her generation, the teens who will soon be young adults. Our youth will face depression in high schools and on college campuses in epidemic proportions that will overwhelm them, their parents, and all counseling resources.
One major obstacle to a more affirmative national conversation is that depression has lacked a unifying public symbol that could bring it out of the dark like Livestrong© bracelets did for cancer or the rainbow flag did for LGBT. When most people think of depression, their first associations are to unfortunate images, such as a dark cloud, the color black, or a noose. One reason that depression stigma lives is that depression has a serious bumper sticker problem.
But this is essentially an issue of failed marketing and messaging. It is very hard to talk about depression when it is always on societies’ terms. Depressed and formerly depressed people are ever on the defensive. To change the terms of the debate, and spark more productive conversation. I have developed a unifying symbol to function in a depression anti-stigma campaign. These are glow-in-the-dark wristbands that are printed with the phrase COME OUT OF THE DARK.
A few weeks back, I was using my Facebook page to probe for interest in these wristbands and I made an offer that I would give away a glow-in-the dark wristband to anyone who would be willing to send me a picture of themselves wearing it. I bought 200 bands from China and planned to give them away from time to time to readers who were interested. Initial response was rather tepid and I started to think it would be complete flop. Well, last Thursday, after I had given away a few dozen, for reasons that I do still do not completely understand, the wristbands went viral on the internet, and I was flooded with requests from all over the world. It’s hard to get an exact count but it’s definitely in the thousands.
I received requests from parents for their depressed children. From people who lost loved ones to suicide. From teachers for their classrooms. From therapists for their patients. From counselors for their support groups. And from many individuals who have been touched personally by depression, both those who have conquered depression and those who were still struggling with.
I think that part of the viral appeal of the wristband campaign is the slogan, which has several possible meanings
• Let’s end society’s ignorance about depression.
• Let’s support depressed people so they get well and stay well.
• Let’s create an environment where people can speak freely about depression and no one feels compelled to conceal their pain.
And part of the appeal is that total strangers are giving you something for free that will make you feel more comfortable living in your own skin.
In any case, this has been a stunning development and my life has been turned a bit upside since Thursday since this all happened. I have a full-time job as a researcher at the University of South Florida and I have been thrust into the beginnings of a social movement. I’ve bought another 2,700 wristbands from China. I’ve enlisted friends, family, students, and total strangers in an effort to respond to the messages and prepare a mailing. I’ve asked for donations. We’ve made a plan of action and my goal is to send out these 2,700 wristbands bands by October 1st. This will end the first phase of the campaign. There will be more to come, but I will need to take a break and develop a plan for the second phase.
People who have received the wristbands are starting to return pictures. If you look at this gallery of the first wave of people who have come out of the dark, I think you can more easily understand why this campaign has taken on a life of its own. It’s both a social media campaign and a word-of-mouth campaign – both of which inevitably will shift the conversation about depression on more favorable terms.
The massive response to the Come-Out-of-The-Dark campaign tells me that change is in the wind. People are tired of hiding, tired of hedging. They are ready to reclaim their identities as fully human.
The stakes are high. Conservatively, 13 million US adults are currently in an episode of depression; more than twice that number have had depression in the past. When we add in caregivers, millions more are indirectly affected by the quality and the quantity of our national dialogue about depression.
But we have the momentum. At this rate I give the stigma of depression about another six months to live.
Jonathan Rottenberg is a leading researcher in the area of emotion and psychopathology, where he has focused on major depression. He recently edited Emotion and Psychopathology: Bridging Affective and Clinical Science, published by the American Psychological Association. Since receiving his PhD degree from Stanford University, he has been at the University of South Florida, where he is an Associate Professor of Psychology and Director of the Mood and Emotion Laboratory. His work has been generously funded by the National Institutes of Mental Health and he has authored over 35 scientific publications, including many in the top journals in psychology and psychiatry. His work has received national and international media coverage, reported in outlets such as Science News, Scientific American, The New York Times. He is author of the forthcoming book, The Depths: The Evolutionary Origins of the Depression Epidemic.
Any dialogue about the warp and woof of depression should include something about its value in our lives. That sounds like a bugged out thing for me to say; all the more so when you consider that much of the national dialogue has been dominated by main stream medicine that tells us that depression is an illness – just like diabetes or heart disease. I have, in fact, been part of this choir at different times.
Leading this charge is psychiatrist, Peter Kramer. He’s the author the best-seller, Listening to Prozac and followed up recently with, Against Depression. His conclusion is that we need an all out war, a full fledged armada, against depression which he maintains is “brain damage” which we must stop from occurring in the first place or progressing once it has gotten a foot-hold.
I think Kramer’s arguments oversimplify the complex malady that is depression. More than just a biological illness, depression is also a dying of one’s soul. Indeed, one’s inner self – that which is most vital and true about us – is a casualty of depression.
What if by medicating our depression, or replacing its jagged thoughts with “clearer” or “more constructive thinking habits” (As defined by whom?), we are moved in the wrong direction? What if medication doesn’t so much result in full remission (i.e. the goal of psychiatry) of depression as a “draw” with the gun-slinging opponent that our melancholy can seem like?
What if we’re not supposed to mute our depression with medication or straighten out our uneven thoughts with a flat iron? What if we are killing the messenger?
In his book, The Swampland of the Soul, psychologist, James Hollis, sees depression less as a biological phenomenon, than as a psychological one. Here’s his description of its causes:
“Depression can feel like a well with no bottom, but is a well with a bottom, though we may have to dive very deeply to find it. Think of what the word means literally, to de-press, to press down. What is “pressed down”? Life’s energy, life’s intentionality, life’s teleology is pressed down, thwarted, denied, violated. While the etiology of such pressing down may or may not be discernible, something in us colludes with it. We might even say that the quantity and quality of the depression is a function of the quantity and quality of the life force which is being pressed down. Life is warring against life, and we are the unwilling host.”
What is pushing down our life force as attorneys with depression? Is it just the long hours, stress and adversarial nature of our craft? No doubt such factors play a role, just like our biology and genetics. But clearly much of the foundation of adult onset depression has been layered, brick by brick, in our childhood experiences for it is here where we learn how much to value ourselves and others. If we learn to value ourselves in a healthy way early on in life’s journey, there are fewer impediments in the future to de-press our life’s energy which is trying to express itself.
If we have grown up in a dysfunctional home, as the majority of adults with depression have, it will be much harder to feel good about ourselves and build a healthy life without depression. This is so because we have learned to devalue our inner experiences and give too much weight to what others expect and think about our life’s value and future course. After all, all parents are giants to small children. In a child’s world of magical thinking, there is no way of filtering out parents’ toxic messages about a child; no way of seeing these voices as a reflection of the parent and not a child’s fledging sense of identity.
This was certainly the case with me. My alcoholic father, who had gaping holes in his psyche and soul, couldn’t nurture himself let alone his five children. The eldest of five children himself in an era of WWII veterans, his feelings were alien to him. As time went by, he crumbled under the weight of his disease and growing awareness, on some level, that he was a failure at work and home. My mother, an equally damaged person who grew up with an alcoholic father, never learned the basic law of reciprocity in love and nurturance.
No wonder I ended up as a young man after a successful undergraduate career; without an internal sense of who I was or what I wanted to be. Like many others without a deep relationship to self and my feelings, I “chose” the law because of one thing I could be sure of – it was a chance to serve others, be a professional and make money. This is, to be sure, why many young people go into this strange business we call the legal profession.
I was estranged from something essential in me for many years, so powerful was the pushing down of my own inner instincts and life force. I felt defined and limited by who I had been in my rocky childhood, whether I was aware of it or not. I always felt a gnawing sense that something was missing – that piece turned out to be nothing less than my essential self.
Dr. Hollis frames the developmental task before us after we have come to sense this elemental truth:
“The task implicit in this particular swampland is to become conscious enough to discern the difference between what has happened to us in the past and who we are in the present. No one can move forward, psychologically, who cannot say, “I am not what happened to me: I am what I choose to become.” Such a person can come to recognize that the early deficit was not inherent in the child, but the result of circumstances beyond the child’s control. One can then begin to tap the energy for life that was previously walled off.”
And so begins the journey out of the well of depression for all of us. We must learn to regain our inner authority – regardless of our biology. This doesn’t mean one needs to quit the law – though some may need to do so to follow their true path. It may be a more modest shift in perspective or a reshuffling of our life’s deck.
Hollis has a great analogy that captures the value of modest changes. He writes that steering our lives is like a pilot using his navigation instruments while flying. A one degree shift here or there will determine where he ends up landing; in Africa or in Europe.
In Listening to Depression, psychologist, Lara Honos-Webb writes that depression is trying to tell us something: that we are on the wrong track in life. In this sense, depression can be a teacher if we would only listen to it. In one interview, she summarizes the five greatest gifts as follows:
– It propels you on a search for the meaning of life
– It’s nature way of pushing you out of your comfort zone. Depression reminds you that you are losing your life while not risking
– It’s a breakdown in the service of offering you an opportunity for a breakthrough
– It means it’s time to reclaim your power to author your own life
– It alerts you when you have gotten off course and guides you towards self-healing.
How do we come to see these truths? Honos-Webb says:
“Depression can be seen as a break-down in the service of offering the person an opportunity for a break-through. In this way, depression can be a corrective feedback to a life with little reflection. We only reflect on those things that break down in life. For example, if life is going along smoothly you won’t spend time thinking about the meaning of life. We tend to think deeply about life when something is not working. When we identify a problem, we begin to reflect on what caused the problem and how to fix the problem. If you are disconnected from your deepest feelings and impulses you may still manage to get through life without realizing it.”
I admit that it’s hard to see depression’s value when in the thick of it, the swamp through which we slog without relief. But there’s much to be said for seeing depression not just as a disease, but as a diminishment of self which makes our world too small. We don’t have to keep colluding in our own victimization. And remember this:
You are not what happened to you – You are what you choose to become.