Biological ≠ Medical

Photo: Mussels attached to rock.

The New England Journal of Medicine (NEJM) published a review (2008) that concluded articles submitted to journals by pharmaceutical companies and psychiatric researchers about the effectiveness of the selective serotonin reuptake inhibitors—SSRI antidepressants—gave a rosier picture of this class of drugs than the studies actually show. By mainly publishing studies that tout SSRIs success and not publishing all the studies conducted, the SSRIs have been promoted as more efficacious than they actually are. Here is the summary of the results from the NEJM article:

“Among 74 FDA-registered studies, 31%, accounting for 3449 study participants, were not published. Whether and how the studies were published were associated with the study outcome. A total of 37 studies viewed by the FDA as having positive results were published; 1 study viewed as positive was not published. Studies viewed by the FDA as having negative or questionable results were, with 3 exceptions, either not published (22 studies) or published in a way that, in our opinion, conveyed a positive outcome (11 studies). According to the published literature, it appeared that 94% of the trials conducted were positive. By contrast, the FDA analysis showed that 51% were positive. Separate meta-analyses of the FDA and journal data sets showed that the increase in effect size ranged from 11 to 69% for individual drugs and was 32% overall.”

For many users, these results imply SSRIs are slightly better than placebo. Yet perhaps more importantly, they show how little has been gained by applying the medical model to the treatment of depression. Certainly, there is a biological component to depression. Medications likely work for some people, but the SSRIs’ limited success cannot be used to prove a pill is the best remedy for the suffering depression causes.

Despite all the applied technology and scientific discoveries, psychiatric researchers in many cases cannot promise better than a 50-50 chance for the success of their best-selling medications. Nevertheless, millions of people continue to take these drugs—54 million worldwide are prescribed Prozac alone. Something is driving SSRIs’ success, even if it isn’t medical evidence.

Some argue the high number of users results from the increased tendency to medicate normal sadness. Others point to the extensive use of direct-to-consumer advertising of these drugs. Still others find increased prescribing of SSRIs by general practitioners and OB/GYNs as a primary source of the widespread use of SSRIs, since many people can now sidestep seeing a psychiatrist—and the stigma associated with having a mental illness. All of these factors likely contribute to SSRIs’ popularity, yet none of them really address why so many people identify themselves as depressed and are willing to take a potentially life-altering medication to end their unhappiness.

While SSRIs may be little more effective than placebos for many people, they are much more potent than a dose of sugar. The increased likelihood of suicidal and homicidal behavior in some users of SSRIs has been documented extensively. Less well known is the extent to which these drugs alter a person’s physiology. SSRIs purportedly act on the neurotransmitter serotonin, which has a range of functions in the human body, including sleep-wake cycles, appetite, memory, learning, cardiovascular function, the regulation of hormones, and aggression. (Serotonin is found mainly in the gut—only five percent is found in the brain.) Thus, SSRIs can have a profound affect on the body. For many, rapidly discontinuing SSRIs can cause a physical and psychological response as intense as heroin withdrawal. SSRIs do ‘work,’ but whether they work to end depression depends on the unique serotonin system of each user, which arises with the development of the brain and largely in response to interactions with the environment.

Despite the lack of convincing medical studies, the efficacy of SSRIs for some people is not surprising when we step outside the medical model driving the use of these drugs and look at the brain. Serotonin is one of several known neurotransmitters in the brain. It is also part of one of four systems that contribute to the elaborate emotional system that is arguably a fundamental function of the brain. We might have named ourselves homo sapien, meaning “wise man,” but much evidence suggest a more appropriate label would be “human emotional” since even the cognitive functions pointed to as evidence of our mental superiority likely evolved in response to increased emotional bonds with others. Together, neuropeptides and neurotransmitters, the autonomic nervous system (controlling bodily functions such as breathing and heart rate), the endocrine system (governing the release of hormones), and the musculoskeletal system (creating bodily movement) work as intricate feedback and ‘feedforward’ channels relaying throughout the brain and body our conscious and unconscious emotional responses to the world. But how well does this system work in our alienating, status-driven society in which many of us were raised in families that were emotionally damaging or lacked supportive emotional connections?

By and large, we’ve become a society disconnected from our bodies with few intimate relationships. Many of the relationships we have are mediated by technologies such as cell phones and email that do not need the face-to-face communication that our emotional systems adapted for over millions of years. Serotonin is but one neurochemical flowing through the body that is altered by our globalized world, but it looks like for some of the users of SSRIs, altering serotonin may be just what is needed to deal with decreased emotional connection and deep-seated emotional hurts.

The real problem with the misrepresentation of SSRIs that the New England Journal of Medicine article reveals is the extent to which the pharmaceutical industry and many psychiatric researchers are willing not only to falsely represent their product, but also misrepresent how well they understand the brain. It’s one thing to say there is a biological component involved in depression; it’s quite another to say that the current medical model can be the basis for treating depression.

© 2009 Laura K Kerr, PhD. All rights reserved (applies to writing and photography).