The drugs don't work

When the Verve complained the drugs didn't work, they were (I assume) talking about illicit drugs. But what about antidepressants (and other psychiatric drugs in general). One of the things I have been asked to speak about at a church in a weeks time is the place of antidepressants for the Christian - so here are my thoughts.

they work... 


At one level, they definately work. This have been proven in thousands of scientific trials which show they have a greater effect than placebo (taking an inert comparison pill). They do this by raising the levels of certain brain chemicals which we know to be depleted in depression and which are hypothesised to be responsible for some of the symptoms of depression - especially the ones we feel in our bodies like tiredness, lack of drive/motivation/libido, poor sleep, body aches... I am convinced that they have a place in helping people with these symptoms of depression - often called clinical depression. They can alleviate symptoms to a great extent if used well.

We also know that they seem to have a deeper effect on the vicious circles of negative thoughts and can help people get out of the 'trap' that this thinking can become in depression - there comes a point when people cannot help themselves or think themselves out of the trap. They are particularly good for a severe episode of depression, maybe helping the first bit of recovery when symptoms and thoughts are very bad, to get people to a place where they are more able to see clearly and help themselves.

We also know that continuing to take antidepressants for a year after an episode of depression (even when you feel OK again) is important in making a relapse less likely. We are less sure how this works, but it is a clear scientific fact that the longer you take the antidepressant for the better you will do in the long run.

they don't work...


However, there are times when antidepressants don't work and may even be dangerous. I have been talking above mainly about severe depression, but in mild depression or a depression that has been grumbling for years it is a different story. The treatment of choice in this case is a psychological therapy, and there is most evidence for cognitive behavioural therapy, though some form of extended counselling or analysis is shown to work with the more grumbling depressions.

There is a role for antidepressants in these case, but probably later on down the line and on a trial basis - "see if they work or not". Medication is unlikely to have such dramatic effects, other factors are probably likely to be more powerful (psychological therapy, social re-integration, removing life-stressors). Medication may even be dangerous - it can encourage us to avoid other responsibilities we need to face up to (see further below) and may even cause direct harm (see next paragraph).

There has been quite a lot in the press recently about whether anti-depressants can precipitate suicide and make you more likely to self harm. Most anti-depressants are now prohibited in the UK for children and are advised against as a first-line treatment in situations of mild depression, grumbling depression and low mood due to lifestyle/lifestress. The jury is still out as to how they can be harmful, but here is my theory:

Antidepressants act mainly to raise the levels of certain brain chemicals. In severe depression, especially when accompanied by lots of body symptoms, these chemicals are low - so the medication returns them to normal levels. In milder or more long-standing forms of depression, there tend to be less body symptoms and more of a inner unhappiness: ie, the brain chemicals are not thought to be lowered. Medication will then make them too high. And, if one of the symptoms of depression is lethargy and is due to low chemicals, then high chemicals could do the opposite - make us more impulsive, and more likely to do impulsive things like harm ourselves. Therefore, taking antidepressants in the wrong situation can be dangerous.

Another explanation is seen in severe depression. Initially people are too depressed to do anything as active as suicide, but as they begin to get better they can go through a dangerous phase where they have more energy but are no more happy and this can result in damaging behaviour.

I should point out that in severe or moderate depression, I think that they are invaluable - it is more the mild and grumbling forms that I am talking about. The very small numbers for whom antidepressants cause problems in this group is far outweighed by the great benefit they can have.

In summary, they do have side effects, but so does chemotherapy and we would not think of avoiding chemotherapy for severe cancer. If something is powerful enough to do good, it is also likely to be powerful enough to do harm and hence needs to be used wisely and cautiously.

what they don't do


If antidepressants raise low levels of brain chemicals, alleviate symptoms, begin the process of escaping from depressive thought cycles and have a role in preventing relapse, what don't they do? This is where I think this post gets interesting as we can all be tempted to avoid things that are our responsibility - we can assume that the drugs will sort it all out. No; there is some stuff for us to do too:

  • - antidepressants can't sort out the causes of depression. If this is accumulated life stresses (like debt, a physical illness or a stressful job) or early life experiences (like bullying or the experience of parents divorcing), then these need to be addressed as well. Sometimes this needs a counsellor, sometimes some a social worker and often just good friends.
  • - antidepressants can't make us love ourselves. If low self-esteem has been part of a persons life even before and episode of depression, then it will still be there afterwards. The same is true of personality traits and addictive behaviour or habits.
  • - antidepressants can't improve our faith. They may remove some of the things that make it hard for us to believe, such as a heavy stream of negative thoughts or bodily symptoms of depression; but only working at our relationship with God will deepen that relationship.
  • - antidepressants can't build community. We still have a responsibility to engage with those around us - being in a supportive group is probably the most important recuperative and preventative factor in depression and also self-esteem.
  • - antidepressants don't excuse unhelpful behaviour. There may be things that depression makes us do - a sharp/snappy word, turning down invitations of help/parties, making others feel bad about themselves - but the illness or the antidepressants cannot become an excuse for this. We still have to live alongside other people, and even though they may be understanding, we still have responsibility for our own behaviour.
Rob Waller, 16/01/2014
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