How Depression Pills can make you More Depressed

When I did my training for general practice it included a residency in psychiatry. From time to time we would get a call from a GP requesting admission for a patient who was threatening suicide. After taking more details the consultant usually commented, ‘This patient is not mentally ill – she’s upset,’ but he admitted her anyway.

Dr Russell Barton
As I student I had the privilege of being taught by an affable mildly eccentric psychiatrist called Dr Russell Barton (‘It’s not hyphenated’) who drove around in an open-top red sports car. He was not just a doctor: he was healer. The nursing staff held him in high esteem and we were told that his patients usually got better, ‘thanks to Dr Russell Barton, Largactil, and God – in that order.’ (Largactil, generic name chlorpromazine, was one of the first so-called antipsychotic drugs, and the name is derived from its ‘large range of actions’ – and that’s a story in itself.)

Check-box diagnosis
Thus, apart from the enlightened views of Dr Russell Barton, I was educated in the then prevailing medical orthodoxy, and until I knew better, believed what I had been taught and what the textbooks said. For instance, there was a mental illness called depression which was diagnosed by asking a series of leading questions:

Do you feel down and as if nothing in life is pleasurable anymore? Is your appetite reduced? Do you tend to wake up very early in the morning? Do you sometimes feel that life is no longer worth living?

If the answers to these and similar questions were affirmative, then the treatment to be considered was with a so-called antidepressant. In those days the main type of drug we used was a tricyclic, named from its molecular structure. The serotonin imbalance theory hadn’t then been thought up and drugs such as Prozac were not available till the late 1980s. One tried to match the patient’s symptoms with the best ‘profile’ of the drug. For instance, a sedating type of might be preferred if the patient had difficulty falling asleep. The orthodox advice was to start with a low dose and gradually increase it over two or three weeks as the patient got used to the side effects – better called harms – before the antidepressant effect took hold. And if the drug seemed to work, the advice was to continue with it for at least six months after improvement was noted.

More likely to kill yourself
Tricyclics are not used much these days and have largely been supplanted by Prozac and similar drugs, known as SSRIs. The main claimed benefit is that if patients take an overdose, there is less chance of them killing themselves with these newer drugs. More recently, the question has been raised of whether taking a tricyclic or SSRI pill might itself increase the risk of suicidal thoughts and attempts. To put it plainly, how can it be that a drug meant to reduce depression and suicide, actually increases the rate of suicide? This terrible result has been demonstrated by Professor Peter C. Gøtzsche, as reported in The British Medical Journal and elsewhere. Professor Gøtzsche has also shown that depression pills can increase the risk of homicide.

Embarrassed
At the start of my career in general practice, one day I was visited by ‘drug rep’ (pharmaceutical company sales representative) who told me about a new formulation of an antidepressant, called Surmontil (generic name trimipramine) which had the claimed advantage that it only needed to be taken once a day, at bedtime. And what a wonderful name, suggestive of surmounting your illness! The advertising bumf falsely claimed that Surmontil ‘works by restoring the balance of certain natural substances (neurotransmitters) in the brain.’ I also learnt that the information provided to patients for this drug included the helpful reminder that ‘this medication has been prescribed because your doctor has judged that the benefit to you is greater than the risk of side effects.’ Oh great. And how are doctors supposed to make this judgement? It’s impossible.

Soon thereafter a young woman attended whose problems seemed to indicate a diagnosis of depression (I forget exactly what her symptoms were) and I prescribed Surmontil. The next day she came back, very annoyed with me. I have seldom been so embarrassed. She had taken one capsule of Surmontil at bedtime, as instructed, and the next day felt terrible, with a headache, dizziness, dry mouth, and blurred vision. Although she soon recovered, this was an unfortunate experience for the patient and a valuable lesson for me. It planted the seeds of doubt: might not these drugs do more harm than good? Nonetheless, not then knowing any better, I continued to used tricyclic antidepressants for patients who seemed to need them, with modest success. But was their apparent improvement due to the personal interest I took in the patients, a placebo effect, or spontaneous recovery?

Doctors should try depression pills on themselves
I think every psychiatrist or GP, before prescribing a depression pill, or a psychosis pill for that matter, should take one daily for, say, two weeks. Then he or she would be in a rather better position to judge whether it would be acceptable to inflict similar harms on patients.

How reliable is the information we are given about drug treatment? How many of the doctors who write guidelines have conflicts of interests? How many papers showing no benefit of a drug are excluded from publication because they could adversely affect potential sales? This is in the case of psychiatric drugs, but to what extent might it apply to other drugs, especially those recommended long-term for prevention of something that might never happen, such as the cholesterol-reducing drugs, statins?

Returning to antidepressants, another very serious harm has recently been recognised, as and reported in The Guardian and passim. It’s been dubbed PSSD, meaning post-SSRI sexual dysfunction.

See also my blog on this devastating treatment-induced harm.

Text © Gabriel Symonds

Picture credit: Amjd Rdwan on Unsplash