The Sketchy Solutions of Drug Culture: Criticism of SSRI Pills Over the Magnified Diagnosis of Western Depression

Lately I've begun to wonder how warranted the prosperity of SSRI manufacturing actually is.  Undoubtedly numbers don't lie: Eli Lilly & Company, the makers of Prozac (fluoxetine), did US$ 24.286 billion worth of business last year with a net income of US$ 4.347 billion (United States Securities and Exchange Commission, 2011).  If profit is the most valid measure of success then it appears that drug companies are providing a helpful solution for those plagued by depression: that is, more people are turning to drugs for relief, which, in turn, justifies these massive revenues.  But perhaps there are other variables worth examining that would indicate a different tale of events.  The whole concept of depression in Western culture, for starts, seems to be magnified beyond our apparent and so-called overwrought livelihoods; moreover, the most popular form of treatment--SSRI medication--has questionable, yet largely ignored, results of negative efficacy.  It's worth understanding, firstly, the true vitality of SSRI anti-depressants and then contrasting this inference to the aimless rate of which these drugs are prescribed.  It is then we can draw more sincere conclusions and accurately consider these drugs for treatment.

There's a myth that continues to linger in regards to how selective serotonin reuptake inhibitors work.  Serotonin, a "chemical messenger" in the brain, is popularly thought to be a contributor of well-being and happiness (Young, 2007).  It's no surprise, then, that increasing levels of this neurotransmitter would be thought to alleviate depression.  Indeed, this class of drugs is said to work by inhibiting the reuptake of serotonin (henceforth the name selective serotonin reuptake inhibitor), which, by proxy, increases levels of serotonin in the synaptic cleft.  For example, GlaxoSmithKline, the makers of the SSRI Paxil (paroxetine), state on their website that, "Paxil helps to block the reuptake of serotonin so that more remains in the space between the brain's nerve cells. This gives the serotonin a better chance of activating the receptors on the next nerve cell."

Contrary to what GSK has to say (and other manufacturers), the serotonin theory has been contested.  The therapeutic effects of SSRI medication have absolutely nothing to do levels of serotonin.  When these drugs are first taken there is a measurably increase in serotonin, but after several days levels return back to normal (Davidson, Blankstein, Flett, Neale, 2010).  This is interesting because any noticeable effect of taking this medication takes several weeks to first appear.  Furthermore, many people who are experiencing depression or mania do not show any disturbances in absolute levels of neurotransmitter (Davidson, Blankstein, Flett, Neale, 2010).  The American Psychiatric Textbook of Clinical Psychiatry states simply, "Additional experience has not confirmed the monoamine [of which serotonin is a subgroup] depletion hypothesis." So why, in fact, does this class of drugs bear a name (selective serotonin reuptake inhibitor) that is purely hypothetical and much less extremely contested?

What made this pseudo-scientific concept so popular, as it were, was that it turned out to be an effective marketing line.  After public scandal in regards to the overprescribing of benzodiazepines, including Valium and Librium (which were initially embraced by the medical establishment until they were revealed to be highly addictive), SSRIs entered a market where the public was understandably wary of psychopharmacology: that is, the story that SSRIs helped restore natural chemicals in the brain was exactly what the public needed to hear.  However, this idea is more of a culturally shared story than scientific fact--in the exact same way neurasthenia's invocation of "frayed nerves" was a story--yet this line still gets pitched ignorantly by physicians and psychiatrists alike.  Then come questions of efficacy.

In a controversial, widely discussed 2008 paper published in the prestigious New England Journal of Medicine Turner, Matthews, Linardtos, Tell, and Rosenthal asked whether there is a reporting bias in the publication of randomized clinical trials of antidepressants.  They examined data from 74 randomized control trials of a dozen antidepressants (involving 12, 564 clients) registered with the U.S Food and Drug Administration (FDA).  The data was then compared with the actual published literature in two ways: first, they conducted a systematic search to determine how many trials had matching publications and the nature of these publications (i.e. positive or negative efficacy), and, second, for trials that were reported in the published literature, they compared the published outcomes to the FDA outcomes.  The results were grossly disturbing:

• Almost one third (31%) of the studies (involving almost 3,500 participants) went unpublished.
• According to the published research literature, it appeared that 94% of the trials were "positive" in striking contrast to the FDA outcome reports that concluded that only 51% of the trials were positive.
• Of the 38 trials viewed by the FDA as having positive results, 37 were published and only one "positive" study was not published.
• Studies that were viewed by the FDA as having "negative" results (with only 3 exceptions) were not published (22 studies) or, if published, were reported in a way that, in the opinion of the authors, conveyed a positive outcome (11 additional studies).

These results are a far cry from statistical significance and, moreover, allude to an extreme publication bias.  After two decades of working at the New England Journal of Medicine, Dr. Marcia Angel became convinced that the system by which these drugs gain scientific status is broken.  "It is simply no longer possible to believe much of the clinical research that is published or to rely on the judgment of trusted physicians or authoritative medical guidelines" she wrote in 2009 in the New York Review of Books. It seems as though ethical research practices are being trumped by the pursuit of profit.

In another more alarming study, it has been shown that SSRI pills have no effect in cases of mild to moderate depression (Fournier et al. 2010).  It seems undoubtedly sketchy that doctors are still so eager to prescribe these pills when mild and moderates cases compromise the majority of depression; this is evident by the fact that 10% of Americans (roughly 27 million people) are currently taking these drugs (Wehrwein, 2011).  When one contrasts this rate to these previous facts, it becomes obvious that many people are being deceived.  These people deserve to know the relevant facts about these drugs, especially when no benefit--only a long list of side effects--is at play, which holds true for the majority of cases.  Most of this knowledge is not new, either.

When there is no difference between taking a placebo pill and prescription medication, alarm bells should be ringing.  Instead, however, the aimless fashion of SSRI prescriptions continue; one cannot help but question the credibility of physicians over this astute ignorance.   Perhaps, doctors are blindfolded by lavish conferences held regularly by these pharmaceutical companies promoting their drugs.  Nothing, however, should come between ethical practice and profit, especially in the field of medicine where individuals are most susceptible.

References:
Davidson, Gerald C, Blankstein, Kirk R, Flett, Gordon L, and Neale, John M (2010).  "Abnormal Psychology (Fourth Edition)."  USA: Wiley.
Fournier, Jay C, et. al. (2010).  "Antidepressant Drug Effects and Depression Severity."  The Journal of the American Medical Association 303 (1): 47-53.
United States Securities and Exchange Commission (2010).  "2010 Form 10-K."  Eli Lilly and Company.
Wehrwein, Peter (2011).  "Astounding Increase in Antidepressant use by Americans."  Harvard Health.
Young, SN (2007).  "How to Increase Serotonin in the Human Brain Without Drugs."  Rev. Psychiatr. Neurosci. 32 (6): 394-99.