Are antidepressants 'antidepressants', or just drugs?
Joanna Moncrieff points out several problems with a 'disease model' of drug action - the assumption (on the basis of their name, perhaps) that psychiatric medication offers 'cures' for 'illnesses'. The two previous chapters contained detailed discussions of the inadequacies of the twin concepts of the biomedical disease model of mental health problems, and psychiatric diagnosis. It is obvious that people can become depressed. I have no doubt that 'depression' exists as a phenomenon. But I don't believe it is right to suggest that depression exists as an illness. As I outlined in Chapter 2, there are very many understandable reasons why people can become demoralised, unhappy and pessimistic. So people obviously have periods of very low mood. They very obviously become depressed. We have a clear moral imperative to offer help. But that isn't the same thing as saying that there exists an 'illness' that requires a 'treatment'.
Antidepressants are chemicals that affect the functioning of the brain. Older antidepressants tended to be rather sedating - in other words, they made people feel tired and slowed down. This was, of course, rather unpleasant, and often dangerous. More modern antidepressants have been chosen or designed, very carefully in some cases, to affect our moods, but to avoid these sedating effects. They can, still, make people drowsy or lethargic. They can sometimes induce a sense of indifference, which for some people, helpfully takes the edge off their feelings of despair, but which others find unpleasant or even distressing. They can have other effects such as sexual dysfunction or feelings of agitation.
These are, just as with street drugs, the chemical effects of the medication on the functioning of the brain. Some people may find the effects helpful. If you are feeling lethargic, a drug that improves your alertness may be helpful. Many people who are in a state of distress experience unpleasant intrusive thoughts, and sometimes ruminate on their problems. In that case, a sense of emotional detachment, brought about by a psychiatric drug, may be helpful. People who are depressed, especially if they are also anxious, may find that a reduction in anxiety and a slight sedative effect is calming and helps sleep. All these changes - which I would argue are recognisable and understandable effects of drugs, whether prescribed or recreational - may be negative or positive. They may well lead to changes on rating scales designed to assess the severity of a depressed mood. But it seems difficult to argue that these medication-induced changes in emotional states represent genuine therapeutic gains. They are real and in a sense genuine; but they are what they are - the understandable effects of psychoactive chemicals.
There is no good evidence that these chemicals are correcting any underlying biological mechanism. There is a danger that people are being subtly misled about the effects of medication. People are often under the impression that the medication is putting right some underlying abnormality, whereas it would be much more honest to outline the general psychoactive and physical effects of the medication. Then people could weigh up any possible benefits against possible adverse effects, and decide themselves whether or not these effects might be useful. There are many chemicals that affect our emotions, perceptions, thought and behaviour. People swallow or smoke these chemicals for understandable reasons, and the chemicals - the drugs - have a range of effects, both good and bad. That's a long way short of a 'treatment' for an 'illness'.
Unfortunately, the possible positive effects of psychiatric medication come with a cost. Antidepressant drugs have some unpleasant adverse effects, too. Some of the newer 'selective serotonin reuptake inhibitors' or SSRIs can lead to sexual dysfunction and loss of libido, which may be related to the phenomenon of emotional indifference that some people experience. There have been very distressing reports of people having intrusive suicidal thoughts, and some researchers believe that antidepressants are associated with an increased risk of suicide, especially in young people. This may be related to the tendency for antidepressants - unsurprisingly - to make people more motivated and impulsive, which might be good in some ways but also somewhat risky in someone who is depressed. And many people report having severe and prolonged withdrawal reactions (for further discussion of all these problems, see Jo Moncrieff's 'The Myth of the Chemical Cure'11).
Representatives of pharmaceutical companies, and some psychiatrists, stress that antidepressants 'aren't addictive'. This seems very important - people are naturally worried about the addictive power of cigarettes, street drugs and some older forms of psychiatric medication such as the benzodiazepines (valium, etc.). It's reassuring for people contemplating taking prescribed antidepressants to know that they 'aren't addictive'. It does seem odd, and a strange use of language, however. Addiction is surprisingly difficult to define, but best refers to a person's dependence on something (in this case drugs) to be able to function normally. It's quite common to hear representatives of pharmaceutical companies comment that 'antidepressants aren't addictive', but then qualify this by saying 'but people can experience a recurrence of their depressive symptoms when they stop taking the drugs'. Which sounds very similar to needing the drugs to function normally. In fact ... isn't that the main selling point of the medication?
The research tells me that antidepressant medication might be slightly better than a placebo at raising people's mood. That's not in itself something to be sniffed at. But the positive effects certainly come with some rather nasty side-effects. The positive effects aren't dramatic, and they don't appear to represent a 'cure'. Researchers haven't been able to identify abnormal biological pathways that are targeted by the antidepressants, and in that context, the discovery of some chemicals that alter brain chemistry to make people feel a little better is hardly ground-breaking science.