Antidepressant Prescribing Up
The latest UK figures reveal that prescriptions for SSRI (serotonin selective reuptake inhibitors) antidepressants such as Prozac, Seroxat and Zoloft have risen by 43% in the past four years to nearly 23 million a year. This rise has been widely attributed in the press to money worries and job insecurity in the current financial climate.
However, other studies including a paper published in the British Medical Journal in 2009 found an increase of 36% in antidepressant prescribing in the UK between 2000 and 2005 prior to the period addressed by the current study and the credit crunch (BMJ 2009; 339: b3999).
Long-term studies examining prescribing and diagnosis rates in Scotland between 1991 and 2009 also found that prescriptions for antidepressants quadrupled during the study period and that the number of people claiming incapacity benefit for a mental or behavioural disorder had continued to rise steadily (B.J. Gen. Practice Jan 2011; 61(582): 47-49).
Depression: Big business
Globally, depression is now the world's largest mental illness and 15 million people have been diagnosed with depression in the United States and a further 25 million in France, Germany, Italy, Spain, the UK and Japan. The World Health Organisation (WHO) has predicted that by 2020 depression will be the second-largest cause of the global health burden.
Since their introduction, SSRIs have become the most widely prescribed antidepressants in many countries replacing the tricyclic antidepressants. Global sales of antidepressants are now worth over $13 billion (£8 billion/€9 billion) per annum and over 80% of those sales are for SSRIs.
Although there is not much difference in effectiveness between tricyclic antidepressants and SSRIs, the toxic dose of the SSRIs is high meaning that it is difficult to use as a means of committing suicide and the SSRIs are said to have fewer and milder side-effects than tricyclic antidepressants.
It is always worth bearing in mind the expiry of patents for the drugs being phased out in such circumstances. This means that generic formulations can be produced with a resulting loss of monopoly and profits for the pharmaceutical companies concerned.
Unsurprisingly, this often coincides with the introduction of new, improved patentable formulations - in this case SSRIs. Note that the patents for these too will expire shortly, so expect to see the introduction of a new generation of antidepressants.
How SSRIs work
Serotonin is a neurotransmitter synthesised by specific nerve cells referred to as serotonergic. Nerves interface at junctions known as synapses. The pre-synaptic nerve releases serotonin which crosses the synaptic space between two nerves and stimulates the post-synaptic nerve which then conducts an electrical message to its terminus. Typically the serotonin is then reabsorbed into the presynaptic nerve for reuse.
SSRIs work by preventing the re-uptake of the serotonin into the pre-synaptic nerve meaning that there is more serotonin in the synpatic space to continue stimulating the post-synaptic nerve. Serotonin is often labelled the 'happiness hormone' in spite of not being a hormone and is known to regulate mood, appetite and sleep and to be involved in memory and learning.
Curiously, about 80% of the body's serotonin is found in the extensive network of nerves in the intestine sometimes referred to as the 'second brain' where it governs muscular contractions. This biochemical link between mood and intestinal function may be key and also part of the reason why some doctors are finding improvements in conditions such as irritable bowel syndrome with the use of SSRIs.
Although primarily intended for the treatment of depression, SSRIs are also increasingly being prescribed for a variety of other problems including:
Anxiety and panic disorders
Post-traumatic stress disorder (PTSD)
Obsessive compulsive disorder (OCD)
Social anxiety disorder
'Off-label' uses. That is conditions that physicians may prescribe pharmaceuticals for, but that are not specifically recommended by the manufacturers. Improvements have been noted in conditions such as irritable bowel syndrome (IBS), Lichen simplex chronicus, premature ejaculation, stress incontinence and nerve pain.
Whilst some sufferers notice an improvement in depressive symptoms within a few days of starting SSRIs, the full effect may take about 2-8 weeks. A typical course of SSRIs would be taken for about six months after the depressive symptoms have eased or longer in the case of recurrent depression. It is worth noting that during this time period a substantial proportion of people with depression would naturally have experienced relief from their symptoms.
Other explanations for the increase in SSRI prescribing found in the study include an actual increase in the number of people suffering from depression; diagnosing depression when people are sad, lonely or unhappy; better diagnosis of depression than previously; less stigma around depression; better access to treatment and people taking longer courses of treatment and/or having difficulty coming off SSRIs.
The side-effects of SSRIs
Sometimes the side-effect of SSRIs are mild and wear off after a week or two. Side-effects can include:
Withdrawing from SSRIs
It is claimed that SSRIs are not addictive, but this is hotly disputed by some experts and patients. One of the interpretations of the current study results would be that a small percentage of people taking SSRIs find that they are unable to come off the drugs because of addiction or serious symptoms of withdrawal and thus are obliged to take these drugs for prolonged periods of time.
Gradually reducing the dose under medical supervision over a period of about four weeks should help to prevent most withdrawal symptoms. Of the SSRIs, paroxetine (Seroxat, Paxil) is most commonly associated with discontinuation symptoms and fluoxetine (Prozac) least commonly.
Another interpretation of the study results is that the symptoms of SSRI withdrawal are mistaken for the depression returning and the physician continues to prescribe the antidepressants.
Symptoms of withdrawal from SSRIs include:
Anxiety and agitation
Pins and needles
In addiition, persistent sexual dysfunction has been reported for months or years by some following cessation of SSRIs.
Some critics claim that SSRIs can actually create the chemical imbalances that they are supposed to correct possibly by means of negative feedback within the body downregulating the amount of serotonin released. Some experts such as Dr Peter Breggin and Dr David Healy maintain that a significant percentage of patients are adversely affected by SSRIs and that withdrawal is a grossly underestimated problem.
Hundreds of lawsuits have been filed against SSRI manufacturers seeking compensation for side-effects and the manufacturers have settled some cases and defended others.
The 'chemical imbalance' theory of depression
The current allopathic theory du jour of depression is the 'chemical imbalance' theory which says that mental health is related to the balance of neurotransmitters in the brain. Based upon this understanding, pharmaceuticals seek either to reduce chemical excesses or to replenish deficits of specific neurotransmitters.
SSRIs are said to 'correct' these chemical imbalances, but since these are never monitored during treatment this claim is hard to substantiate. Some prominent critics such as the psychologist and neuroscientist, Elliot Valenstein, also claim that these assertions are not supported by the evidence.
The efficacy of SSRIs is also currently being disputed. A widely reported meta-analysis conducted in 2010 found that in mild to moderate depression, the effect of SSRIs over that of a placebo was 'minimal or nonexistent', but that the effect was 'substantial' for patients with severe depression. In 2004 the UK National Institute of Clinical Excellence (NICE) after studying the available evidence recommended that antidepressants be prescribed for only cases of moderate or severe depression only.
Critics also claim bias in the publication of studies supporting the effectiveness of SSRIs. According to a study in The New England Journal of Medicine, the effectiveness and risk-benefit ratios of SSRIs has been greatly exaggerated with 94% of the published studies showing positive outcomes even though of the 74 studies registered with the US Food and Drug Administration only 51% had a positive outcome.
The allopathic stance is that the body is in some way faulty and needs chemically correcting using petrochemical-derived pharmaceuticals. Even if the chemical imbalance theory were correct, it still does not answer the question: What is causing the chemical imbalance?
The answer, most naturopaths would maintain, is as ever, either an underlying toxicity or deficiency possibly precipitated by stress. The natural medicine default stance is that the body is governed by a vast intelligence and that the symptoms it produces are compensatory and may be in response to an unidentified agent.
Among the suspects, mercury which is primarily derived from fish, dental amalgam and vaccinations is known to adversely alter brain chemistry, to bind to receptors throughout the body, to inhibit neuronal growth and to actively destroy neurons. There is considerable evidence supporting the idea that mercury toxicity may be responsible for causing much depression and other mental and behavioural disorders and also evidence of recovery with effective mercury detoxification. For more information about detoxifying mercury and other toxic metals using natural means, please refer to The Natural Recovery Plan book.