Anatomy of an Epidemic (25 page)

The WHO investigators reported that a higher percentage of the unmedicated group recovered, and that “continuing depression” was highest in those treated with an antidepressant. Source: Goldberg, D. “The effects of detection and treatment of major depression in primary care.”
British Journal of General Practice
48 (1998): 1840–44.

The Risk of Disability for Depressed Patients

This was a study of 1,281 employees in Canada who went on short-term disability due to depression. Those who took an antidepressant were more than twice as likely to go on to long-term disability. Source: Dewa, C. “Pattern of antidepressant use and duration of depression-related absence from work.”
British Journal of Psychiatry
183 (2003): 507–13.

Several countries also observed that following the arrival of the SSRIs, the number of their citizens disabled by depression dramatically increased. In Britain, the “number of days of incapacity” due to depression and neurotic disorders jumped from 38 million in 1984 to 117 million in 1999, a threefold increase.
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Iceland reported that the percentage of its population disabled by depression nearly doubled from 1976 to 2000. If antidepressants were truly helpful, the Iceland investigators reasoned, then the use of these drugs “might have been expected to have a public health impact by reducing disability, morbidity, and mortality due to depressive disorders.”
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In the United States, the percentage of working-age Americans who said in health surveys that they were disabled by depression tripled during the 1990s.
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NIMH’s Study of Untreated Depression

In this study, the NIMH investigated the naturalistic outcomes of people diagnosed with major depression who got treatment and those who did not. At the end of six years, the treated patients were much more likely to have stopped functioning in their usual societal roles and to have become incapacitated. Source: Coryell, W. “Characteristics and significance of untreated major depressive disorder.”
American Journal of Psychiatry
152 (1995): 1124–29.

There is one final study we need to review. In 2006, Michael Posternak, a psychiatrist at Brown University, confessed that “unfortunately, we have little direct knowledge regarding the untreated course of major depression.” The poor long-term outcomes detailed in APA textbooks and the NIMH studies told the story of
medicated
depression, which might be a very different beast. To study what untreated depression might be like in modern times, Posternak and his collaborators identified eighty-four patients enrolled in the NIMH’s Psychobiology of Depression program who, after recovering from an initial bout of depression, subsequently relapsed but did not then go back on medication. Although these patients were not a
“never-exposed” group, Posternak could still track their “untreated” recovery from this second episode of depression. Here were the results: Twenty-three percent recovered in one month, 67 percent in six months, and 85 percent within a year. Kraepelin, Posternak noted, had said that untreated depressive episodes usually cleared up within six to eight months, and these results provided “perhaps the most methodologically rigorous confirmation of this estimate.”
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The old epidemiological studies were apparently not so flawed after all. This study also showed why six-week trials of the drugs had led psychiatry astray. Although only 23 percent of the unmedicated patients were recovered after one month, spontaneous remissions continued after that at the rate of about 2 percent per week, and thus at the end of six months, two-thirds were depression free. It takes
time
for unmedicated depression to lift, and that is missed in short-term trials. “If as many as 85% of depressed individuals who go without somatic treatment spontaneously recover within one year, it would be extremely difficult for any intervention to demonstrate a superior result to this,” Posternak said.
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It was just as Joseph Zubin had warned in 1955: “It would be foolhardy to claim a definite advantage for a specified therapy without a two- to five-year follow-up.”
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We can now see how the antidepressant story all fits together, and why the widespread use of these drugs would contribute to a rise in the number of disabled mentally ill in the United States. Over the short term, those who take an antidepressant will likely see their symptoms lessen. They will see this as proof that the drugs work, as will their doctors. However, this short-term amelioration of symptoms is not markedly greater than what is seen in patients treated with a placebo, and this initial use also puts them onto a problematic long-term course. If they stop taking the medication, they are at high risk of relapsing. But if they stay on the drugs, they will also
likely suffer recurrent episodes of depression, and this chronicity increases the risk that they will become disabled. The SSRIs, to a certain extent, act like a trap in the same way that neuroleptics do.

We can also track the rise in the number of people disabled by depression during the antidepressant era. In 1955, there were 38,200 people in the nation’s mental hospitals due to depression, a per-capita disability rate of 1 in 4,345. Today, major depressive disorder is the leading cause of disability in the United States for people ages fifteen to forty-four. According to the NIMH, it affects 15 million American adults, and researchers at Johns Hopkins School of Public Health reported in 2008 that 58 percent of this group is “severely impaired.”
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That means nearly nine million adults are now disabled, to some extent, by this condition.

It’s also important to note that this disability doesn’t arise solely from the fact that people treated with antidepressants are at high risk of suffering recurrent episodes of depression. SSRIs also cause a multitude of troubling side effects. These include sexual dysfunction, suppression of REM sleep, muscle tics, fatigue, emotional blunting, and apathy. In addition, investigators have reported that long-term use is associated with memory impairment, problem-solving difficulties, loss of creativity, and learning deficiencies. “Our field,” confessed Maurizio Fava and others at Massachusetts General Hospital in 2006, “has not paid sufficient attention to the presence of cognitive symptoms emerging or persisting during long-term antidepressant treatment…. These symptoms appear to be quite common.”
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Animal studies have also produced alarming results. Rats fed high doses of SSRIs for four days ended up with neurons that were swollen and twisted like corkscrews. “We don’t know if the cells are dying,” the researchers from Jefferson Medical College in Philadelphia wrote. “These effects may be transient and reversible. Or they may be permanent.”
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Other reports have suggested that the drugs may reduce the density of synaptic connections in the brain, cause cell death in the hippocampus, shrink the thalamus, and trigger abnormalities in frontal-lobe function. None of these possibilities has been well studied or documented, but something is clearly going
amiss if symptoms of cognitive impairment in long-term users of antidepressants are “quite common.”

I interviewed a number of people who receive SSI or SSDI due to depression, and many told stories similar to Melissa Sances’s. They first took an antidepressant when they were in their teens or early twenties, and the drug worked for a time. But then their depression returned, and they have struggled with depressive episodes ever since. Their stories fit to a remarkable degree with the long-term chronicity detailed in the scientific literature. I also caught up with Melissa a second time, nine months after our first interview, and her struggles remained much the same. In the fall of 2008, she started taking a high dose of a monoamine oxidase inhibitor, which provided a few weeks of relief, and then her depression returned with a vengeance. She was now considering electroshock therapy, and as we ate lunch at a Thai restaurant, she spoke, in a wistful manner, of how she wished her treatment could have been different.

“I do wonder what might have happened if [at age sixteen] I could have just talked to someone, and they could have helped me learn about what I could do on my own to be a healthy person. I never had a role model for that. They could have helped me with my eating problems, and my diet and exercise, and helped me learn how to take care of myself. Instead, it was you have this problem with your neurotransmitters, and so here, take this pill Zoloft, and when that didn’t work, it was take this pill Prozac, and when that didn’t work, it was take this pill Effexor, and then when I started having trouble sleeping, it was take this sleeping pill,” she says, her voice sounding more wistful than ever. “I am so tired of the pills.”

At the American Psychiatric Association’s 2008 annual meeting in Washington, D.C., there were press conferences each day, and during the presentations that told of the great advances that lay ahead, the leaders of the APA regularly urged the reporters and science writers in attendance to help “get out the message that [psychiatric] treatment works and is effective, and that our diseases are real diseases just like cardiovascular diseases and cancer,” said APA president Carolyn Robinowitz. “We need to work together as partners so we can get the word out to patients and families.” The press had an important role to play, explained incoming president Nada Logan Stotland, because “the public is vulnerable to misinformation.” She urged the reporters to “help us inform the public that psychiatric illnesses are real, psychiatric treatments work, and that our data is as solid as in other areas of medicine.”

I scribbled all of these quotes in my notebook, even though it didn’t seem that
Anatomy of an Epidemic
was going to quite fit the partnership model that the APA had in mind, and then each day I would go for a stroll in the great exhibit hall, which I always enjoyed. Eli Lilly, Pfizer, Bristol-Myers Squibb, and the other leading vendors of psychiatric drugs all had huge welcoming centers, where,
if you were a doctor, you could collect various trinkets and gifts. Pfizer’s seemed to be the most popular, as the psychiatrists could pick up a new personalized gift each day, their names printed on a mini-flashlight one day and a mobile phone charger the next. They could also win a gift by playing a video game called the
Physician’s Race Challenge
, the pace of their virtual self racing toward the finish line governed by how well they answered questions about the wonders of Geodon as a treatment for bipolar illness. After playing that game, many lined up to have their photo taken and stamped on a campaign button that said: “Best Doctor on Earth.”