The complicated truth about taking antidepressants

Today I’m answering a $15-billion question.

That colossal figure is the value of the global antidepressant market. Depression can be absolutely debilitating, and I believe we should use every tool in our ever-expanding toolbox to help treat it, without judgment — whether that be antidepressants, spiritual practices, psychotherapy, or the right mix of these.

Still, the question of whether antidepressants actually work and whether they’re worth the risks is a complicated debate that has been going on since the ’90s, when their popularity exploded. I wasn’t surprised when questions about the issue landed in our inbox. Here are a few of them:

“My granddaughter uses antidepressants, which makes me worry. I’ve read so much about these drugs’ side effects and aftereffects if someone tries to quit. The idea about a physical problem in the brain causing depression sounds fishy.” — Edith, 80, Saratoga, Wyo.

“When I started on antidepressants in 2019, I thought it would be temporary but I get nervous thinking about not taking them. Are antidepressants forever?” — Emma, 35, Tulsa, Okla.

“Are antidepressants more help or harm when taken long term?” — Mary, 66, Orange County, California

The amount of contradictory information out there about psychiatric meds is maddening, so I had these questions, too. But this week’s experts helped me parse some of it, including how antidepressants stack up against, and work with, other depression interventions; the personal risk analysis that should go into deciding whether these drugs are right for you; and the many unknowns about how they work.

(Before we dive in, a quick note: We’re going to host a conversation — with experts quoted in today’s newsletter — about antidepressants on Twitter at 3 p.m. Tuesday. To find the Twitter Spaces conversation, go to the L.A. Times Twitter page on your mobile phone, where you can listen through the Twitter app. We welcome your questions there, too.)

The serotonin hypothesis

First, a brief science/history lesson.

For the last half-century, the dominant explanation for depression is that low levels of serotonin in the brain lead to symptoms, including feelings of sadness or emptiness, trouble concentrating, and exhaustion. This theory led drug companies to develop the most widely prescribed kind of antidepressant, selective serotonin reuptake inhibitors (SSRIs), which boost the brain’s serotonin levels.

But over the past few decades, researchers have challenged the idea that serotonin deficiency plays a primary or even major role in depression. It’s still unknown exactly what causes the condition, but it’s thought to be brought on by several interacting factors including genetics, trauma, chronic stress, the environment and upbringing.

Serotonin and other neurotransmitters help regulate emotions, so giving your brain a serotonin boost may help your mood, explained Dr. Awais Aftab, a psychiatrist at Case Western Reserve University with a special interest in psychiatric philosophy. But that doesn’t mean serotonin deficiency is at the root of depression. Research has pointed to changes in parts of the brain that regulate mood, and the neurotransmitters within them, in people with depression. But it’s unclear whether these alterations cause depression or result from it.

“This idea of a chemical imbalance has perpetuated the misconception that there’s some kind of central brain problem in people with depression,” Aftab said. “The reality is much more complicated.”

One problem with describing it solely as a biological issue is this notion that depression must be permanent — that the only way to treat it is taking antidepressants for the rest of your life, said Alex Korb, a neuroscientist and professor in the psychiatry and behavioral sciences department at UCLA.

“And then some people resist taking antidepressants because their depression is more situational. But that’s a false dichotomy,” Korb said. “Yes, some people’s brains might be more influenced by their genetics, and some are more influenced by current life circumstances, like going through a divorce. All of those things change biology and the tuning of various brain circuits. We just can’t know ahead of time what’s the best way for you to personally, at this point in your life, start changing those brain circuits.”

With this level of complexity, I can see how two people might have similar symptoms of depression but respond very differently to the same medicine. And believe it or not, researchers still aren’t clear on why antidepressants work well for some people and not for others.

According to the largest antidepressant study ever conducted, a third of people who take these medications fully recover, while another third get somewhat better. The final third don’t notice any relief from symptoms.

Research has found that “the people who are less likely to respond are those who have a lot going on besides depression, like other psychiatric disorders or a history of addiction.” said Dr. Chris Aiken, a psychiatrist and founder of the Mood Treatment Center in Winston-Salem, N.C. “Or they have a lot of other stressors in their life that are working against the antidepressant.”

How long someone takes antidepressants

So we’ve established that these medicines do really help a lot of people. I knew this anecdotally, from seeing loved ones’ lives drastically improve after taking these drugs, but I’ve always been skeptical of the pharmaceutical industry. And, like our reader above, I also don’t love the idea of people I care about being on antidepressants for the rest of their lives, mostly because of how little is known about how and why they work.

With that said, I want to answer our readers’ central question, which is whether antidepressants are forever. The short answer: It depends.

About half of the people who experience an episode of depression will never get depressed again after their first time, studies show. “If it’s your first episode of depression, it’s recommended that you take antidepressants anywhere from six to 12 months, then go off them if you’re feeling better,” Aftab said. “That tends to work for a lot of people.”

(Before we go on, I just want to say that it’s really important to not suddenly stop taking antidepressants without talking to your doctor first. Doing so can lead to intense and sometimes dangerous withdrawal symptoms).

But say you’ve had two or more bouts of depression in your lifetime. If you stop taking antidepressants after you get better, there’s a very high chance you’ll get depressed again, Aftab told me. For people with recurring depression, staying on medicine can reduce the risk of future episodes, but won’t prevent them completely.

For this reason and many others, the decision to take antidepressants for any amount of time is very personal. Each of the five experts I spoke with for this piece told me that long-term use of antidepressants is fairly safe. But depending on your side effects and the severity of your depression, you may not want or need to be on them indefinitely.

Side effects can include restlessness, gastrointestinal problems, lower sex drive, changes in appetite, fatigue and insomnia. About 10% of people experience a blunting of their emotions, otherwise described as feeling numb. If that’s happened to you, or if you experience any other effects, Aftab recommends telling your doctor and potentially switching to another medication.

Given all that information, it’s up to you to decide whether taking antidepressants is right for you.

“Being depressed is very bad for your health and quality of life,” said Phil Cowen, a University of Oxford professor whose research focuses on the psychopharmacology of depression. “If antidepressants keep you well, the benefits may outweigh the risks.” If you’re unable to eat, are having few meaningful interactions with other people, and are thinking about suicide, the choice may be clear.

On the other hand, it’s completely appropriate for someone to look at the side effects and decide that antidepressants aren’t for them, and that they will instead try other pathways, like psychotherapy, Aftab said.

This brings me to my next point: Antidepressants are only one tool used to treat and prevent depression. Psychotherapy has been found to be just as effective in treating depression, and, when combined with antidepressant use, often works better than taking meds alone. When you’re very depressed it can be hard to engage in therapy, so taking antidepressants can help make that process easier and more worthwhile.

Cowen recommends trying psychotherapy on its own first, especially for those with mild and moderate symptoms. Unlike antidepressants, therapy teaches you skills that might help you cope with depression in the future. But psychotherapy isn’t readily available to the average American in the way that antidepressants are.

Exercise, practicing gratitude and mindfulness, and getting enough sunlight have also been shown to decrease depression symptoms. One Duke University study showed that 30 minutes of exercise three times weekly was just as effective as drug therapy in relieving depression symptoms, and also greatly reduced the chances of future episodes.

“The great news is that, oftentimes, these low-tech interventions that you can do on your own target the same brain regions and neurotransmitters as these high-tech ones, often in more nuanced or powerful ways,” Korb said.

If you’re going to walk away with anything from this piece, I want you to understand that what works for one person may not work for you, and vice versa — whether that means taking antidepressants, going to therapy, running regularly, or a combination of those things. And there should be no value judgment attached to taking, or not taking, antidepressants.

“If you have to stay on these meds your entire life,” Korb said, “it wouldn’t mean anything negative about you.”

I couldn’t agree more.

If you’d like to share your experience with depression or antidepressants, or what you learned from this newsletter, please send us an email. We love hearing from you.

Until next week,

Laura

If what you learned today from these experts spoke to you or you’d like to tell us about your own experiences, please email us and let us know if it is OK to share your thoughts with the larger Group Therapy community. The email [email protected] gets right to our team. As always, find us on Instagram at @latimesforyourmind, where we’ll continue this conversation.

See previous editions here. To view this newsletter in your browser, click here.

More perspectives on today’s topic & other resources

An intriguing body of research suggests the power of antidepressants doesn’t come from chemicals in the drugs, but from the power of placebo. In this episode of the podcast Science Vs, researchers and medical professionals on either side of the debate weigh in.

The pandemic’s true toll on mental health won’t be known for a long time, but data from the past two years indicates a rise in prescription drugs for conditions like ADHD and depression.

Ketamine therapy is going mainstream. The mind-altering drug has been shown to help people suffering from anxiety and depression. But how it helps and who it will serve are open questions.

In his book “The Upward Spiral,” Alex Korb demystifies the intricate brain processes that cause depression and offers an approach to getting better, based on the latest neuroscience research.

This list from Healthline includes Korb’s book and 14 others for anyone who’d like to do further reading on depression, including one from a Buddhist philosophy, which I particularly appreciate, and one for pessimists who roll their eyes when they hear about the “power of positive thinking.”

Other interesting stuff

Surfing is all about feeling present. In her first book, “I Just Wanna Surf,” photographer Gabriella Angotti-Jones crystalizes the way the cyclical nature of trauma and healing mirrors the nature of chasing a wave.

An untold number of families are dealing with myriad challenges finding and paying for mental health care, and then ending up in debt. A recent poll found that about 100 million Americans currently have some kind of healthcare debt, and 20% of those owe money for mental health services.

Perfectionists: Lowering your standards can improve your mental health. Advice from a psychology and neuroscience professor (and a recovering perfectionist).

Talking to the children in your life about fentanyl can feel daunting. My colleague Paul Thornton hosted a discussion on the topic earlier this month with experts who suggested a “just say know” approach over the old “just say no” adage.