Every year, the World Happiness Report garners a brief moment of media attention with its happiness rankings for over one hundred fifty countries.1 The “top ten” honors consistently go to the Nordic nations as well as countries like Switzerland, Iceland, Australia and New Zealand—but not to the United States, which instead has seen its rankings fall over the past decade to its current rank of eighteen. One report author attributes America’s lackluster showing (compared to other wealthy nations) to its lower scores for social indicators such as social support.2
Studies report, in fact, that quite a few Americans are depressed. According to the National Institute of Mental Health (NIMH), major depression is one of the nation’s most common mental disorders.3 As of 2016, almost 7 percent of U.S. adults aged eighteen and older (over sixteen million) had reported at least one major depressive episode in the previous year, and the percentages were even higher for young people: 12.8 percent of adolescents aged twelve to seventeen and 10.9 percent of young adults between ages eighteen and twenty-five.3 More often than not for adults (64 percent) as well as adolescents (70 percent), the level of impairment accompanying these depressive episodes was rated as severe.3
THE RISE OF MEDICATION
In tandem with the increasing diagnosis of depression, the prescribing and use of antidepressants are also increasingly common. Antidepressants are psychotropic medications that have “an altering effect on perception, emotion or behavior.”4 According to Scientific American, antidepressants were (as of 2014) the third most frequently taken medication in the U.S., with four times more adult use of antidepressants in the late 2000s than in the early 1990s.5 By 2012, 13 percent of U.S. adults were reporting antidepressant use in the preceding month.6 Analyses of pharmacy claims data also reveal that almost twice as many women (21 percent) as men (11 percent) use antidepressants.7 Nor does pregnancy deter doctors from putting pen to prescription pad: antidepressant use by pregnant women tripled between 2002 and 2010, “despite controversy over possible negative effects.”8
The surge in antidepressant use has occurred in the context of a broader trend toward increased use of all prescription drugs. Three-fifths (59 percent) of adults reported taking one or more prescription drugs in 2012, up from half (51 percent) in 1999.6 During the same period, the proportion of adults relying on “polypharmacy”—concurrent use of five or more prescription drugs—had nearly doubled (15 percent versus 8.2 percent).6 In another illustration of polypharmacy, a study of over five thousand American adults with chronic lower back pain found that many study participants had doubled up on antidepressants and pain medications, including opioids; almost one-fifth of back pain sufferers had used opioids and antidepressants in the preceding month.9
The U.S. Food and Drug Administration (FDA) has approved numerous medications for use as antidepressants. Describing just some of the antidepressants available, WebMD listed forty-five different medications as of February 2017.10 The antidepressants called selective serotonin reuptake inhibitors (SSRIs)—which target the neurotransmitter serotonin—are the most well-known and the most commonly prescribed.6 In addition to SSRIs, other newer-generation antidepressants tackle the reuptake of two neurotransmitters—those include SNRIs (serotonin-norepinephrine reuptake inhibitors) and NDRIs (norepinephrine-dopamine reuptake inhibitors). Other types of antidepressants include serotonin antagonist and reuptake inhibitors (SARIs) as well as the older-generation tricyclic and tetracyclic antidepressants, which have fallen somewhat out of favor since the advent of SSRIs.
Whereas some antidepressants on the market are approved exclusively for diagnosed depression, others—the SSRIs, in particular—are approved for a broader range of mental health diagnoses: obsessive-compulsive disorder (OCD), anxiety disorders, panic attacks, post-traumatic stress disorder (PTSD) and even bulimia and premenstrual dysphoric disorder (“a severe and disabling form of premenstrual syndrome”) (see Table 1). Physicians also increasingly prescribe SSRIs and other antidepressants for off-label (non-approved) uses, even in children—these off-label uses may not even be “psychological” in nature.5 One study found that only 9.2 percent of ambulatory care visits by children aged six to eighteen (2000–2006) “were associated with FDA-approved indications,” indicating a “very high prevalence of off-label antidepressant prescribing patterns among children and adolescents.”11 Another analysis of prescribing patterns, which found that seven in ten antidepressant users had never met the criteria for major depressive disorder, concluded that antidepressants “are commonly used in the absence of clear evidence-based indications.”12
Doctors’ willingness to hand out brain-altering SSRIs freely for all kinds of health conditions is disquieting for many reasons, not least because of the well-documented risks of adverse outcomes. Although industry-funded websites and researchers continue to promote SSRIs as having a “favorable profile regarding adverse effects,”6 a 2017 study that systematically reviewed one hundred thirty-one randomized placebo-controlled trials of SSRIs reached a different conclusion. Characterizing the antidepressants’ clinical significance as “questionable,” the authors reported that SSRIs “significantly increase the risk of both serious and non-serious adverse events” and that “the potential small beneficial effects seem to be outweighed by harmful effects.”13
Adverse outcomes range from unpleasant to serious to life-threatening. For example, sexual dysfunction is a well-known side effect of SSRIs and SNRIs, and is a top reason for nonadherence to or discontinuation of treatment.14 (In an illustration of an unfortunate drug treatment cascade, doctors sometimes prescribe additional antidepressants to treat SSRI- and SNRI-induced sexual dysfunction!14) A by-no-means exhaustive list of other SSRI risks includes significant bleeding risks for individuals who undergo surgery while taking the drugs;15 an increased odds (in men) of developing metabolic syndrome;16 drug-induced movement disorders (called “extrapyramidal symptoms”) such as parkinsonism;17 and balance problems.18
A national survey involving about three thousand adults aged forty or older who were taking antidepressants or other psychotropic medications found that one third had balance impairment; moreover, there was a dose-response relationship for the number of psychotropic medications taken, with each additional medication associated with a 35 percent increased odds of balance problems.18 With balance impairment, not surprisingly, comes a greater risk of falling. A British study that followed thousands of adults of all ages taking antidepressants (aged twenty to sixty-four) for five years found that eight of eleven commonly prescribed antidepressants were associated with significantly increased fall rates (compared with non-use of the drugs), and there was also a significantly increased fracture rate for SSRIs specifically.19
PREVENTING OR CAUSING SUICIDE?
Even more troubling than fractures are the numerous studies linking SSRIs and SNRIs to suicidal thoughts and behaviors, particularly in children, adolescents and younger adults.20,21 This is not an insignificant concern: suicide is the second leading cause of death in young Americans aged ten to thirty-four, and the fourth leading cause of death for U.S. adults aged thirty-five to fifty-four.22 In the early 2000s, a medical researcher, reviewing FDA reports on psychotropic drugs that the agency had approved between 1985 to 2000, ascertained that the suicide risk was six hundred fifty-five per one hundred thousand in trials of antidepressants versus eleven per one hundred thousand in the general population—an almost 6,000 percent increased risk—and especially noteworthy given that the trials excluded patients considered suicidal at baseline or suffering from other mental illnesses.23
In 2004, an FDA-convened committee concluded that there was “a causal link between pediatric antidepressant use and suicidality,” and the FDA mandated that SSRIs and related antidepressant labels add black-box warnings about the risks. (Black-box warnings address serious or life-threatening risks and are “the sternest warning…that a medication can carry and still remain on the market in the United States.”24) The added black-box language describes the suicide risks, stating that “patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior” and that “families and caregivers should be advised of the need for close observation and communication with the prescriber.”25
MORE HARM THAN GOOD
In light of the data on adverse outcomes, it seems reasonable to ask not only whether antidepressants’ perceived benefits are worth their considerable risks, but also whether the drugs actually represent an effective treatment for depression. Considerable evidence suggests that they do not. In fact, antidepressants (especially SSRIs and SNRIs) have exhibited a substantial placebo response.26 The organization Mad in America (an international group of writers covering psychiatric research) has summarized several strands of neuroscientific and clinical trial research indicative of a placebo effect in the severely depressed, including imaging studies showing “the same changes in brain scans when [people] respond to a placebo as…when they take an actual antidepressant.”27-29 The most recent systematic review to examine placebo-controlled trials reiterated the finding that newer-generation antidepressants “did not clearly demonstrate benefit above placebo”30—a startling result given that most of the trials included in the review were industry-sponsored!
Psychiatrist Peter Breggin is the author of numerous books about the risks of psychiatric medications, including Toxic Psychiatry,31Medication Madness,32 Talking Back to Prozac33 and The Antidepressant Fact Book.34 Breggin has repeatedly called attention to the dangerous partnership between psychiatry and the pharmaceutical industry (what he calls the “psychopharmaceutical complex”). He also argues that the partnership’s aggressive and successful promotion of toxic drugs has done “infinitely more harm than good” by conveying the “demoralizing and physically destructive idea that there are medical experts who can tinker with our brains and ’make us better.’”35 Dr. Candace Pert, the late researcher who several decades ago elucidated the brain biochemistry that made SSRIs and SNRIs possible, came to regret her discovery; as early as 1997, Pert spoke out against the drugs, stating that she had contributed to the creation of a “monster.”36
Along the same lines, writer Jon Rappoport asserts, “We are looking at a program of opinion and propaganda, and this program has the effect of making people believe they are deficient in serious ways; they are limited; they have brain-function flaws; and they must receive chemical treatment.”37 Rappoport often cites Dr. Breggin when reporting on the abuses of psychiatry and psychiatric drugs, as does journalist Kelly Patricia O’Meara, who writes about the same issues for the watchdog group Citizens Commission on Human Rights (CCHR).38 Their reporting frequently raises questions about the medical validity of psychiatric diagnoses, pointing out that there are no definitive medical or laboratory tests “to prove mental disorders are medical conditions requiring the administration of mind-altering and potentially lethal psychiatric drugs” (emphasis in original).39 Making the same point, an op-ed writer has stated, “Of course, the decades-long theory of the alleged chemical imbalance remains just that. . . a theory. There is no test to determine the chemical levels in the brain, making it impossible to know whether the chemicals are in or out of balance or, for that matter, what ’normal’ levels may be.”40
Rappoport and CCHR both also have quoted Dr. Allen Frances, the psychiatrist who headed up the revisions for the fourth edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). In an interview for Wired magazine, Dr. Frances stated: “There is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it.”41 In the same interview, Frances also admitted that the DSMIV may have “fostered an increasing tendency to chalk up life’s difficulties to mental illness and then treat them with psychiatric drugs.”41
If one views psychiatric labeling through a skeptical lens, psychiatry’s continual attempts to broaden its diagnostic reach are troubling. In the mid-1990s, for example, mental health specialists coined the term “subsyndromal depression” (SD), defined as the presence (for a minimum of
two weeks) of at least two but less than five of the quality-of-life-impairing symptoms required for a diagnosis of major depression.42 Mental health providers now embrace SD as an “early prognostic indicator” of subsequent major depression (and other disorders) and as a way to “identify individuals who may benefit from preventive interventions”—such as medication.43 A longitudinal study published in 2013 suggested that more than one in ten U.S. adults (11.6 percent) met the diagnostic criteria for SD at baseline—and a baseline SD diagnosis was associated with an increased likelihood of receiving additional depression-related diagnoses three years later, including major depression, “dysthymia” (less severe but more chronic depression), “social phobia” or “generalized anxiety disorder.”43
The age of children taking antidepressants and other psychiatric drugs has been creeping steadily downward in recent years, with a 23 percent jump in the number of Prozac prescriptions written for children under age two from 2013 to 2014.44 Table 2, which displays the number of U.S. children taking various psychiatric drugs as of 2017, shows that one-fourth of the psychiatric drugs taken that year by children and adolescents were antidepressants, second in line after the equally worrisome medications prescribed for attention-deficit/hyperactivity disorder (ADHD).
Belatedly, questions are arising about the wisdom of medicating so many of our youth. A meta-analysis of thirty-four clinical trials published in the top-tier journal The Lancet in 2016 weighed the risk-benefit profile of antidepressants in young people and concluded that “these drugs do not seem to offer a clear advantage for children and adolescents.”45 Only one drug showed any possible benefit—Prozac—but a researcher asked to comment on the findings characterized the case for Prozac as “quite weak.”46
Antidepressant use in young people has been connected not just to increased suicidality but also to violent behavior and even mass shootings.47,48 Dr. Breggin published a paper describing SSRI-induced violence against “others” as well as “self” almost fifteen years ago, providing details about the SSRI “stimulant continuum” that starts with “lesser degrees of insomnia, nervousness, anxiety, hyperactivity and irritability and then progresses toward more severe agitation, aggression, and varying degrees of mania.”49 Many of these symptoms are similar to the effects produced by cocaine and amphetamines. Weighing evidence from clinical trials, case reports, coroner’s reports, epidemiological studies and more, Breggin confirmed that “SSRI antidepressants can cause violence, suicide, mania and other forms of psychotic and bizarre behavior,” even in individuals with no prior history of any of these symptoms or behaviors.
Another neglected issue, important to note in the context of Americans’ widespread reliance on prescription drugs in general, is the potential for medications not related to depression to cause depression (and lead to further prescribing). A 2018 study in The Journal of the American Medical Association (JAMA) looked at the proportion of U.S. adults not taking antidepressants but taking three or more medications that list depression as a potential adverse effect: three times as many of the individuals taking these medications subsequently had depression (15 percent) than those not using such medications (4.7 percent).50
A third problem worth mentioning is the link between antidepressants and drug errors (such as taking a medication twice or taking someone else’s medication). A study that assessed reports to poison control centers from 2000 to 2012 found that Americans reported an average of almost sixteen thousand errors annually in association with antidepressants and antipsychotic medications, and SSRIs were the medications most frequently associated with the errors.51 The rate of errors related to antidepressants increased almost continuously over the twelve-year period. Another study documented almost ninety thousand annual emergency department (ED) visits by American adults (about half of whom were in their twenties and thirties) attributable to adverse reactions to psychiatric medications from 2009 through 2011; antidepressants accounted for 28 percent of the emergency visits, second to sedatives and anti-anxiety medications.52 One in five ED visits resulted in hospitalization.
Unfortunately, individuals who learn of SSRI and SNRI risks after the fact and decide to discontinue taking the drugs face more potential dangers. Overly abrupt withdrawal (or too rapid dose reduction or even missed doses) can result in severe withdrawal symptoms, including psychiatric symptoms such as hallucinations, agitation, delirium and “weird and bizarre dreams” as well as cardiovascular problems and “severe symptoms resembling a stroke.”53 Mad in America, the organization mentioned above, has compiled over thirty published articles about what has come to be known as “discontinuation syndrome,” some of which describe effects that persist for years after discontinuation.54
MEDICATION IS NOT THE ANSWER
Depression—or at least its diagnosis—has become more than just a U.S. phenomenon. A global analysis of years lived with disability (YLDs) in one hundred and ninety-five countries and territories in 2016 reported that “major depressive disorder” ranked in the top ten causes of YLDs in all but four countries.55 Antidepressant use is on the rise globally as well, even in the countries garnering the top honors in the World Happiness Report. A survey of twenty-five member countries of the Organisation for Economic Co-operation and Development (OECD) found that antidepressant use had increased “in every single country.”56
Commenting on the across-the-board rise in antidepressant use in OECD countries, a 2016 Business Insider article suggested that “the popularity of antidepressants in a given country is the result of a complicated mix of depression rates, stigma, wealth, health coverage, and availability of treatment.”56 However, this list of factors omits what is perhaps the biggest driver of antidepressant use of all: pharmaceutical industry marketing and the push for profits. CCHR takes the position that psychiatric labels, by and large, are a clever strategy to protect the industry’s hold on billions of dollars in psychiatric drug revenues.57 If this is the case, then we should dissuade other countries from following in America’s drug-addled footsteps.
CCHR acknowledges that people do get “depressed, sad, troubled, anxious, nervous and even sometimes act psychotic,” but there are many possible responses that are less harmful than antidepressants. Helpful and effective non-drug supports include cognitive behavioral therapy,58 dietary changes,59 physical activity60 and non-pharmaceutical modalities such as homeopathy61 and Chinese medicine.62 In addition, as Wise Traditions readers know, the gut-brain axis means that a healthy gut is essential, not just to health but happiness.63 Peter Breggin also encourages each of us to draw on resources such as “self-understanding, wisdom, education, art, nature, spirituality and God”—and have faith in ourselves. With these and other health-promoting tools, it is fully possible to “triumph over our mental confusion and emotional turmoil” and live “principled and love-filled lives.”35
In the era of electronic medical records and hackable digital data, it may make sense to consider carefully whether to seek a formal diagnosis of depression or anxiety. It also goes without saying that throwing personal mental health information around on social media may be a bad idea. In a flippant tone, one blogger describes what she perceives as a modern-day catch-22 for the person who self-identifies with depression or other mental illnesses: “The burden of keeping it all inside is cumbersome, but so is sharing [on social media] the true extent of your illness to extended family members, people you hooked up with one and a half times, your sister’s husband’s brother’s daughter, even actual friends.”64 Individuals wanting to avoid being labeled for life in the digital universe or aggressively pushed toward pharmaceutical solutions may wish to be cautious about using the words “depressed” or “anxious” when interfacing with drug-oriented health care providers.
ANTIDEPRESSANTS IN THE WATER
An important but little-publicized side branch of public health estimates community drug usage based on drug residues in wastewater at water treatment plants and in community water sources. A study in the Midwest found high levels of two SNRI and SSRI antidepressants (venlafaxine and citalopram) in the wastewater.65 The local rivers and creeks also showed worrisome levels of several SSRIs and SNRIs as well as a variety of other prescription and illicit drugs. A 2013 Salon report that described the “lacing” of tap water with antidepressants noted that an estimated 80 percent of ingested prescription medications get excreted rather than being broken down in our bodies—and there are no federal guidelines requiring sewage treatment plants to filter out these pharmaceuticals.66 According to Salon, “In Britain, where psychoactive drugs are prescribed at a fraction of U.S. levels, a 2004 Environment Agency study cited ‛low-level, almost continuous discharge’ of Prozac through the tap water there. [A] Parliament member…stated ominously, ‛This looks like a case of hidden mass medication upon the unsuspecting public.’”66
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This article appeared in Wise Traditions in Food, Farming and the Healing Arts, the quarterly magazine of the Weston A. Price Foundation, Fall 2018.